Post-intensive care outpatient clinic: is it feasible and effective? A literature review

Teixeira, Cassiano; Rosa, Regis Goulart

doi:10.5935/0103-507X.20180016

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REVIEW ARTICLES • Rev. bras. ter. intensiva 30 (1) • Mar 2018 • https://doi.org/10.5935/0103-507X.20180016 linkcopy

Post-intensive care outpatient clinic: is it feasible and effective? A literature review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

The follow-up of patients who are discharged from intensive care units follows distinct flows in different parts of the world. Outpatient clinics or post-intensive care clinics represent one of the forms of follow-up, with more than 20 years of experience in some countries. Qualitative studies that followed up patients in these outpatient clinics suggest more encouraging results than quantitative studies, demonstrating improvements in intermediate outcomes, such as patient and family satisfaction. More important results, such as mortality and improvement in the quality of life of patients and their families, have not yet been demonstrated. In addition, which patients should be indicated for these outpatient clinics? How long should they be followed up? Can we expect an improvement of clinical outcomes in these followed-up patients? Are outpatient clinics cost-effective? These are only some of the questions that arise from this form of follow-up of the survivors of intensive care units. This article aims to review all aspects relating to the organization and performance of post-intensive care outpatient clinics and to provide an overview of studies that evaluated clinical outcomes related to this practice.

Keywords:
Intensive care units; Patient discharge; Quality of health care; Ambulatory care

Goals	For patients	For family members and caregivers	For the ICU team
Diagnosis	Recognition of chronic diseases prior to ICU admission	Recognition of psychological changes acquired during the patient's stay in the ICU	Identification of physical and psychological sequelae of post-ICU discharge patients
	Recognition of chronic diseases acquired during ICU admission	Recognition of psychological changes acquired after the patient's stay in the ICU	Recognition of actions taken during ICU hospitalization that may have led to physical or psychological sequelae in patients and relatives
Counseling	Promotion of medication reconciliation	Guidance on psychological conditions related to patient care	Assistance from the ICU team in the understanding of post-ICU discharge sequelae
	Guidance on the prognosis of diseases acquired during ICU admission	Elucidation of doubts regarding the patient's stay in the ICU	Promotion of team well-being (reduction of burnout) by the recognition of their work by patients and their families
	Promotion of visits to the ICU to recall positive and negative passages that occurred during ICU admission		Promotion of meetings with patients and/or family members presenting "positive feedback" of patients and their family members regarding their stay in the ICU
	Elucidation of doubts regarding ICU admission
	Promotion of better management of financial resources related to chronic conditions of patients in the health network
Treatment	Meeting the functional rehabilitation needs of patients
	Meeting the psychological rehabilitation needs of patients

Study	County	Participant (n)	Clinical Staff	Inclusion criteria	Study type	Time of consultation (after ICU discharge)	Intervention or evaluation	Outcome or conclusion
Griffiths et al.⁽²⁰⁾	United Kingdom	127	N/R	≥ 3 days of ICU	Observational	3, 6, and 12 months	Regular outpatient clinic for survivors of the ICU with application of specific questionnaires	43.7% reported symptoms of sexual dysfunction and there was relationship to PTS symptoms
Modrykamien et al.⁽²⁶⁾	U.S.A.	N/R	N/R	N/R	Descriptive	N/R	Clinical follow-up and referral	N/R
Schmidt et al.⁽³¹⁾*	Germany	291 CG: 141 IG: 148	Nurse	Sepsis and septic shock	RCT	6 months	CG: primary care physicians IG: 12 months of regular contact with patients, reference to specialists, prescription of medications or other interventions. The intervention also consisted of training of primary care physicians and patients, management of cases provided by trained nurses, and clinical decision support (through specialists) for primary care physicians	There was no difference in the main outcome of the study, which was the change in quality of life related to mental health between discharge from the ICU and 6 months after discharge from the ICU, measured by the SF-36 Mental Component
Cuthberston et al.⁽³⁴⁾*	Scotland	286 CG: 143 IG: 143	Doctor and nurse	Patients discharged from the ICU	Non-randomized CT	3 and 9 months	IG: self-monitored physical rehabilitation program started before hospital discharge, clinical evaluation by the nurse at 3, 9, and 12 months, discussion of ICU experiences, ICU visit, medication review, reference based on HADS score, cost analysis	192 patients completed 1-year follow-up There were no differences between the two groups regarding quality of life (EQ-5D), incidence of PTSD (Davidson Trauma Scale), depression and anxiety (HADS)
Lasiter et al.⁽³⁵⁾*	U.S.A.	53	N/R	≥ 48 hours of MV or ≥ 48 hours of delirium	Descriptive	3 months	Evaluation by the interdisciplinary team (intensive care physician, nurse, social worker) and the creation of a personalized care plan, including cognitive exercises, self-management training manuals, pharmacological and non-pharmacological prescriptions, and proactive referrals to community resources, neuropsychologists, and physical rehabilitation services	Physical: patients who participated in 3 visits showed better physical performance in the 6-minute Walk Test and better leg strength over time Psychological: there were improvements in scores on anxiety, depression, and PTS scores
Jones et al.⁽³⁶⁾*	United Kingdom	126	N/R	≥ 48 hours of ICU and patients in MV	RCT	8 weeks and 6 months	CG: received in-room visits, 3 home phone calls, and clinical consultations at 8 weeks and 6 months IG: received the same as the control group + 6-week self-help rehabilitation manual	There was improvement of the physical function (SF-36) in the intervention group, but the effect of the treatment may be related to the rehabilitation intervention, and not to the outpatient procedure per se
Engstrom et al.⁽³⁹⁾	Sweden	9	Doctor and nurse	≥ 3 days of ICU and ≥ 24 hours of MV		6 months	Visit to ICU + debriefing about ICU stay + ICU diary review	The thematic analysis of these interviews revealed four fundamental roles of the post-ICU clinic: - ICU staff and family members reported that "they are given the strength to return together" - Patients found that experience allowed "to give meaning to the experience of critical illness" - Patients "felt grateful to have survived," and both survivors and family members appreciated the opportunity to meet with the ICU staff - Patients and family members viewed the visits as an "opportunity to improve care" and to return to the give a feedback to the ICU about their positive and negative experiences
Knowles et al.⁽³⁷⁾*	United Kingdom	36CG: 18 IG: 18	Nurse	≥ 48 hours of ICU	Pragmatic RCT	2 months	IG: access to a prospective ICU diary kept by ICU nurses about events, treatments, procedures, and monitored conditions together with a verbal feedback from an ICU nurse in the psychological well-being, compared to a control condition without treatment	Prospective diaries designed to help patients understand what happened to them in the ICU significantly decreased anxiety and depression rates at the assessment performed 2 months after discharge from the ICU
Jones et al.⁽³⁸⁾*	Europe	352 CG: 175 IG: 177	N/R	≥ 72 hours of ICU and ≥ 24 hours of MV	RCT	3 months	IG: patients received their prospective ICU diary in the first month after discharge from the ICU. A final evaluation of the development of acute PTSD was made during the 3-month period	The incidence of acute PTSD was significantly reduced in IG, especially in patients with higher scores
Crocker⁽⁴⁰⁾	United Kingdom	6	Physician, nurse, physical therapist, and occupational therapist	≥ 4 days of ICU	Description of cases	2, 6, and 12 months	Visit to ICU + referral to specialist = drug reconciliation + physical therapy and occupational therapy assistance	Description of the experience of a multidisciplinary clinic
Hall-Smith et al.⁽⁴¹⁾	United Kingdom	26	Nurse	≥ 5 days of ICU	Unstructured interviews conducted by clients	Room, 2, and 6 months	Clinical interview	Description of the neuropsychological and physical findings of patients
Granja et al.⁽⁴²⁾	Portugal	29	N/R	ARDS	Paired prospective cohort (patients without ARDS)	6 months	Evaluation in the post-ICU outpatient clinic	The quality of life of patients with ARDS was similar to that of other critically ill patients
Fletcher et al.⁽⁴³⁾	United Kingdom	22	N/R	≥ 28 days of ICU	Prospective Cohort	N/R	After consultation with a general practitioner, all patients were invited to follow-up with the post-ICU outpatient clinic	Evaluation of the incidence of muscular weakness through electromyography
Kvale et al.⁽⁴⁴⁾	Norway	346	Physicians	≥ 24 hours of ICU	Prospective Cohort	7 - 8 months	Respond to a survey in the ICU post-discharge and refer to an expert	Reduction of the quality of life (SF-36) in most patients
Flatten⁽⁴⁵⁾	Norway	N/R	N/R	N/R	Editorial and descriptive population statistics	N/R	Regular outpatient clinic for ICU survivors
Sukantarat et al.⁽⁴⁶⁾	United Kingdom	51	N/R	≥ 3 days of ICU	Prospective, descriptive and correlational	3 and 9 months	Patients were recruited at a follow-up clinic at 3 and 9 months. No report on the clinic was included. The psychologist discussed the results of the research	45 patients completed the study Large proportion of patients with symptoms of anxiety, depression, and PTS
Holmes et al.⁽⁴⁷⁾	Australia	90 CG: 39 IG: 51	Physician	Polytrauma with ≥ 24 hours of MV	RCT	3 and 6 months	CG: Interpersonal counseling with trained psychiatrist	77 patients completed the study The intervention was not effective to reduce psychiatric morbidity after a physical trauma, which can increase morbidity in vulnerable individuals
Douglas et al.⁽⁴⁸⁾	U.S.A.	335 CG: 103 IG: 231	Nurse	≥ 3 days of MV	Near-experiment	2 months	Intervention centered on case management and interdisciplinary communication	247 patients completed the study There was no difference in patients' quality of life (SF-8)
Samuelson et al.⁽⁴⁹⁾*	Sweden	170	Nurse	≥ 48 hours of ICU	Descriptive and evaluative	2 - 3 months	Visits in the ward (1-3 days after discharge from the ICU) + information flyer to patient + offer of a nurse telephone number for post-service + follow-up letter to provide information and offer a follow-up visit 2 - 3 months after discharge from ICU Patients' diaries with photographs were delivered. Long-term health rehabilitation counseling was provided, including identifying existing problems. A visit to the ICU, if they wished.	82% of factual and delusional ICU memories 51% remembered the visit of the post-care ward 60% remembered the information pamphlet. Those who remembered evaluated the experience of the ward visit between 9.3 and 9.7 (out of 10). The 2-month follow-up visit achieved a median score by patients and family members Some patients described in detail how information, explanations, and support enabled them to complete the puzzle of ICU stay and helped them move forward
Schandl et al.⁽⁵⁰⁾*	Sweden	61	Physical therapist, pain clinician, and psychiatrist	≥ 4 days of ICU	Descriptive	3, 6, and 12 months	Visit to the ward + ICU diary + offer of follow-up at the clinic at 3, 6, and 12 months after discharge from the ICU	Multidisciplinary follow-up was able to identify untreated physical and psychological problems
Glimelius Peterson et al.⁽⁵¹⁾	Sweden	96	Physician and nurse	≥72 h of ICU	Exploratory	Immediate discharge, 2 and 6 months	In-room and clinic visit + outpatient or telephone follow-up	Reported as important by patients to elucidate doubts
Dettling-Ihnenfeldt et al.⁽⁵²⁾	Netherlands	65	N/R	≥ 48 hours of VM	Prospective cohort	3 months	Comparison of 2 post-ICU outpatient clinics models (evaluation by SF-36 and HADS)	Most patients had significant functional restrictions
Jensen et al.⁽⁵³⁾*	Denmark	386 CG: 196 IG: 190	Nurse	≥ 48 hours of MV	RCT	1 - 3, 5, and 10 months	IG: recovery program based on theoretical approaches to psychological recovery, including Antonovsky's salutogenic model, disease narratives, person-centered communication, elements of guided self-determination, and cognitive-behavioral therapy focused on trauma	There was no difference in quality of life, risk of anxiety and depression, and sense of coherence
Daffurn et al.⁽⁵⁴⁾	Australia	54	Physician and nurse	≥ 48 hours of ICU	Prospective cohort	3 months	Semi-structured interview + clinical examination + ICU visit + referral to medical specialists or other health professional	Patients presented mild-moderate physical and psychosocial sequelae, but these symptoms did not impede their activities of daily living
Waldmann⁽⁵⁵⁾	United Kingdom	N/R	Physician and nurse	≥ 4 days of ICU	Theoretical with descriptive statistics	2, 6, and 12 months	ICU visit + specialist referral + tracheostomy management + pulmonary function tests	N/R
Eddleston et al.⁽⁵⁶⁾	United Kingdom	143	N/R	Patients discharged from the ICU	Prospective cohort	3 months	Visit the clinic in the third month for evaluation	Description of the findings referring to patients' quality of life
Sharland⁽⁵⁷⁾	United Kingdom	N/R	N/R	≥ 4 days of ICU or referenced by ICU staff	N/R	2, 6, and 12 months	ICU visit + interview + information on rehabilitation + reference to specialists	N/R
Cutler et al.⁽⁵⁸⁾	United Kingdom	N/R	Nurse	≥ 5 days of ICU	N/R	6 months	ICU Visit after discharge	N/R
Combe⁽⁵⁹⁾*	United Kingdom	35	N/R	≥ 4 days of ICU	Prospective cohort	2, 6, and 12 months	Patients received their ICU diary at the first consultation (2 months) at the clinic with a later informal meeting	There was a better understanding of ICU events by the patients and improved communication with their family members
Jones et al.⁽⁶⁰⁾*	United Kingdom	39	Nurse	Patients discharged from the ICU	Prospective audit	N/R	Nursing counseling	Patients required fewer counseling sessions. There was no difference in psychological outcome profiles

Estimated outcome	Result
PTSD	Reduction of the risk of PTSD (0.49, 95% CI: 0.26-0.95) in 3-6 months after discharge from the ICU⁽³⁶⁾ Improvement in PTSD scores in the third month after discharge from the ICU⁽³⁵⁾ Reduction of acute PTSD in the third month of evaluation after discharge from the ICU⁽³⁸⁾
Cognitive decline	-----
Anxiety	Improvement in anxiety scores in the third month after discharge from the ICU⁽³⁵⁾ Reduction of anxiety symptoms assessed 2 months after discharge from the ICU⁽³⁷⁾
Depression	Improvement in depression scores in the third month after discharge from the ICU⁽³⁵⁾ Reduction of symptoms of depression assessed 2 months after discharge from the ICU(37)
Sexual disturbance	-----
Functionality/ADL	Better performance in the WT-6 evaluated in the third month after discharge from the ICU⁽³⁵⁾ Improvement of physical function assessed by the SF-36 in 2-6 months after discharge from the ICU⁽³⁶⁾
Hospital readmission	-----
Post-ICU mortality	-----

Post-ICU Stages	Who evaluates?	Who is evaluated?	How?	When?
Immediate post-discharge	Intensivist nurse	Patients requiring ICU ≥ 3 days	Face-to-face assessment of the degree of dependence (e.g., Barthel's Modified Scale)	During the first week after discharge from the ICU (still in the hospital)
Screening	Intensivist nurse	Patients assessed in the immediate post-discharge	Telephone evaluation on the degree of dependence (e.g., Barthel's Modified Scale) and on anxiety/depression symptoms (e.g., HADS) and PTSD (e.g., IES)	1-2 months after ICU discharge
Outpatient evaluation	Intensivist nurse and intensive care physician	Patients who present alterations in some of the questionnaires performed during screening	Face-to-face assessment of the degree of dependence (e.g., Barthel's Modified Scale) and cognition (e.g., MEEM)	3 months after discharge from ICU
Telephone evaluation	Intensivist nurse	Patients who were in the outpatient clinic consultation	Telephone assessment on the degree of dependence (e.g., Barthel's Modified Scale) and on anxiety/depression symptoms (e.g., HADS) and PTSD (e.g., IES)	12 months after discharge from ICU

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[TFN7] ICU - intensive care unit.