so you’ve been asked to see a recovering covid patient in
TRANSCRIPT
So You’ve Been Asked to See a Recovering COVID Patient in Clinic: What Do You Do?
Carla M. Sevin, MD, FCCMDirector, The ICU Recovery Center at Vanderbilt
Nashville, Tennessee
@ICU_Recovery
The Why
Iwashyna 2011 JAGS
Survival is not the end-point for patients and families
Post-Intensive Care Syndrome (PICS)
Needham et al. Crit Care Med 2012Adapted with permission from Hallie Prescott
Stressed Families DepressionAnxietyPTSD
Cognitive ImpairmentsExecutive Function
Mental Processing SpeedVisuo‐spatialMemoryAttention
Physical ImpairmentsMuscle Weakness and Loss
NeuropathiesPulmonary Function
Mental HealthDepressionAnxietyPTSD
High Burden of Chronic Health Conditions
Kamdar et al AJCC 2017
How is recovery different in COVID-19?Now add:
Increased sedationIncreased use of benzodiazepinesIncreased time on vent
mobilityfamily visitationresources and staff
Physical sequelae 6MWT
Battle et al J Crit Care 2018
Alopecia Onychomadesis
Shoulder Impairment
Gustafson et al Crit Care Med 2018
ROM
Global Cognition Scores in Survivors
Pandharipande et al NEJM 2013
MoCA
https://www.mocatest.org/remote‐moca‐testing/
Delirium is the strongest independent predictor of cognitive impairment
0 2 4 6 8 10
70
60
80
90
N=382
P=0.004 for 0 vs. 5 days of delirium
RBANS Global
Cognitive Score
Days of ICU DeliriumPandharipande et al. NEJM 2013
CAM
PTSD after critical illness
• Meta-analysis: – PTSD symptoms in 1/5– More likely in those with
• comorbid psychopathology• benzodiazepines • early memories of frightening
ICU experiences
Parker et al CCM 2015Art by Nancy Andrews
PCL‐5IES‐6HADS
Unroe et al Ann Int Med 2010
Models of post ICU care
The Vanderbilt ModelSELECTION CRITERIA:• Mechanical ventilation• Shock• Delirium
TEAM:• Respiratory therapy• Pharmacy• Critical Care• Psychology• Case management
An Interdisciplinary ICU Recovery ClinicPatient check in Patient check in
Spirometry (RT)Spirometry (RT)
Patient in exam room
Patient in exam room
Vital signs checked (LPN)
Vital signs checked (LPN) 6MWT6MWT
Patient back in exam room
Patient back in exam room
Med reconciliation (pharmacist)
Med reconciliation (pharmacist)
Medical history and exam (NP)Medical history and exam (NP)
Neuropsych evaluation Neuropsych evaluation
Case management evaluation
Case management evaluation
Assessment and plan discussed with patient
Assessment and plan discussed with patient
Patient and family feedback
Patient and family feedback
Updated med list and plan (checkout)
Updated med list and plan (checkout)
Team conferenceTeam conference
Report for primary provider prepared
and sent
Report for primary provider prepared
and sent
Data recordedData recorded
Minimum criterion
Sevin and Jackson Crit Care Med 2019
Components of an ICU recovery program
McPeake et al April 2020
TelemedicineAdvantages
• Reach patients at critical time points
• Start up costs are low• Can pull in multidisciplinary
team members from afar• See family, home environment• ”Screen and triage”
Disadvantages• Limited objective data
gathering, physical exam, and treatments
• Still some regulatory hurdles despite COVID
Interview tips• Diagnostic: Ask very specific questions, and listen to the answers
– Patient may not want to know the answer– You may not know how to deal with the answer*
• Therapeutic: Normalize recovery problems
*This is ok. If you don’t seek you will not find.
Content: Iwashyna, Johnson, McPeake, McSparron, Prescott, SevinGraphics: Chelsea Harris @CAHarrisMD
https://litfl.com/the‐dirty‐dozen‐common‐errors‐on‐discharging‐patients‐recovering‐from‐critical‐illness/
Serial assessments
Adapted from “Timing It Right” Framework:Cameron and Gignac 2008
Anticipatory guidance
Education
Discharge planning Post ICU Clinic
Telehealth? Peer support
Weeks Months Years?
Haines et al ICM 2019
ICU Recovery Programs
Peer support
Clinic
Both
https://www.sccm.org/MyICUCare/THRIVE/Connect‐With‐Patients‐and‐Families
Vanderbilt ICU Recovery@ICU_Recovery
@CAIROrg