Understanding and Managing Anxiety Sensitivity During Critical Illness and Long-Term Recovery.

Anxiety sensitivity is a fear of symptoms associated with anxiety (eg, rapid respiration and heart rate, perspiration), also known as "fear of fear." This fear is a misinterpretation of nonthreatening symptoms as threatening across 3 domains: physical ("When my heart rate increases, I'm afraid I may have a heart attack"), social ("If people see me perspire, I fear they will negatively evaluate me"), and cognitive ("When I feel these symptoms, I fear it means I'm going crazy or will lose control and do something dangerous like disconnect my IV"). These thoughts stimulate the sympathetic nervous system, resulting in stronger sensations and further catastrophic misinterpretations, which may spiral into a panic attack. Strategies to address anxiety sensitivity include pharmacologic and nonpharmacologic interventions. In intensive care unit settings, anxiety sensitivity may be related to common monitoring and interventional procedures (eg, oxygen therapy, repositioning, use of urine collection systems). Anxiety sensitivity can be a barrier to weaning from mechanical ventilation when patients are uncomfortable following instructions to perform awakening or breathing trials. Fortunately, anxiety sensitivity is a malleable trait with evidence-based intervention options. However, few health care providers are aware of this psychological construct and available treatment. This article describes the nature of anxiety sensitivity, its potential impact on intensive care, how to assess and interpret scores from validated instruments such as the Anxiety Sensitivity Index, and treatment approaches across the critical care trajectory, including long-term recovery. Implications for critical care practice and future directions are also addressed.

Palliative Care in Survivors of Critical Illness: A Qualitative Study of Post-Intensive Care Unit Program Clinicians.

Background: Survivors of critical illness experience high rates of serious health-related suffering. The delivery of palliative care may assist in decreasing this burden for survivors and their families. Objectives: To understand beliefs, attitudes, and experiences of post-intensive care unit (ICU) program clinicians regarding palliative care and explore barriers and facilitators to incorporating palliative care into critical illness survivorship care. Design: Qualitative inquiry using semistructured interviews and framework analysis. Results were mapped using the Consolidated Framework for Implementation Research. Setting/Subjects: We interviewed 29 international members (United States, United Kingdom, Canada) of the Critical and Acute Illness Recovery Organization post-ICU clinic collaborative. Results: All interprofessional clinicians described components of palliative care as essential to post-ICU clinic practice, including symptom management, patient/family support, facilitation of goal-concordant care, expectation management and anticipatory guidance, spiritual support, and discussion of future health care wishes and advance care planning. Facilitators promoting palliative care strategies were clinician level, including first-hand experience, perceived value, and a positive attitude regarding palliative care. Clinician-level barriers were reciprocals and included insufficient palliative care knowledge, lack of self-efficacy, and a perceived need to protect ICU survivors from interventions the clinician felt may adversely affect recovery or change the care trajectory. System-level barriers included time constraints, cost, and lack of specialty palliative care services. Conclusion: Palliative care may be an essential element of post-ICU clinic care. Implementation efforts focused on tailoring strategies to improve post-ICU program clinicians' palliative care knowledge and self-efficacy could be a key to enhanced care delivery for survivors of critical illness.

Driving decisions after critical illness: Qualitative analysis of patient-provider reviews during ICU recovery clinic assessments.

BACKGROUND: Driving a vehicle is a functional task requiring a threshold of physical, behavioral and cognitive skills. OBJECTIVE: To report patient-provider evaluations of driving status and driving safety assessments after critical illness. DESIGN: Qualitative secondary analysis of driving-related dialog drawn from a two-arm pilot study evaluating telemedicine delivery of Intensive Care Unit Recovery Clinic assessments. Multidisciplinary providers assessed physical, psychological, and cognitive recovery during one-hour telemedicine ICU-RC assessments. Qualitative secondary analysis of patient-provider dialog specific to driving practices after critical illness. SETTING AND PATIENTS: Multidisciplinary Intensive Care Unit Recovery clinic assessment dialog between 17 patients and their providers during 3-week and/or 12-week follow-up assessments at a tertiary academic medical center in the Southeastern United States. MAIN MEASURES AND KEY RESULTS: Thematic content analysis was performed to describe and classify driving safety discussion, driving status and driving practices after critical illness. Driving-related discussions occurred with 15 of 17 participants and were clinician-initiated. When assessed, driving status varied with participants reporting independent decisions to resume driving, delay driving and cease driving after critical illness. Patient-reported driving practices after critical illness included modifications to limit driving to medical appointments, self-assessments of trip durations, and inclusion of care partners as a safety measure for new onset fatigue while driving. CONCLUSION: We found that patients are largely self-navigating this stage of recovery, making subjective decisions on driving resumption and overall driving status. These results highlight that driving status changes are an often underrecognized yet salient social cost of critical illness. TRIAL REGISTRATION: Clinicaltrials.gov: NCT03926533.

Health system approaches to providing posthospital care for survivors of sepsis and critical illness.

PURPOSE OF REVIEW: In the current review, we highlight developing strategies taken by healthcare systems to improve posthospital outcomes for sepsis and critical illness. RECENT FINDINGS: Multiple studies conducted in the adult population over the last 18 months have advanced current knowledge on postdischarge care after sepsis and critical illness. Effective interventions are complex and multicomponent, targeting the multilevel challenges that survivors face. Health systems can leverage existing care models such as primary care or invest in specialty programs to deliver postdischarge care. Qualitative and implementation science studies provide insights into important contextual factors for program success. Several studies demonstrate successful application of telehealth to improve reach of postdischarge support. Research is beginning to identify subtypes of survivors that may respond to tailored intervention strategies. SUMMARY: Several successful critical illness survivor models of care have been implemented and knowledge about effectiveness, cost, and implementation factors of these strategies is growing. Further innovation is needed in intervention development and evaluation to advance the field.

Return to Driving After Critical Illness.

This cross-sectional study examines the postintensive care syndrome in patients who had vs patients who had not resumed driving 1 month after hospitalization for a critical illness.

Hospital factors that influence ICU admission decision-making: a qualitative study of eight hospitals.

PURPOSE: Some hospitals in the United States (US) use intensive care 20 times more than others. Since intensive care is lifesaving for some but potentially harmful for others, there is a need to understand factors that influence how intensive care unit (ICU) admission decisions are made. METHODS: A qualitative analysis of eight US hospitals was conducted with semi-structured, one-on-one interviews supplemented by site visits and clinical observations. RESULTS: A total of 87 participants (24 nurses, 52 physicians, and 11 other staff) were interviewed, and 40 h were spent observing ICU operations across the eight hospitals. Four hospital-level factors were identified that influenced ICU admission decision-making. First, availability of intermediate care led to reallocation of patients who might otherwise be sent to an ICU. Second, participants stressed the importance of ICU nurse availability as a key modifier of ICU capacity. Patients cared for by experienced general care physicians and nurses were less likely to receive ICU care. Third, smaller or rural hospitals opted for longer emergency department patient-stays over ICU admission to expedite interhospital transfer of critically ill patients. Fourth, lack of clarity in ICU admission policies led clinicians to feel pressured to use ICU care for patients who might otherwise not have received it. CONCLUSION: Health care systems should evaluate their use of ICU care and establish institutional patterns that ensure ICU admission decisions are patient-centered but also account for resources and constraints particular to each hospital.

Examining the needs of survivors of critical illness through the lens of palliative care: A qualitative study of survivor experiences.

OBJECTIVE: To examine the needs of adult survivors of critical illness through a lens of palliative care. RESEARCH METHODOLOGY: A qualitative study of adult survivors of critical illness using semi-structured interviews and framework analysis. SETTING: Participants were recruited from the post-intensive care unit clinic of a mid-Atlantic academic medical center in the United States. FINDINGS: Seventeen survivors of critical illness aged 34-80 (median, 66) participated in the study. The majority of patients were female (64.7 %, n = 11) with a median length of index ICU stay of 12 days (interquartile range [IQR] 8-19). Interviews were conducted February to March 2021 and occurred a median of 20 months following the index intensive care stay (range, 13-33 months). We identified six key themes which align with palliative care principles: 1) persistent symptom burden; 2) critical illness as a life-altering experience; 3) spiritual changes and significance; 4) interpreting/managing the survivor experience; 5) feelings of loss and burden; and 6) social support needs. CONCLUSION: Our findings suggest that palliative care components such as symptom management, goals of care discussions, care coordination, and spiritual and social support may assist in the assessment and treatment of survivors of critical illness.

Multidisciplinary ICU Recovery Clinic Visits: A Qualitative Analysis of Patient-Provider Dialogues.

BACKGROUND: Research confirms the heterogeneous nature of patient challenges during recovery from the ICU and supports the need for modifying care experiences, but few data are available to guide clinicians seeking to support patients' individual recovery trajectories. RESEARCH QUESTION: What is the content of patient-provider dialogues in a telemedicine multidisciplinary ICU recovery clinic (ICU-RC)? STUDY DESIGN AND METHODS: We conducted a qualitative descriptive study in a telemedicine multidisciplinary ICU-RC at a tertiary academic medical center in the southeastern United States. The sample included 19 patients and 13 caregivers (≥ 18 years of age) attending a telemedicine ICU-RC visit after critical illness resulting from septic shock or ARDS. Patients and caregivers met with an ICU pharmacist, ICU physician, and a psychologist via a secure web-conferencing platform for 33 ICU-RC visits within 12 weeks of hospital discharge. Telemedicine ICU-RC visits were audio-recorded and transcribed verbatim for analysis. A coding system was developed using iterative inductive and deductive approaches. RESULTS: Two themes were identified from the patient-provider dialogue: (1) problem identification and (2) problem-solving strategies. We identified five subthemes that capture the types of problems identified: health status, mental health and cognition, medication management, health-care access and navigation, and quality of life. Problem-solving subthemes included facilitating care coordination and transitions, providing education, and giving constructive feedback and guidance. INTERPRETATION: Patients surviving a critical illness experience a complexity of problems that may be addressed best by a multidisciplinary ICU-RC. Through analysis of our telemedicine ICU-RC dialogues, we were able to identify problems and solutions to address challenges during a critical transitional phase of ICU recovery. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03926533; URL: www. CLINICALTRIALS: gov.

A Learning Health System Approach to Long COVID Care.

Background: Global initiatives to mitigate COVID-19 transmission have shifted health system priorities to management of patients with prolonged long COVID symptoms. To better meet the needs of patients, clinicians, and systems, a learning health system approach can use rapid-cycle methods to integrate data and real-world experience to iteratively evaluate and adapt models of long COVID care. Observations: Employees in the Veterans Health Administration formed a multidisciplinary workgroup. We sought to develop processes to learn more about this novel long COVID syndrome and innovative long COVID care models that can be applied within and outside of our health care system. We describe our workgroup processes and goals to create a mechanism for cross-facility communication, identify gaps in care and research, and cocreate knowledge on best practices for long COVID care delivery. Conclusions: The learning health system approach will be critical in reimagining health care service delivery after the COVID-19 pandemic.

Patient and Caregiver-Derived Health Service Improvements for Better Critical Care Recovery.

OBJECTIVES: To engage critical care end-users (survivors and caregivers) to describe their emotions and experiences across their recovery trajectory, and elicit their ideas and solutions for health service improvements to improve the ICU recovery experience. DESIGN: End-user engagement as part of a qualitative design using the Framework Analysis method. SETTING: The Society of Critical Care Medicine's THRIVE international collaborative sites (follow-up clinics and peer support groups). SUBJECTS: Patients and caregivers following critical illness and identified through the collaboratives. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eighty-six interviews were conducted. The following themes were identified: 1) Emotions and experiences of patients-"Loss of former self; Experiences of disability and adaptation"; 2) Emotions and experiences of caregivers-"Emotional impacts, adopting new roles, and caregiver burden; Influence of gender roles; Adaptation, adjustment, recalibration"; and 3) Patient and caregiver-generated solutions to improve recovery across the arc of care-"Family-targeted education; Expectation management; Rehabilitation for patients and caregivers; Peer support groups; Reconnecting with ICU post-discharge; Access to community-based supports post-discharge; Psychological support; Education of issues of ICU survivorship for health professionals; Support across recovery trajectory." Themes were mapped to a previously published recovery framework (Timing It Right) that captures patient and caregiver experiences and their support needs across the phases of care from the event/diagnosis to adaptation post-discharge home. CONCLUSIONS: Patients and caregivers reported a range of emotions and experiences across the recovery trajectory from ICU to home. Through end-user engagement strategies many potential solutions were identified that could be implemented by health services and tested to support the delivery of higher-quality care for ICU survivors and their caregivers that extend from tertiary to primary care settings.

Meeting the Challenges of Establishing Intensive Care Unit Follow-up Clinics.

Intensive care unit follow-up clinics are becoming an increasingly widespread intervention to facilitate the physical, cognitive, psychiatric, and social rehabilitation of survivors of critical illness who have post-intensive care syndrome. Developing and sustaining intensive care unit follow-up clinics can pose significant challenges, and clinics need to be tailored to the physical, personnel, and financial resources available at a given institution. Although no standard recipe guarantees a successful intensive care unit aftercare program, emerging clinics will need to address a common set of hurdles, including securing an adequate space; assembling an invested, multidisciplinary staff; procuring the necessary financial, information technology, and physical stuff; using the proper screening tools to identify patients most likely to benefit and to accurately identify disabilities during the visit; and selling it to colleagues, hospital administrators, and the community at large.

Evolution in Care Delivery within Critical Illness Recovery Programs during the COVID-19 Pandemic: A Qualitative Study.

Rationale: There are limited data on the impact of the coronavirus disease (COVID-19) pandemic on intensive care unit (ICU) recovery clinic care delivery practices. Objectives: We sought to better understand the patient-level factors affecting ICU recovery clinic care and changing clinical thinking during the COVID-19 pandemic. We also sought to understand how the COVID-19 pandemic sparked innovation within ICU recovery clinics. Methods: A multicenter qualitative study was conducted with ICU recovery clinic interprofessional clinicians involved with the Critical and Acute Illness Recovery Organization (CAIRO) between February and March 2021. Data were collected using semistructured interviews and were analyzed using thematic analysis. Key themes were organized in a working analytical framework. Results: Twenty-nine participants from 15 international sites participated in the study. Participants identified three patient-level key themes that influenced care delivery in ICU recovery programs: 1) social isolation, 2) decreased emotional reserve in patients and families, and 3) substantial social care needs. Changes in ICU recovery clinic care delivery occurred at both the clinician level (e.g., growing awareness of healthcare disparities and inequities, recognition of financial effects of illness, refinement of communication skills, increased focus on reconstructing the illness narrative) and the practice level (e.g., expansion of care delivery modes, efforts to integrate social care) in response to each of the patient-level themes. Identified gaps in ICU recovery clinic care delivery during the COVID-19 pandemic included a need for multidisciplinary team members, access to care issues (e.g., digital poverty, health insurance coverage, language barriers), and altered family engagement. Conclusions: This study demonstrates that addressing patient-level factors such as efforts to integrate social care, address financial needs, refine provider communication skills (e.g., empathic listening), and enhance focus on reconstructing the illness narrative became important priorities during the ICU recovery clinic visit during the COVID-19 pandemic. We also identified several ongoing gaps in ICU recovery clinic care delivery that highlight the need for interventions focused on the integration of social and clinic services for critical care survivors.

The Prevalence of Spiritual and Social Support Needs and Their Association With Postintensive Care Syndrome Symptoms Among Critical Illness Survivors Seen in a Post-ICU Follow-Up Clinic.

OBJECTIVES: Spiritual and social support may be key facilitators for critical illness recovery and are identified as high priority for research. Understanding the prevalence of spiritual and social support needs in critical illness survivors may guide development of targeted interventions for support, which, in turn, may improve critical illness survivor quality of life. To characterize unmet spiritual and social support needs in critical illness survivors approximately 1 month after hospital discharge and examine the association of these needs with postintensive care syndrome (PICS)-related symptom burden. DESIGN: Retrospective, cross-sectional study. SETTING: University-affiliated hospital in Pittsburgh, PA. PATIENTS: One hundred ninety-six consecutive adult critical illness survivors seen during an initial post-ICU clinic visit from June 2018 to March 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient-reported clinical outcome measures assessing spiritual and social support needs and PICS-related symptoms were extracted from the electronic health record. Patients had a median age of 61 (interquartile range [IQR], 51-68.5), and majority were male (55.1%) with a moderate comorbidity burden (Charlson comorbidity index median score, 3; IQR, 2-5). Social support and spiritual needs were prevalent. Of the 196 patients, over 50% reported unpreparedness/fearful for the future, half of patients reported not feeling in control of their care, and over one-third reported needing more support than their family, friends, or insurance can provide. Nearly 13% of respondents reported feeling abandoned or punished by God/not supported by their church/faith. Many patients reported overlapping PICS-related symptom domains (physical, psychologic, and cognitive). Univariate and multivariate analyses revealed associations between reported PICS-related symptoms and the presence of spiritual and social needs. CONCLUSIONS: Patients surviving critical illness experience significant social support and spiritual needs independent of commonly identified manifestations of PICS. These findings support the need for formal assessment and tailored interventions for social support and spiritual needs in critical illness survivors.

Barriers and facilitators to resuming meaningful daily activities among critical illness survivors in the UK: a qualitative content analysis.

OBJECTIVE: To identify critical illness survivors' perceived barriers and facilitators to resuming performance of meaningful activities when transitioning from hospital to home. DESIGN: Secondary content analysis of semistructured interviews about patients' experiences of intensive care (primary analysis disseminated on the patient-facing website www.healthtalk.org). Two coders characterised patient-perceived barriers and facilitators to resuming meaningful activities. To facilitate clinical application, we mapped the codes onto the Person-Task-Environment model of performance, a patient-centred rehabilitation model that characterises complex interactions among the person, task and environment when performing activities. SETTING: United Kingdom, 2005-2006. PARTICIPANTS: 39 adult critical illness survivors, sampled for variation among demographics and illness experiences. RESULTS: Person-related barriers included negative mood or affect, perceived setbacks; weakness or limited endurance; pain or discomfort; inadequate nutrition or hydration; poor concentration/confusion; disordered sleep/hallucinations/nightmares; mistrust of people or information; and altered appearance. Task-related barriers included miscommunication and managing conflicting priorities. Environment-related barriers included non-supportive health services and policies; challenging social attitudes; incompatible patient-family coping (emotional trauma and physical disability); equipment problems; overstimulation; understimulation; and environmental inaccessibility. Person-related facilitators included motivation or attitude; experiencing progress; and religion or spirituality. Task-related facilitators included communication. Environment-related facilitators included support from family, friends or healthcare providers; supportive health services and policies; equipment; community resources; medications; and accessible housing. Barriers decreased and facilitators increased over time. Six barrier-facilitator domains dominated based on frequency and emphasis across all performance goals: mood/motivation, setbacks/progress, fatiguability/strength; mis/communication; lack/community support; lack/health services and policies. CONCLUSIONS: Critical illness survivors described a comprehensive inventory of 18 barriers and 11 facilitators that align with the Person-Task-Environment model of performance. Six dominant barrier-facilitator domains seem strong targets for impactful interventions. These results verify previous knowledge and offer novel opportunities for optimising patient-centred care and reducing disability after critical illness.

Characteristics of Post-ICU and Post-COVID Recovery Clinics in 29 U.S. Health Systems.

The multifaceted long-term impairments resulting from critical illness and COVID-19 require interdisciplinary management approaches in the recovery phase of illness. Operational insights into the structure and process of recovery clinics (RCs) from heterogeneous health systems are needed. This study describes the structure and process characteristics of existing and newly implemented ICU-RCs and COVID-RCs in a subset of large health systems in the United States. DESIGN: Cross-sectional survey. SETTING: Thirty-nine RCs, representing a combined 156 hospitals within 29 health systems participated. PATIENTS: None. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: RC demographics, referral criteria, and operating characteristics were collected, including measures used to assess physical, psychologic, and cognitive recoveries. Thirty-nine RC surveys were completed (94% response rate). ICU-RC teams included physicians, pharmacists, social workers, physical therapists, and advanced practice providers. Funding sources for ICU-RCs included clinical billing (n = 20, 77%), volunteer staff support (n = 15, 58%), institutional staff/space support (n = 13, 46%), and grant or foundation funding (n = 3, 12%). Forty-six percent of RCs report patient visit durations of 1 hour or longer. ICU-RC teams reported use of validated scales to assess psychologic recovery (93%), physical recovery (89%), and cognitive recovery (86%) more often in standard visits compared with COVID-RC teams (psychologic, 54%; physical, 69%; and cognitive, 46%). CONCLUSIONS: Operating structures of RCs vary, though almost all describe modest capacity and reliance on volunteerism and discretionary institutional support. ICU- and COVID-RCs in the United States employ varied funding sources and endorse different assessment measures during visits to guide care coordination. Common features include integration of ICU clinicians, interdisciplinary approach, and focus on severe critical illness. The heterogeneity in RC structures and processes contributes to future research on the optimal structure and process to achieve the best postintensive care syndrome and postacute sequelae of COVID outcomes.

Transitions of Care After Critical Illness-Challenges to Recovery and Adaptive Problem Solving.

OBJECTIVES: Investigate the challenges experienced by survivors of critical illness and their caregivers across the transitions of care from intensive care to community, and the potential problem-solving strategies used to navigate these challenges. DESIGN: Qualitative design-data generation via interviews and data analysis via the framework analysis method. SETTING: Patients and caregivers from three continents, identified through the Society of Critical Care Medicine's THRIVE international collaborative sites (follow-up clinics and peer support groups). SUBJECTS: Patients and caregivers following critical illness. INTERVENTIONS: Nil. MEASUREMENTS AND MAIN RESULTS: From 86 interviews (66 patients, 20 caregivers), we identified the following major themes: 1) Challenges for patients-interacting with the health system and gaps in care; managing others' expectations of illness and recovery. 2) Challenges for caregivers-health system shortfalls and inadequate communication; lack of support for caregivers. 3) Patient and caregiver-driven problem solving across the transitions of care-personal attributes, resources, and initiative; receiving support and helping others; and acceptance. CONCLUSIONS: Survivors and caregivers experienced a range of challenges across the transitions of care. There were distinct and contrasting themes related to the caregiver experience. Survivors and caregivers used comparable problem-solving strategies to navigate the challenges encountered across the transitions of care.

Benefits of Peer Support for Intensive Care Unit Survivors: Sharing Experiences, Care Debriefing, and Altruism.

BACKGROUND: After critical illness, patients are often left with impairments in physical, social, emotional, and cognitive functioning. Peer support interventions have been implemented internationally to ameliorate these issues. OBJECTIVE: To explore what patients believed to be the key mechanisms of effectiveness of peer support programs implemented during critical care recovery. METHODS: In a secondary analysis of an international qualitative data set, 66 telephone interviews with patients were undertaken across 14 sites in Australia, the United Kingdom, and the United States to understand the effect of peer support during recovery from critical illness. Prevalent themes were documented with framework analysis. RESULTS: Most patients who had been involved in peer support programs reported benefit. Patients described 3 primary mechanisms: (1) sharing experiences, (2) care debriefing, and (3) altruism. CONCLUSION: Peer support is a relatively simple intervention that could be implemented to support patients during recovery from critical illness. However, more research is required into how these programs can be implemented in a safe and sustainable way in clinical practice.

Key Components of ICU Recovery Programs: What Did Patients Report Provided Benefit?

To understand from the perspective of patients who did, and did not attend ICU recovery programs, what were the most important components of successful programs and how should they be organized. DESIGN: International, qualitative study. SETTING: Fourteen hospitals in the United States, United Kingdom, and Australia. PATIENTS: We conducted 66 semi-structured interviews with a diverse group of patients, 52 of whom had used an ICU recovery program and 14 whom had not. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Using content analysis, prevalent themes were documented to understand what improved their outcomes. Contrasting quotes from patients who had not received certain aspects of care were used to identify perceived differential effectiveness. Successful ICU recovery programs had five key components: 1) Continuity of care; 2) Improving symptom status; 3) Normalization and expectation management; 4) Internal and external validation of progress; and 5) Reducing feelings of guilt and helplessness. The delivery of care which achieved these goals was facilitated by early involvement (even before hospital discharge), direct involvement of ICU staff, and a focus on integration across traditional disease, symptom, and social welfare needs. CONCLUSIONS: In this multicenter study, conducted across three continents, patients identified specific and reproducible modes of benefit derived from ICU recovery programs, which could be the target of future intervention refinement.