Society of Critical Care Medicine's International Consensus Conference on Prediction and Identification of Long-Term Impairments After Critical Illness

Mark E. Mikkelsen, MD, MSCE; Mary Still, MSN, RN, ANP-BC; Brian J. Anderson, MD, MSCE; O. Joseph Bienvenu, MD, PhD; Martin B. Brodsky, MD, ScM; Nathan Brummel, MD; Brad Butcher, MD; Alison S. Clay, MD; Hali Felt, MFA; Lauren E. Ferrante, MD; Kimberley J. Haines, PhD; Michael O. Harhay, PhD; Aluko A. Hope, MD; Ramona O. Hopkins, PhD; Megan Hosey, PhD; Catherine "Terri" L. Hough, MD; James C. Jackson, PsyD; Annie Johnson, ACNP-BC; Babar Khan, MD; Nazir I. Lone, MBBS, MD, MPH; Pamela MacTavish, MSc; Joanne McPeake, PhD; Ashley Montgomery-Yates, MD; Dale M. Needham, MD, PhD; Giora Netzer, MD; Christa Schorr, DNP, RN, NEA-BC; Becky Skidmore, BA, MLS; Joanna L. Stollings, PharmD; Reba Umberger, PhD, RN; Adair Andrews, RN, MATD; Theodore J. Iwashyna, MD, PhD; Carla M. Sevin, MD, PhD

Disclosures

Crit Care Med. 2020;48(11):1670-1679. 

In This Article

Abstract and Introduction

Abstract

Background: After critical illness, new or worsening impairments in physical, cognitive, and/or mental health function are common among patients who have survived. Who should be screened for long-term impairments, what tools to use, and when remain unclear.

Objectives: Provide pragmatic recommendations to clinicians caring for adult survivors of critical illness related to screening for postdischarge impairments.

Participants: Thirty-one international experts in risk-stratification and assessment of survivors of critical illness, including practitioners involved in the Society of Critical Care Medicine's Thrive Post-ICU Collaboratives, survivors of critical illness, and clinical researchers.

Design: Society of Critical Care Medicine consensus conference on post-intensive care syndrome prediction and assessment, held in Dallas, in May 2019. A systematic search of PubMed and the Cochrane Library was conducted in 2018 and updated in 2019 to complete an original systematic review and to identify pre-existing systematic reviews.

Meeting Outcomes: We concluded that existing tools are insufficient to reliably predict post-intensive care syndrome. We identified factors before (e.g., frailty, preexisting functional impairments), during (e.g., duration of delirium, sepsis, acute respiratory distress syndrome), and after (e.g., early symptoms of anxiety, depression, or post-traumatic stress disorder) critical illness that can be used to identify patients at high-risk for cognitive, mental health, and physical impairments after critical illness in whom screening is recommended. We recommend serial assessments, beginning within 2–4 weeks of hospital discharge, using the following screening tools: Montreal Cognitive Assessment test; Hospital Anxiety and Depression Scale; Impact of Event Scale-Revised (post-traumatic stress disorder); 6-minute walk; and/or the EuroQol-5D-5L, a health-related quality of life measure (physical function).

Conclusions: Beginning with an assessment of a patient's pre-ICU functional abilities at ICU admission, clinicians have a care coordination strategy to identify and manage impairments across the continuum. As hospital discharge approaches, clinicians should use brief, standardized assessments and compare these results to patient's pre-ICU functional abilities ("functional reconciliation"). We recommend serial assessments for post-intensive care syndrome-related problems continue within 2–4 weeks of hospital discharge, be prioritized among high-risk patients, using the identified screening tools to prompt referrals for services and/or more detailed assessments.

Introduction

Each year, with advances in care delivery, millions of patients survive critical illness. Unfortunately, after critical illness, new or worsening impairments in physical, cognitive, and/or mental health function are common among survivors.[1–4] In 2010, a stakeholders' conference was convened by the Society of Critical Care Medicine (SCCM) to improve long-term impairments experienced by survivors of critical illness.[5] To increase awareness of the long-term consequences of critical illness, the term "post-intensive care syndrome" (PICS) was recommended to describe these impairments.[5]

In 2012, SCCM held a second stakeholders meeting which engaged representatives of professional organizations, health systems, patient advocates, and professionals with experience and expertise in post-ICU patient care.[6] At the second meeting, it was recognized that "a substantial but unknown proportion of survivors of a critical illness are at risk of developing mental health, cognitive, and/or physical impairments".[6] To improve long-term outcomes, participants concluded that "systematic recognition of mental health, cognitive, and/or physical impairments related to PICS is required during transitions of care settings across the continuum of critical illness and recovery".[6] Barriers to practice were identified and included the need to develop educational information for providers that included PICS risk factors and triggers to refer survivors for additional medical care.

At ICU discharge, as a result of the impact of the acute illness and the hazards of bed rest and hospitalization, nearly all survivors of critical illness experience impairments in one or more PICS domains. At 3 and 12 months, 64% and 56% of survivors experience one or more new post-intensive care problems, respectively, and co-occurrence is common.[3] As such, prediction, risk-stratification, and screening remain vitally important areas to improve the long-term outcomes of survivors of critical illness.

This report summarizes the findings of a consensus conference convened by SCCM on May 21, 2019, in Dallas, Texas. The purpose of the conference was to provide pragmatic recommendations to clinicians caring for adult survivors of critical illness related to screening for long-term impairments in cognition, mental health, or physical health as a means to improve long-term outcomes. The conference was organized around three fundamental questions related to posthospital discharge assessments for adult survivors of critical illness. First, who should be screened for these often inter-related impairments? Second, what screening tools should be used? Third, when should these assessments be performed?

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