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CICM 2021 VIRTUAL ASM | RESPIRATORY
CICM 2021 ASM: Respiratory
CICM 2021 VIRTUAL ASM | RESPIRATORY
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Session 3: Life after ventilation

Session Description

SESSION CHAIR: Dr Paul Young
Session Sponsor: GE Healthcare

Session Program

This talk will review the definition, burden, and prognosis of chronic and persistent critical illness. Historically, prolonged ICU stays have been thought of as being synonymous with prolonged mechanical ventilation, which was termed “chronic critical illness”. However, many patients remain stuck in the ICU for reasons other than persistent mechanical ventilation. While some patients have persistent organ failure necessitating ICU care, other patients experience a cascade of problems, such that what keeps them in the ICU may differ substantially from what brought them to the ICU in the first place. A new syndrome of “persistent critical illness” has been defined to encompass the broad scenarios by which patients remain ICU-dependent due to ongoing illness and clinical instability that is no longer directly attributable to the original organ dysfunction prompting ICU admission.  In several large-scale epidemiologic studies across multiple countries, persistent critical illness had been empirically determiend to begin around 10 days after ICU admission. This is the point at which characteristics at ICU admission (admission diagnoses and physiologic derangements) are no longer more predictive of mortality than antecedent characteristics (age, sex, chronic health status). While persistent critical illness occurs in just 5% of ICU admissions, it has a disproportionate impact on ICU resource use—accounting for nearly a third of all ICU bed-days. Furthermore, rates of persistent critical illness vary more than 3-fold across hospitals, suggesting the importance of contextual as well as patient factors in the development of persistent critical illness.

Despite emerging awareness of Post Intensive Care Syndrome (PICS), there is lack of robust evidence on optimal rehabilitation strategies for ICU survivors. The precise timing of initiation, duration, frequency (dose) of early physical rehabilitation remains unclear. Studies that focus on psychological rehabilitation of ICU survivors are sparse and show mixed benefit. 

There are multiple modifiable barriers to the ongoing rehabilitation of ICU survivors in acute care hospitals. Some of the barriers to in-hospital rehabilitation include:

A)      Patient factors: delirium, weakness, frailty, physiological safety
B)      Knowledge and skills: knowledge of PICS; general knowledge and skills around mobilisation; inadequate training and adherence to pain, agitation and delirium guidelines
C)      Environment and resources: Inadequate staffing/equipment/space/funding
D)      Behavioural: Lack of mobility champions, absence of protocol/medical order for mobilisation, lack of interprofessional communication

Addressing these barriers and investing in future research related to rehabilitation strategies may have benefits for the ongoing care of ICU survivors.

Most children are surviving critical illness in highly resourced paediatric intensive care units (PICUs). However, in research studies, many of these children survive with multi-domain health sequelae that has the potential to affect development and be life-long, termed post-intensive care syndrome-paediatrics (PICS-p). Clinically, there are no recommendations for the assessment and follow-up of children with critical illness as exists for the premature neonatal and congenital heart disease populations. 
 
To date, primary and secondary outcomes have been largely assessed at or prior to hospital discharge, disregarding post-hospital outcomes important to PICU stakeholders. Incorporating longer term outcomes into clinical and research programs, however, can no longer be overlooked. Barriers to outcomes assessments are varied and generalized vs. individualized, but some PICU centres are discovering how to overcome them and are providing this service to families – sometimes specific populations - in need. Research programs and funders are increasingly recognizing the value and need to assess long-term outcomes post-PICU. 
 
The considerations, challenges and barriers to long-term follow-up following paediatric critical illness will be explored and current national and international approaches to research and clinical follow-up discussed. 

THE USE OF PHENOMENOLOGY AND INTERPRETATIVE PHENOMENOLOGCICAL ANALYSIS TO STUDY INTENSIVE CARE PATIENTS’ EXPERIENCES AT POST-ICU DISCHARGE FOLLOW-UP: ENSURING COMMUNICATION AND EMPATHY AS THE CORNERSTONES TO GOOD CLINICAL PRACTICE

Introduction

Post Intensive Care Syndrome (PICS) describes the health problems that remain after critical illness. There is an increasing interest in the human experiences of Intensive Care Unit (ICU) patients, to ensure greater holistic care and management.

Research question
What is the lived experience of patients with critical illness in the ICU?

Design
Phenomenological study.

Sample
The first fifteen patients referred to a post-ICU follow-up clinic.

Data collection and analysis
Face-to-face interviews with Interpretative Phenomenological Analysis.

Results and methodological insights
Two superordinate themes were identified. The superordinate-theme ‘I have a voice, you’re just not listening’ had three themes: ‘Patience, not predictive text’, ‘Yes, I did just say that’, and ‘Talk to the hand’. The superordinate-theme ‘Wear my shoes-empathic understanding’ had three themes: ‘Care not pity’, ‘From the minute I wake up’, and ‘Small things are massive’.

Whilst empathy and communication are often discussed as vital aspects of patient care, this study provides context and examples of how they impact everyday practice for all healthcare staff. The methodology and methods used in this study, phenomenological and IPA are ideally suited to the patient experience and will be critical in future analysis of ‘long-COVID’ patients, which are currently being studied in COVID-recovery.

The use of phenomenology and interpretative phenomenological analysis to study intensive care patients’ experiences at post-ICU discharge follow-up: ensuring communication and empathy as the cornerstones to good clinical practice

 
 

As we look beyond ICU to the impact of critical illness and intensive care therapy on survivors, we also recognise the impact on the bereaved.  Complicated or difficult grief and post traumatic distress are common experiences after a bereavement in ICU.   Follow up by intensive care teams can help address questions that may be barriers to grieving.  Learning more about the experience of the bereaved in our units can help us improve the care we provide to dying patients and their families, and the support we provide to clinicians caring for patients. 
 
This presentation will discuss what we know about grief after a death in ICU.  The evidence for bereavement follow up will be reviewed.  Guiding principles for follow up teams, which acknowledge the limitations of the evidence and the vulnerability of those followed up, will be discussed.  
 

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