REVIEW

C URRENT
OPINION Anticipating ICU discharge and long-term follow-up
Regis Goulart Rosa a, Cassiano Teixeira a,b, Simone Piva c
and Alessandro Morandi d,e
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Purpose of review
This review aims to summarize recent literature findings on long-term outcomes following critical illness and to
highlight potential strategies for preventing and managing health deterioration in survivors of critical care.
Recent findings
A substantial number of critical care survivors experience new or exacerbated impairments in their
physical, cognitive or mental health, commonly named as postintensive care syndrome (PICS). Furthermore,
those who survive critical illness often face an elevated risk of adverse outcomes in the months following
their hospital stay, including infections, cardiovascular events, rehospitalizations and increased mortality.
These findings underscore the need for effective prevention and management of long-term health
deterioration in the critical care setting. While robust evidence from well designed randomized clinical
trials is limited, potential interventions encompass sedation limitation, early mobilization, delirium
prevention and family presence during intensive care unit (ICU) stay, as well as multicomponent transition
programs (from ICU to ward, and from hospital to home) and specialized posthospital discharge follow-up.
Summary
In this review, we offer a concise overview of recent insights into the long-term outcomes of critical care
survivors and advancements in the prevention and management of health deterioration after critical illness.
Keywords
critical care outcomes, postintensive care syndrome, survivors

INTRODUCTION critical illness-related disabilities and other potential

The development of critical care has led to improved
patient outcomes over the last decades [1]. Together
with advancements in life-sustaining technologies,
improvements in intensive care unit (ICU) organ-
ization have substantially contributed to reducing
short-term mortality among critically ill patients [2].
Nevertheless, this reduction in mortality has intro-
duced new challenges such as the emergence of new
or exacerbated impairments in physical, cognitive
or mental health among survivors, commonly
referred as postintensive care syndrome (PICS) [3],
and an increased risk of postdischarge complica-
tions such as exacerbation of chronic medical con-
ditions, major cardiovascular events, infections,
rehospitalizations, and mortality (Fig. 1) [4].
Recently, professional society guidelines have
highlighted the need to improve long-term outcomes
for critical care survivors [5]. Consequently, the
implementation of strategies aimed to prevent and
manage heath deterioration following an ICU stay
have become priority. Accordingly, this review aims
to elucidate key aspects of long-term outcomes for
critical care survivors, offering useful information on
epidemiology, prevention, and management of
contributing factors for health deterioration follow-
ing an ICU stay.
LONG-TERM OUTCOMES OF CRITICAL
CARE SURVIVORS
Physical impairment
The etiology of physical impairment following
critical illness is multifactorial, involving various
factors such as critical illness myopathy and
a
Internal Medicine Department, Hospital Moinhos de Vento, bCritical
Care Department, Hospital de Clínicas de Porto Alegre, Porto Alegre
(RS), Brazil, cDepartment of Medical and Surgical Specialties, Radio-
logical Sciences and Public Health, University of Brescia, Brescia,
d
Rehabilitation and Intermediate Care, Azienda Speciale Cremona
Solidale, Cremona, Italy and eREFiT Bcn Research Group, Parc Sanitari
Pere Virgili and Vall d’Hebrón Institut de Recerca (VHIR), Barcelona,
Spain
Correspondence to Regis Goulart Rosa, Rua Ramiro Barcelos, 630, 108
andar, sala 1007, 90660-020 Porto Alegre, RS, Brazil.
Tel: +55 51 994538804; e-mail: regis.rosa@hmv.org.br
Curr Opin Crit Care 2024, 30:157–164
DOI:10.1097/MCC.0000000000001136

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Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.

 Acute neurological problems
KEY POINTS

New physical, cognitive or mental health impairments
are frequent long-term complications of critical illness,
and are associated with reduced quality of life.

Survivors of critical care are also at increased risk for
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poor long-term outcomes including infections,
cardiovascular events, rehospitalizations and
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increased mortality.

Potential interventions to prevent new disabilities during
critical care include sedation limitation, delirium
prevention, early mobilization, and family presence
during ICU stay.

Multicomponent transition programs and specialized
posthospital discharge follow-up are promising
interventions to enhance recovery of critical
care survivors.
polyneuropathy, respiratory impairments, and cog-
nitive and mental health symptoms [6]. Findings
from a recent study of 2345 ICU survivors in Nether-
lands indicate that one-year post-ICU discharge, new
physical problems are highly prevalent among med-
ical, urgent surgical, and elective surgical ICU survi-
vors, with reported rates of 57%, 63%, and 43%,
respectively [7]. These physical problems encompass
a range of conditions, including weakness, joint stiff-
ness, joint pain, dyspnea, dizziness, paresthesia, and
swallowing difficulties. In a study involving 732
FIGURE 1. Long-term complications of critical illness and critical care. COPD, chronic obstructive pulmonary disease; PTSD,
posttraumatic stress disorder.
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acute respiratory distress syndrome survivors in the
United States (US), fatigue symptoms were very com-
mon, with 70% reporting them at the 6-month fol-
low-up, 31% reporting no clinically important
change, and 28% reporting worsening symptoms
by the 12-month follow-up [8]. The ability of patients
to function independently after a critical illness is
often compromised as well. A recent study involving
hospitalized COVID-19 patients in Brazil revealed
that the incidence of new disabilities in instrumental
activities of daily living (such as telephone use, trans-
portation, shopping, managing medications, and
financial tasks) reached 40% one year after hospital
discharge among those who required mechanical
&
ventilation [9 ]. Although there is a possibility of
improvement of physical function in the months
following hospital discharge, physical function often
remains below the normal levels observed in the
general population and may not fully return to
pre-ICU admission levels in a relevant portion of
patients [10]. A systematic review aiming to synthe-
size data on the six-minute walk test after critical
illness, identified a significant improvement in the
walked distance between 3 and 12 months [11].
Nevertheless, even the distance walked 60 months
after critical illness remained below the population
norms, indicating a slow recovery.
Cognitive impairment
Critical care patients may experience neurological
damage due to several mechanisms, including
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 Anticipating ICU discharge and long-term follow-up Rosa et al.
cerebral ischemia, hypoxia, glucose dysregulation,
and neuroinflammation [12]. Cognitive impair-
ment is frequent among critical illness survivors,
with the prevalence ranging from 10% to 78%
(pooled estimate, 43%) after one year, depending
on the studied population [13]. In a study with 821
ICU survivors with respiratory failure or shock con-
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ducted in US, 40% of patients exhibited global
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cognition scores similar to those with moderate
traumatic brain injury, while 26% had scores similar
to those with mild Alzheimer’s disease at 3 months
[14]. Notably, this study showed that only 6% of
patients had evidence of mild to moderate cognitive
impairment before ICU admission, suggesting that
profound cognitive deficits in a quarter of patients
were largely new. In another US study involving 174
survivors of acute lung injury, the findings at
12 months indicated that 25% of survivors experi-
enced cognitive impairment, with significant
improvement from 36% at 6 months (P < 0.001).
This suggests that cognitive impairment may be
reversible in a proportion of cases [15]. Commonly
affected cognitive domains in critical care survivors
include processing speed, memory, attention, and
executive function (i.e., ability to plan and perform
multiple tasks) [16]. Potential risk factors for cogni-
tive impairment after ICU include the level of cog-
nitive reserve and delirium. In a study of 156
mechanically ventilated critically ill patients in
Spain, higher levels of cognitive reserve measured
by educational attainment and literacy, emerged as
a protective factor against cognitive decline [odds
ratio (OR), 0.37] [17]. Additionally, a recent system-
atic review found delirium as a predictor of a greater
likelihood for chronic cognitive impairment among
mechanically ventilated patients (OR, 3.76) [18].
Mental health impairment
After ICU discharge, around 32–40% of critical care
survivors experience anxiety [19], 29–34% deal with
depression [20], and 16–23% exhibit symptoms of
posttraumatic stress disorder [21]. Although there is
variation in the prevalence of these symptoms over
time, it is clear that these mental health disabilities
can persist for an extended period following ICU
discharge. Accordingly, published studies have dem-
onstrated that a significant proportion of patients
continue to experience symptoms of anxiety,
depression and posttraumatic stress even at the
one-year follow-up [19–21]. Additionally, a popula-
tion-based cohort of 24 179 mechanically ventilated
critically ill patients in Denmark showed an
increased risk of new psychoactive medication pre-
scriptions at 3 months compared to a matched
cohort of hospitalized patients [hazard ratio (HR),
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2.45] and the general population (HR, 21.09) [22]. In
another population-based cohort of 423 060 critical
care survivors in Canada, there was an increased risk
of suicide (HR, 1.22) and self-harm (HR, 1.15) com-
pared to a matched cohort of hospitalized patients
without ICU admission [23]. The presence of mental
health symptoms in critical care survivors is associ-
ated with a decrease in the quality of life. A recent
cohort study involving 579 adult ICU survivors
found that patients with post-ICU mental health
symptoms had lower health-related quality of life
scores in both physical and mental dimensions
compared to those without symptoms [24]. Psychi-
atric syndromes co-occurred in 70% of cases, and a
higher number of psychiatric syndromes were asso-
ciated to an incremental deterioration in mental
health-related quality of life with a dose-response
effect. Predictors of mental illness among post-ICU
patients included age, preexisting mental health
conditions, acute emotional stress, and physical
impairment experienced during the ICU stay.
Rehospitalizations
Readmissions are common among survivors of crit-
ical care [25]. A recent systematic review, including
data from 3 897 597 critical care survivors, found the
following pooled estimates for hospital readmis-
sions after critical illness: 16.9% at 30 days, 31.0%
at 90 days, 29.6% at 6 months, and 53.3% at
&&
12 months [26 ]. The systematic review identified
three key risk factors associated with acute care
rehospitalization one year after discharge: the pres-
ence of comorbidities, events during the initial hos-
pitalization (e.g., the presence of delirium and
duration of mechanical ventilation), and subse-
quent infections after hospital discharge. The pri-
mary reasons for readmission often involve
potentially preventable conditions, such as sepsis,
heart failure exacerbation, acute worsening of
chronic kidney disease, and exacerbation of chronic
obstructive pulmonary disease [27]. Survivors of
critical illness may experience impaired balance
due to organic dysfunctions (e.g., declining renal
or respiratory function) and disruption of homeo-
static mechanisms (e.g., blood pressure instability,
fluid imbalance, immunosuppression, and dysregu-
lated inflammation). This susceptibility increases
their risk of worsening chronic diseases and devel-
oping new conditions, such as infections and car-
diovascular events [28]. For instance, sepsis
survivors have an elevated risk of recurrent infec-
tions in the year following their septic episode,
which is associated with increased mortality [29].
Additionally, these patients exhibit a higher risk of
late cardiovascular events, such as myocardial
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 Acute neurological problems
infarction, stroke, sudden cardiac death, or ventric-
ular arrhythmias, which may persist for up to 5 years
following hospital discharge [30]. In a recent retro-
spective cohort study involving 2 258 464 survivors
of nonsurgical hospitalizations in the US, sepsis was
associated with an increased risk of cardiovascular
hospitalization (HR, 1.43) and heart failure hospital-
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&
ization (HR, 1.51) [31 ].
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Mortality
Recent published studies have shown mortality rates
in the year following discharge among ICU patients
&&
around 15.9% to 28% [32 ,33–35]. In a Brazilian
cohort of ICU survivors with over 3 days of ICU stay,
28.2% died within the first-year postdischarge [35].
Notably, infections were the main cause of death,
suggesting that many of these deaths could be pre-
ventable. Identified risk factors for 1-year mortality
in this study included older age, pre-ICU comorbid-
ities, pre-ICU physical dependence, severity of ill-
ness at ICU admission, and ICU readmission.
Notably, potentially modifiable ICU factors like
the duration of critical illness and intensive care
can influence mortality beyond one year after dis-
charge. A study involving 4619 critical care patients
in Belgium revealed that a prolonged ICU stay
(8 days) was associated with excess 5-year mortal-
ity compared to a brief ICU stay (<8 days) (40.8% vs.
29.7%) [36]. Similarly, published studies have dem-
onstrated that ICU complications such as lower
functional status at hospital discharge [37], neuro-
logic dysfunction [38], and ICU-acquired infections
[35] might contribute to an increased risk of long-
term mortality.
PREVENTING DISABILITIES DURING
CRITICAL CARE
Pathophysiologic models of critical illness-related
disabilities often implicate both critical illness itself
and ICU interventions as potential contributors to
&
PICS [39 ]. Accordingly, an appropriate acute critical
care aimed at controlling the cause of critical illness
and supporting organ dysfunctions, while minimiz-
ing potential iatrogenic effects of ICU treatments,
appears to be a reasonable component of a poten-
tially effective prevention strategy. While it is plau-
sible that the modulation of interventions in the
critical care setting could mitigate the development
of disabilities, the available evidence from rigor-
ously designed randomized clinical trials is cur-
rently limited. Even so, some strategies deserve
particular attention such as sedation limitation,
delirium prevention, early mobilization and family
presence in the ICU. These strategies have been part
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of the ICU liberation bundle (ABCDF) for instance,
which is aimed to reduce the occurrence of prevent-
able harms in ICU patients (e.g., delirium, muscle
&
weakness, PICS, and death) [40 ]
Sedation limitation
Deep and prolonged sedation has been associated
with delayed time to extubation, higher need for
tracheostomy, longer ICU length of stay, and
increased risk of hospital and long-term death
[41]. Moreover, evidence supports the use of less
sedation to prevent long-term disabilities. In the
randomized clinical trial of Treggiari et al. [42], light
sedation (patient awake and cooperative) was asso-
ciated with less depression at ICU discharge and a
reduced impairment in remembering the event and
disturbing memories of the ICU 4 weeks after hos-
pital discharge than profound sedation (patient
asleep, awakening upon physical stimulation). In
the study of Kress and colleagues, daily sedative
interruption was associated with less symptoms of
posttraumatic stress 6 months after hospital dis-
charge [43]. Additionally, the study of Pandhari-
pande et al. [14] found that higher benzodiazepine
doses were independently associated with executive
dysfunction at 3 months.
Delirium prevention
Given the association between delirium and poor
long-term outcomes (e.g., cognitive impairment,
and posttraumatic stress) [14,44], the implementa-
tion of delirium prevention strategies becomes para-
mount. Practices such as reorientation, cognitive
stimulation, improved sleep, early mobilization,
the timely removal of catheters and physical
restraints, and family presence are anticipated to
enhance long-term outcomes associated with delir-
ium [45]. However, the need for well designed
randomized clinical trials is evident to systemati-
cally assess the effectiveness of these interventions
in preventing cognitive dysfunction.
Early mobilization
Early mobilization strategies in the ICU have been
associated with improved physical and cognitive
outcomes among ICU survivors possibly by prevent-
ing muscle weakness, preserving joint and cardio-
pulmonary function and by sparing patients of
potentially excessive sedation or social isolation.
A recent systematic review of randomized clinical
trials found that early mobilization in the ICU was
associated with a decreased incidence of ICU-
acquired weakness and an improved strength and
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 Anticipating ICU discharge and long-term follow-up Rosa et al.
functionality scores at hospital discharge [46]. In the
randomized clinical trial of Schweickert et al. [47]
early physical and occupational therapy in mechan-
ically ventilated patients resulted in an increased
chance to return to independent functional status at
hospital discharge. More recently, the Treatment of
Mechanically Ventilated Adults with Early Activity
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and Mobilization (TEAM) randomized clinical trial
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demonstrated that an increase in early active mobi-
lization did not result in a significantly greater
number of days that patients were alive and out
of the hospital compared to the usual level of mobi-
lization in the ICU among mechanically ventilated
&&
patients [48 ]. However, due to the high frequency
of early mobilization in the usual care group, it is
reasonable to conclude that the TEAM trial actually
assessed different ’doses’ of early mobilization rather
than compared the realization of early mobilization
or not. The small difference found in the mean
duration of active mobilization per day between
the two study groups (12 min) might explain the
lack of impact on clinical outcomes. The random-
ized clinical trial of Patel and colleagues showed a
significant reduction of cognitive impairment at
1 year with early mobilization in comparison to
usual care (24% vs. 43%) among mechanically ven-
&&
tilated critically ill patients [49 ]. At one year, the
early mobilization group also had fewer ICU-
acquired weaknesses, and higher physical compo-
nent scores on quality-of-life testing than did the
usual care group.
Family presence
Extended family presence in the ICU has been asso-
ciated with less anxiety and delirium during ICU
stay in patients [50], and lower occurrence of symp-
toms of anxiety and depression among family mem-
bers [51]. Although these manifestations are
probably in the causal pathway for long-term men-
tal-health disability and cognitive impairment,
studies assessing the association between flexible
family visitation models and long-term outcomes
are scarce. A recent retrospective cohort with 14 344
patients in Canada, found that in-person family
visitation in the ICU was associated with a lower
risk of received a diagnosis of any incident psychi-
atric disorder within 1 year after discharge (risk ratio,
&
0.79) [52 ].
ENHANCING RECOVERY
Long-term disabilities among survivors of critical
care are typically underdiagnosed and long-lasting.
In such context, screening patients with disabilities
following a critical care (Table 1) and providing a
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patient- and family-centered process of rehabilita-
tion across different rehabilitation settings (e.g.,
ICU, ward and home) is essential. Accordingly,
the Surviving Sepsis Campaign guideline has sug-
gested implementing screening, discharge plans and
posthospital follow-ups for survivors of sepsis,
although most of these recommendations are best
practice statements or have a weak level of evidence
[5]. For patients at high risk for long-term disabil-
ities, characterized as survivors with one or more
potential risk factors, the Society of Critical Care
Medicine task force recommends serial assessments
starting within 2–4 weeks of hospital discharge to
identify and manage impairments after critical ill-
ness. These assessments can utilize screening tools
such as the Montreal Cognitive Assessment for cog-
nitive dysfunction, Hospital Anxiety and Depres-
sion Scale for anxiety and depression symptoms,
Impact of Event Scale-Revised for posttraumatic
stress symptoms, 6-min walk test for physical func-
tion, and the EuroQol-5D-5L for health-related qual-
ity of life [53]. Multicomponent interventions
aimed to optimize recovery after critical illness have
been associated with improved outcomes. In a
recent randomized clinical trial with 691 survivors
of sepsis, a 30-day multicomponent intervention
using a navigator to provide best practices for post-
sepsis care (postdischarge medication review, evalu-
ation for new impairments or symptoms, monitoring
comorbidities, and palliative care approach when
appropriate) resulted in a significant reduction com-
posite of mortality or hospital readmission at 30 days
&&
(OR, 0.80) [54 ]. Given the interdisciplinary nature
of these interventions, it is conceivable that team-
based approaches, incorporating multidisciplinary
rounds and checklist utilization before hospital
discharge, could improve adherence [55]. Other
potential intervention is the posthospital discharge
follow-up, which can be conducted by either the
multidisciplinary ICU team or a non-ICU team with
specialized training. A systematic review analyzing
post-ICU follow-up effects, the pooled analysis of
randomized clinical trials showed improvement of
depression symptoms and mental health-related
quality of life in the short term for models focusing
on physical therapy and posttraumatic stress symp-
toms in the medium term for models focusing on
psychological or medical management interventions
[56]. In the context of post-ICU discharge, the clini-
cian should be aware that, besides new impairments,
infections, exacerbation of comorbidities and medi-
cation toxicity might contribute to deterioration of
health in the months after hospital discharge.
Equally important is effective communication to
ensure an appropriate patient transition across differ-
ent levels of healthcare [5]. This strategy can
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 Acute neurological problems

Table 1. Screening patients at high-risk for long-term physical, cognitive, mental health disabilities after critical illness
Disability Premorbid health
domain status risk factors Critical illness risk factors Clinical picture Suggested screening tools

Physical
Preexisting functional
High illness severity
Reduction of physical functional
6-min walking test or
disability, frailty, and
Multiple organ dysfunctions capacity Barthel index for physical
cognitive impairment
Prolonged use of sedatives,
Fatigue functional status

Comorbidities neuromuscular blocking agents
Musculoskeletal complaints (e.g.,
Functional oral intake scale
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and corticosteroids joint stiffness, joint pain, muscle (FOIS) and/or eating

Invasive mechanical ventilation pain) assessment tool-10 (EAT-10)
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need
Respiratory symptoms (e.g., for dysphagia

ICU-acquired weakness
Cognition
Advanced age
Incidence and duration of

Preexisting cognitive delirium
dysfunction
Profound or prolonged sedation

Low cognitive reserve (specially with benzodiazepines)

Sepsis

Shock

Hypoxia

Cardiac arrest

Need for life support (e.g.,
invasive mechanical ventilation
or dialysis)
Mental health
Younger age,
Prolonged or profound sedation

Low education
Memories of frightening

Low resilience experiences in ICU

Preexisting mental
Absence of family visits
health disorders
Relevant decrease in physical
(e.g., anxiety or functional status in comparison
depression) to the pre-ICU period
shortness of breath)

Symptoms of dysphagia
(coughing or choking when
eating or drinking, bringing
food back up, a sensation that
food is stuck in throat or chest,
persistent drooling of saliva)

Cognitive complaints such as
Montreal cognitive
memory loss, brain fog, and assessment (MoCA)
difficulties with attention and
execution of tasks

Symptoms of anxiety (e.g.,
Hospital anxiety and
excessive anxiety and worry, depression scale (HADS)
difficulty controlling the for anxiety and depression
worrying, restlessness or feeling symptoms
keyed up or on edge, irritability,
Impact event scale revised
muscle tension, palpitations) (IES-R) or the abbreviated

Symptoms of depression (e.g., Impact event scale-6 (IES-6)
depressed mood, loss of
interest/pleasure, insomnia or
hypersomnia, fatigue, feeling
worthless)

Symptoms of posttraumatic stress
(e.g., unwanted upsetting
memories from the critical illness
period, nightmares, flashbacks,
emotional distress after exposure
to traumatic reminders, physical
reactivity after exposure to
traumatic reminders)

synergize with available resources, such as the care
provided by general practitioners and community
caregivers, contributing to improved long-term
outcomes.
CONCLUSION
The multifaceted challenges faced by survivors of
critical care underscore the critical need for a com-
prehensive approach to their care. The extensive
burden of physical, cognitive, and mental health
impairments post-ICU discharge, along with their
increased vulnerability to adverse outcomes, includ-
ing infections, cardiovascular events, rehospitaliza-
tions, and mortality cannot be overlooked. A
proactive strategy involving sedation limitation,
delirium prevention, early mobilization, and family
presence during critical illness management holds
promise in mitigating long-term disabilities. Equally
important is the identification of patients at height-
ened risk for these disabilities, enabling interven-
tions aimed to improve quality of life. Furthermore,
a well structured transition program, followed by
posthospitalization follow-up focusing on rehabil-
itation and support, can contribute significantly to
improve outcomes for these survivors.
Acknowledgements
None.
Financial support and sponsorship
None.

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 Anticipating ICU discharge and long-term follow-up Rosa et al.
Conflicts of interest
R.G.R. and C.T. have received research grants from the
Brazilian Ministry of Health for conducting studies on
long-term outcomes of critical care survivor. S.P. and A.
M. have nothing to disclose.
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www.co-criticalcare.com 163
 Acute neurological problems
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Downloaded from http://journals.lww.com/co-criticalcare by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XM
This randomized clinical trial compared increased early mobilization (sedation
i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/27/2024
minimization and daily physiotherapy) with usual care (the level of mobilization
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outcome) was significantly lower in the intervention group (24% vs. 43%,
P ¼ 0.004).
164 www.co-criticalcare.com
Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.
At one year, the intervention group had fewer ICU-acquired weaknesses, and
higher physical component scores on quality-of-life testing than did the usual care
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composite of mortality or hospital readmission at 30 days (odd ratio, 0.80).
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evaluation for new impairments or symptoms, monitoring comorbidities, and
palliative care approach when appropriate.
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Volume 30
Number 2
April 2024