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Evaluation Synthesis: Life After the ICU

Zachary Tomczyk

Department of Nursing, Madonna University

NUR 5150: Translating & Integrate Scholarship for Advanced Practice Nursing

Dr. Diane Burgermeister

November 12, 2021

 
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Life After the ICU: The Nurse Practitioner’s Role in Post-ICU Follow Up

Up to a third of intensive care unit (ICU) survivors will experience depression or

another form of mental health problems, half will suffer from cognitive impairments, and

most will have long lasting physical debility once they leave the ICU (Huggins, et al.,

2016). ICU survivors have frequently experienced painful procedures, prolonged

mechanical ventilation (with and without sedation), irregular sleep/wake hours, and a

slew of other complications associated with critical illness and therefore the long-term

outcomes need to be evaluated.

In the last year ICUs around the world were overrun by patients infected with the

SARS-CoV-2 virus. Many of these patients may exhibit a collection of symptoms that

has been described as Post-Intensive Care Unit Syndrome (PICS) (Flaatten &

Walkdman, 2020). In response to the increasing prevalence and understanding of PICS

a few hospitals in the United States have begun to establish PICS Clinics. These clinics

are meant to reduce readmission rates and premature death with the best quality of life

possible.

PICS is often associated with higher readmission rates, decreased life

expectancies, and decreased quality of life (Hua et al., 2015). Intensive care nurse

practitioners are often put in a unique and pivotal role in the PICS recovery process

through identification of PICS symptoms, recruitment of adult patients and their families

through follow up at time of discharge from the ICU and the hospital, and providing

direct care in the PICS clinics (Huggins et al., 2016). Post-ICU clinics typically target
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adult patients and their families who have survived critical illness. A literature review

was preformed to address the question: “Does post-ICU follow up by an ICU nurse

practitioner improve the longer lasting effects of PICS and decrease the length and

severity of debility in ICU survivors as compared to ICU survivors who do not receive

specific post-ICU outpatient follow up?”

Literature Review

           The collection of symptoms, now referred to as PICS, is not a new phenomenon.

These symptoms were first described in literature as early as the 1950s, but were often

describe independent of each other. These symptoms were grouped as to describe a

specific syndrome and the term “PICS” was first used in literature around 2010 (Flaatten

& Walkdman, 2020). Common themes appear in the literature including a lack of

quantitative data, the utilization of randomized control trials to evaluate the efficacy of

post-ICU follow-up and the need for more research.

The literature also appears to be contradictory as found by Rosa et al. (2019)

and Jensen et al. (2015). Through a meta-analysis and systematic review of MEDLINE,

PsychINFO, CINAHL, Cochrane CENTRAL, and EMBASE, Rosa et al. found that

quantifiable data on the effectiveness of post-ICU follow-up is difficult to find and often

controversial due to low levels of evidence (2019).  Jensen et al. (2015) echoed these

findings in a systematic review and meta-analysis using the same databases stating,

“the overall quality of evidence [is] low” (pp. 764) in reference to the efficacy of post-ICU

follow up. However, the same analyses found that the literature supports the notion that

post-ICU follow up improves quality of life scores, and decreases depressive and post-
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traumatic stress disorder symptoms (PTSD), but may not improve physical debility

(Rosa et al., 2019) (Jenson et al., 2015). Corner and Brett (2020) agree that current

research provides little light on the physical benefits of post-ICU follow up, but state that

it may provide a safety net for ICU survivors whose unique needs may slip through the

cracks of healthcare systems.

Sevin and Jackson (2019) define the goals of post-ICU follow up is to limit

adverse and to “reduce emergency room visits and hospital readmissions”, “improve

continuity of care” by using ICU clinicians to provide the follow up, “accelerate the

resolution of critical illness sequelae”, “remove barriers to recovering” including

financial, geographical, and social, “enhance employment outcomes” by improving the

timeliness of returning to work, “integrate the patient and caregiver as partners in

recovery”, and “prevent further morbidity and mortality” (pp. 270-271). Furthermore,

Marra and Ely (2017) state that patient and caregiver empowerment is crucial to

reducing the prevalence and severity of PICS. While little research focuses directly on

the role of the APRN, many of these interventions can be effectively executed by nurse

practitioners as supported by Cody et al. (2020).

A systematic review of CINAHL and PubMed by Cody et al. (2020), found that

nurse practitioners are effective at patient empowerment, are able to reduce length of

stay, and improve patient outcomes. These traits found by Cody et al. (2020), directly

align with the goals of many strategies to reduce PICS. One article published by a team

at Vanderbilt University Medical Center (VUMC), who utilizes APRNs in the ICU,

described the role of the nurse practitioner in post-ICU follow up. The NP’s role extends

from being a bedside ICU clinician and is further defined by coordinating services at
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time of discharge from the hospital after completing a thorough medical and social

history including pre and post ICU levels of functionality and independence with

activities of daily living (ADLs), as well as a physical assessment (Huggins, et al.,

2016). 

Many of the articles that stress the importance of post-ICU follow up by critical

care providers are informed by an array of research that describes the short- and

longer-term effects of PICS. Colbenson, Johnson, and Wilson (2019) state that an

estimated one third of ICU survivors do not go back to work or return to work with a

lower than pre-ICU salary, and while the full extent of ICU survival detriments has not

been effectively quantified, morbidity after ICU admission remains a significant problem.

Another study by Harvey and Davidson (2016) states up to 80% of ICU survivors will

have cognitive problems similar to Alzheimer’s disease to varying degrees, up to 57%

will suffer from psychiatric illness such as depression or PTSD, and up to 80% will have

new physical impairments that may be lifelong. Hua et al. (2015) also suggest that ICU

survivors account for a significant portion of hospital readmissions. 

There has been a lot of discussion in the research about who specifically should

be providing the post-ICU care follow up and in what setting. Sevin and Jackson (2019)

advocate that ICU clinicians should follow the ICU survivor through discharge and also

be the primary clinician to see them in the outpatient setting. They state, “there is a

disconnect between ICU level care and post-discharge care,” (pp. 268) citing patients

who state outpatient providers have little understanding of their critical illness. Other

concerns are that overtaxed primary care providers often do not have the time to fully

familiarize themselves with the nuances of prolonged critical illness or primary care
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providers can be dismissive of the idea that critical illness can result in persistent

sequelae stating that post-ICU care is critical care. Sevin and Jackson give a nod to the

importance of including the primary care provider, but as a recipient of education

relating to critical illness and not as a collaborator in care.

Ling and Casida (2020) suggest that the follow up should be led by family

practice nurse practitioners who are more intimately familiar with a person’s social and

medical history but done so in conjunction with the acute care nurse practitioners. They

continue with the argument for the “Cup of Coffee” model in which primary care

providers sit down with the ICU/acute care providers to provide a more holistic nursing

approach to PICS. Ling and Casida (2020) further suggest that poor interprofessional

communication cost hospitals over $12 billion annually in 2009. They also point out that

natural gaps in care occur when care models do not overlap which is common between

acute care and primary care settings. This leaves the patient to navigate the gap in what

is an already complex medical system while struggling to redefine their new normal in

the wake of PICS.

Ling and Casida (2020) acknowledge that primary care providers “may not

identify the PICS constellation in a timely way” (pp. 77) as that acute care providers may

not recognize how medications needed for acute care management might negatively

affect day to day management of chronic or underlaying health concerns. Therefore,

they propose an intersective model in which the acute care and primary care provider

collaborate to develop a comprehensive care plan that is individualized to the patient’s

needs. Huggins et al. (2016), similar to Ling and Casida (2020), supports a

multidisciplinary model but does not expressly state inclusion of the primary care
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provider, but does state the goal of the inter-professional team should be to work

towards providing a comprehensive follow-up in the outpatient setting.

The Ling and Casida model and the Sevin and Jackson model have not been

thoroughly evaluated in the research to suggest which is more effective. However, more

literature appears to use the Sevin and Jackson model in which the ICU providers,

namely the nurse practitioner, follows the patient through the discharge phase and into

the outpatient setting. This model has been adapted not only at VUMC, but broadly in

the United Kingdom, which was the first country to provide post-ICU specific care. It has

also been adapted by other leading institutions such as the Critical Care Recovery

Center at the Indiana University School of Medicine (Sevin & Jackson, 2016) and

University of Michigan Post ICU Longitudinal Survivor Experience Clinic (U-M PULSE).

This suggests a move towards an industry standard.

The literature reviewed includes meta-analysis and systematic review (Rosa et

al, 2019; Jensen et al, 2015; Cody et al., 2020). These meta-analyses are limited by

lack of high-level evidence and used similar scholarly databases which might prevent

inclusion of research outside the mainstream databases.

The articles by Sevin and Jackson (2016), Colbenson et al. (2019), and Ling and

Casida (2020) offer editorial data by experts in their field supported by statistics from

other studies. However, professional opinion is low level information and should be

viewed as such. While these articles should be used to guide practice in its infancy,

further peer reviewed, and evidence-based practice will need to take its place.
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Marra and Ely (2017) offer a framework for ICU liberation which has been

validated by hundreds of studies across various databases and can be accepted as a

reliable model. However, it’s efficacy in the reduction of PICS severity and prevalence

has yet to be validated. Huggins et al. (2016) provides a framework for how a post-ICU

clinic could be established however, they acknowledge that “the data on the effects of

Vanderbilt’s ICU Recovery Center remain[s] anecdotal” (pp. 208) and warrants further

exploration.

Harvey and Davidson (2016), Flaatten, and Walkdman (2020), and Corner and

Brett (2020) offer descriptive studies of PICS including symptoms, risk factors,

prognosis, and suggestions for mitigating the effects of PICS. However, these articles

are generally broad and do not offer concrete descriptions stating there is a need for

more quantifiable data and more reliable diagnostic and treatment models.

Hua et al. (2015) provides a retrospective cohort study which offered tangible

statistics regarding readmission rates for ICU survivors in the state of New York.

However, this study is limited to the state of New York and does not delineate the

various demographics, including geographical location within the state. Additionally,

without a validated tool for identifying PICS it is difficult to determine if PICS contributed

to the readmission rate. Confounding variables were not taken into consideration either,

including time of year or natural disasters.

As treatment of PICS moves forward and research is developed to support

interventions several gaps in knowledge have been identified by various researchers.

Ling and Casida (2020) identified that the recovery trajectory for PICS is not fully
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understood or mapped out. Additionally, many studies noted the lack of high-level data

and the absence of quantifiable data on how to best use nurse practitioners in the PICS

recovery process. This leaves a lot of room for continued innovation and discovery into

the pathogenesis, pathophysiology, and recovery process of the millions of people who

survive critical illness every year.

Theoretical Framework

Due to new physical limitations, cognitive and memory deficits, and new or

exacerbated mental health concerns, an ICU survivor’s role within their family and

community, and self-perception drastically changes. These external changes, influence

role transitions within the person according to Chick and Meleis (1986). Meleis’s

Transitions Model identified four primary areas of transition: developmental, health and

illness, situational, and organizational (Chick and Meleis, 1986). Meleis expands on this

by stating there are subcategories in each of the four classic areas of transition which

can be directly transcribed into the ICU survivor’s experience (Schumacher and Meleis,

1994).

Traditionally, a pattern of congruency is observed in the Transitions Model as

exemplified by Davies (2005) who discusses transitions in adults into older adulthood

moving from independent living to assisted living. This is also recognized by

Schumacher and Meleis (1994) who expand that role transitions often occur

simultaneously and has inspired the work of multiple researchers. This pattern of

congruency is often accompanied by corresponding situational transitions as the person

loses independence and requires transfer from living at home to assisted living and
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health-illness transitions as chronic conditions progress and, in some situations,

become dependent on artificial life support (chronic artificial ventilation or

enteral/parenteral nutrition).

However, this symphony of transitions in which each transition is in harmony with

the others, can be interrupted by the presence of critical illness and its survival. PICS

interrupts this homogenous transition and creates transitional disagreement. For

instance, a 45-year-old who is the primary income provider for their family and

respected member of the community survives an arduous ARDS course, but are left

wheelchair bound, have new depression and PTSD, and have short term memory loss

quickly transitions from the provider role to the recipience of care as they have lost

independence with their activities of daily living. In this short period of time, their

development station is now incongruous with their situational station due to a rapid shift

in their identity as a healthy person. The complexity of their ICU course often leaves

patients with the inability to full articulate their experience or understand the changes to

personal identity which hinders recovery (Ewens, et al., 2018).

Transitions never exist independent of the environment in which they are

experienced (Chick and Meleis, 1984). A central assumption of the Transitions Model is

that personal experience is influenced by interactions with other and interested groups

like family, healthcare workers, hospitals, etc. (Chick and Meleis, 1984). Other things

can influence change as well including expectations, level of knowledge and skill, and

level of planning (Schumacher and Meleis, 1994). Schumacher and Meleis (1994) state

that people may or may not know what to expect as they transition through various

transitional periods based on past experiences which may or may not be applicable to
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their current situation. It can be reasonably stated that many ICU survivors are

traversing unfamiliar territory. However, as ICU clinicians, APRNs are intimately familiar

with ICU courses and can help guide patient expectations surrounding their recovery

process and long-term outcomes. Furthermore, Schumacher and Meleis (1994),

demonstrate that “uncertainty [is] interwoven with the need for new knowledge and skill

development” (pp. 122). The ICU survivor will develop an enhanced sense of resilience

when provided with education and new skills by the APRN.

The Transitions Model further supports the need for advanced levels of planning

before and during a transition (Schumacher and Meleis, 1994). Schumacher and Meleis

find that a comprehensive understanding of the problems, issues, and need that may

arise during a transitional period are required for effective planning (1994). After ICU

survival, people are in a vulnerable position and great care must be taken when building

care plans that are multidisciplinary in nature and consider their physical, mental, and

spiritual health. This advanced level of planning will promote a healthy transition for the

survivors in an effort to mitigate the long-lasting effects of PICS.

Proposed Change

PICS can lead to extensive and life limiting conditions, thus the aim of any PICS

intervention should be to reduce morbidity and mortality after surviving critical illness.

While the APRN is uniquely qualified to lead many of the interventions, intervention

should be done through a multidisciplinary lens. It is proposed that the ICU APRN would

orchestrate the moving parts of recovery while keeping focus on Person Centered Care
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which has been shown to improved coordination between providers and patients,

improve health outcomes and improve patient satisfaction (Ekman et al., 2011).

Many of the responsibilities the APRN takes on are an extension of current skills,

but may need to be fine-tuned in order to provide individualized care to each patient

whose experience is unique. As patients prepare to leave the ICU and eventually the

hospital, the APRN would complete a detailed history and physical assessment catered

to the nature of the patient’s critical illness while focusing on and reenforcing education

around skilled nursing care the patient will need after discharge such as tracheostomy

care, pulmonary hygiene, new physical impediments, and skin care (Huggins et al.,

2016). A baseline assessment should also be made to understand and track a patient’s

nutritional status, activity tolerance, independence with activities of daily living (ADLs),

mood, affect, and cognitive status. A social history should be taken to understand work

status and responsibilities within and outside the home. Additionally, enrollment in a

post-ICU clinic, staffed by the ICU providers, would also be established at this time as

well as a consult to case management to address insurance or logistical barriers to

follow up.

At time of follow up, many of the same elements of the initial assessment would

be repeated in an effort to understand functional decline or progression. At this time, the

APRN should ask the patient how their life now compares to the life they had before

critical illness and ask them to identify the most troublesome deficits. This would allow

the APRN to guide consultation and put the patient’s concerns at the forefront of the

care plan. Each problem would be reviewed by various members of the PICS clinics

which often comprises of the APRNs, intensivist physicians, clinical psychologist, and
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pharmacists. For instance, if a patient identifies their primary problem as the inability to

walk from their bedroom to the living room without assistance, the APRN would help

reenforce fall precautions, review strength building exercises, and ensure proper

consultation to physical therapy, the clinical psychologist could address the patient’s

fear of falling which may limit their effort to walk, the pharmacist could review

medications that may lead to dizziness and muscular weakness and propose changes

to medication regimens, and the intensivist could help rule out other organic barriers.

Huggins et al. (2016), identifies several barriers that have limited PICS clinics

success including the logistical challenges of recruitment and the scarcity of resources

(2016). As patients experience a prolonged hospital course, they can easily become

overwhelmed with the sheer number of providers, consulting services, and ancillary

support they meet. However, establishing care early in their ICU admission and periodic

follow up until time of discharge can establish a pattern of care and help build patient

relations with the ICU providers. Other logistical barriers including lack of transportation,

financial limitation, and family support. Some of these hurdles can be overcome with the

expansion in tele-health that has exploded since the start of the COVID-19 pandemic.

Furthermore, due the relatively new acceptance of PICS as a condition worth

treating, hospitals often do not have available resources for PICS such as funding, a

physical space for the clinic, laboratory equipment, and adequate staffing dedicated to

the treatment of PICS. Financial constraints pose a serious risk to the survival and

development of PICS clinics as PICS does not carry a specific, billable DSM diagnosis.

However, as healthcare continues to shift its efforts on ambulatory and preventative

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care, there is a hope that PICs will soon be recognized by the DSM and allow providers

to bill directly for care specifically related to PICS.

Evaluation

As PICS is a relatively new phenomenon to be studied and treated, the

evaluation process is open to innovation and should be modified as PICS becomes

better understood. Spies et al. (2021) suggests that assessment of PICS recovery

should a two-step process that measures performance-based and patient-reported

outcomes.

Several validated tools are currently used in practice to measure physical

recovery. Handgrip strength can be measured using a hand-held dynamometer which is

considered a valid test to measure muscle strength (Spies et al., 2021). Timed Up-and-

Go measures how long it takes for a person to stand from a seated position. This can

be used to assess a person’s risk for falling (Csepe, 2021). These two tests should be

measured in conjunction and offer assessments that can be done quickly in an

outpatient setting, offering substantial insight into a person’s physical recovery (Spies et

al, 2021).

PICS can also bare significant weight on a person’s mental health. Using

standardized assessment tools for anxiety, depression, and post-traumatic stress

disorder will allow the APRN to assess on a continuum the ICU survivors mental health.

The Impact of Event Scale (IES) can assess how a patient perceived their experience in

the ICU (Spies et al., 2021). The Patient Health Questionnaire (PHQ) provides a brief
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assessment into a survivor’s level of anxiety and depression. Additionally, the

Generalized Anxiety Disorder (GAD) can be used to further assess for anxiety.

Mental health plays a vital role in recovery, but in order to continue to provide

assessment that fully encapsulates the breath of PICS, other patient reported outcomes

should be tracked. One assessment scale, the European Quality of Life Five Dimension

(EQ-5D), measures 5 aspects of patient reported recovery. These include mobility, self-

care, usual activities (also known as activities of daily living), pain and discomfort, and

anxiety and depression (EuroQual Research Foundation, 2020). The patient reported

scores of the EQ-5D can be compared to functional scores from TUG and hand strength

assessments to allow the APRN to allow the care to focus on what the patient perceives

as their greatest deficit.

All of the assessments described in this section have both a brief and long form.

These allow for more in-depth assessment as new conditions appears or evolve. The

brief nature of these assessments allows for the time constraints of typical outpatient

clinics but are specific enough to offer key insight into the patient’s recovery. By using

the physical outcomes in conjunction with the patient reported outcomes as benchmarks

of recovery, the APRN can fulfill their role in providing holistic and patient centered care.

Conclusion

APRNs will play a pivotal role as PICS continues to become a better understood

phenomenon. The literature demonstrates clear-cut gaps in knowledge including the

need for high level evidence to support clinical intervention, the absence quantifiable

markers of patient success, confusion around the presentation of PICS and its
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diagnosis, and the best way to follow up with ICU survivors. The prevalence of PICS will

continue to rise as medical technologies advance and people increasingly survive

critical illness. This is already being seen as people start to recover from long stays in

the ICU related to the COVID-19 pandemic. APRNs are uniquely positioned to

recognize the cacophony of symptoms that make up PICS including new or

exacerbated mental health concerns, a decline in physical mobility and independence

and loss of functional status within their family or community. Furthermore, by viewing

the PICS experience through the Transitions Model, the APRN can help guide the

transition process as to facilitate recovery. The use of assessment tools to measure

patient perceived and physical outcomes allows the APRN tangible markers of recovery

while allowing the patient to prioritize the recovery of various deficits. PICS can cause

severe debility in ICU survivors and with continued intervention and understanding,

APRNs will help people transition from living after the ICU to life after the ICU.
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