Post-ICU Recovery Clinic

Overview

Patients who experience a critical illness, including a stay in the intensive care unit (ICU), are more likely to develop physical, mental and emotional setbacks that prevent them from returning to their previous functional status; this constellation of symptoms is called Post-Intensive Care Syndrome (PICS).

In 2019 a group of critical care physicians and advanced practice providers (APPs), together with a multidisciplinary group of providers at the Cleveland Clinic developed the Post-ICU Recovery Clinic (PIRC). The program’s goal is to recognize impairments, provide therapeutic interventions and support to patients and their families following critical illness.

Critical care physicians, APPs, pharmacists, physical therapists and respiratory therapists contribute to the multidisciplinary approach to our patient care. The team works together to optimize multiple facets of a patient’s health, focusing to restore respiratory function, physical capacity, cognitive, and emotional well-being while promoting a successful recovery for the patient.

Who Do We Evaluate

We welcome patients who have had a critical illness requiring an ICU stay.

The common ICU diagnosis among patients that we see in our clinic include the following:

Shock (requiring vasopressor support).
Acute Respiratory Distress Syndrome (ARDS).
Mechanical ventilation >= 3 days.
Prolonged ICU stay (>= 7 days).
Delirium present during ICU stay.
COVID-19 with ICU stay >= 72hrs.

Care & Services Provided

We use a variety of assessment tools and screenings in the form of questionnaires to better quantify the physical, cognitive and mental health concerns of our patient population. These tools are then reviewed and used by the multidisciplinary team to determine the best recovery treatment plan for the patient. Supplemented by the findings of our assessment tools, services provided by the clinic include:

ICU stay debriefing with a critical care physician or APP.
Comprehensive and detailed history and physical evaluation.
Medication reconciliation with a critical care pharmacist.
Physical therapy evaluation of functional assessment, mobility, strength and physical therapy needs.
Screening for common mental health problems that may happen after ICU stay.
Respiratory therapy evaluation with education on inhalers, oxygen use, tracheostomy care, and coordination or cessation of medical equipment such as oxygen or non-invasive ventilation.
Review of screening surveys with coordination and referrals to subspecialty services as needed (referral teams below).
Education regarding physical, cognitive, and emotional struggles with daily living often experienced by ICU survivors.
Resources and support for patients and their caregivers.

First Appointment Expectations

Each appointment is tailored to the needs of our patients which are identified a few days prior to the appointment via a phone encounter.

Debrief of ICU course and associated health challenges/concerns on behalf of the patient.
Depending on health status, obtain spirometry (pulmonary function test), a chest x-ray, and a 6 minute walk test, with results of tests being delivered by the physician and APP.
Complete assessment tools for nutrition, activities of daily living, surveillance of depression, anxiety and post-traumatic stress disorder (PTSD).
Appraisal of physical function with a physical therapist.
Evaluation with respiratory therapy, if indicated, for reconciliation of and education regarding oxygen and/or inhaled treatments.
Based on this throughout evaluation, an assessment and plan are assembled by the multidisciplinary team, and conveyed to the patient by the physician, with details of the recovery treatment plan. A comprehensive visit summary is given to the patient, as well as sent to patient’s primary care provider.

Description of assessment tools and screenings mentioned above:

Activities of Daily Living (ADL)
After multiple days in an ICU setting, physical weakness becomes a major reality for many critically ill patients and therefore physical impairment is often noted after hospital discharge. The ADL assessment tool identifies the shortcomings of a patient’s ability to perform activities of daily living.

Instrumental Activities of Daily Living (iADL)
Adverse effects of critical illness can lead to poor functional status. This negatively impacts an ICU survivor’s ability to live independently. Instrumental activities of daily living (IADL) encompass complex tasks necessary for independent living and are an important component of post-ICU functional outcomes.

General Anxiety Disroder-7 (GAD-7)
This tool is a self-reported screening tool and symptom severity measure for anxiety disorders. Mental health impairments are very common after a patient survives critical illness and is left feeling as if they have not returned to their prior health and wellbeing baseline.

Patient Health Questionnaire-9 (PHQ-9)
This self-directed assessment tool is a multipurpose instrument that can be used not only for screening, diagnosing, and monitoring depression but also measuring the severity of it. Similar to the above indication in this patient population.

Impact of Event Scale-6 (IES-6)
This tool is a self-reported measure that assesses subjective distress caused by traumatic events. Critical illness is a stressful life event. This tool contains items that are related to the hyperarousal symptoms identified as PTSD symptoms. Specifically, ICU survivors reflect on the stressful event of their ICU stay and indicate how distressed or bothered they have been over a period of the past seven days.

Montreal Cognitive Assessment (MoCA)
A screening instrument that can identify cognitive dysfunction. It assesses attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation. Screening of neuropsychological functions can estimate the need for additional rehabilitation during the recovery period of ICU survivors.

Malnutrition Screening Tool (MST)
A screening tool that addresses the quality of nutrition in patient’s after critical illness. Depending on a patients score, we can identify nutritional deficits that can be addressed through a referral with a nutritionist if the patient is willing and interested.

Eating Assessment Tool (EAT-10)
For multiple reasons, including but not limited to ICU acquired weakness or prolonged endotracheal tube intubation, patients may experience symptoms or signs of dysphagia after critical illness. This assessment tool quantifies the symptomatic severity of dysphagia from the patient’s perspective.

Glottal Function Index (GFI)
Many patient’s after critical illness, particularly those on mechanical ventilation, can experience changes in their voice. The GFI stands for the Glottal Function Index and it is a reliable, reproducible, self-administered symptom index that is used to evaluate and treat patient’s that identify as having glottal dysfunction.

Description of Tests

PFT:
Pulmonary function tests (PFTs) are noninvasive tests that show how well the lungs are working. The tests measure lung volume, capacity, rates of flow, and gas exchange. This information can help your healthcare provider diagnose and decide the treatment of certain lung disorders. This is important after critical illness in patients that have/had a significant lung diagnosis in the hospital which has the potential to negatively affect overall lung health following their illness.

6 min walk test (6MWT):
The purpose of a 6MWT is to assess distance walked over 6 minutes as a sub-maximal test of aerobic capacity and endurance. The distance covered over a time of 6 minutes is used as the outcome by which to compare changes in performance capacity after critical illness. This allows clinicians to identify potential cardiopulmonary issues in ICU survivors and have an objective tool to evaluate a patient’s functional capacity.

Chest X-Ray (CXR):
A CXR is an imaging test that uses X-rays to look at the structures, tissues, bones, and organs in your chest. Often a patient will have an abnormal finding on a CXR that was taken during their critical illness in the ICU. Repeating an x-ray during their clinic appointment offers surveillance and ensures that during their recovery any abnormalities that were previously identified have resolved or are actively resolving.

Referrals made as needed to with utilization of care paths:

Pulmonologist for follow up.
Psychiatry.
Psychology.
Physical Therapy.
Occupational Therapy.
Pulmonary Rehabilitation.
Geriatric.
Neurology/Brain Health Center.
Cardiology.
Ear Nose and Throat (ENT).
Speech Therapy.
Endocrinology/Weight Management Center.

Our Team

Medical Director

Michelle Biehl, MD, MS

Physicians

Michelle Biehl, MD, MS

Pharmacists

Heather Torbic, PharmD, BCPS, BCCCP

Jessica Ward, PharmD

Grace Conroy, PharmD

Olivia Marchionda, PharmD

Physical Therapist

Michelle Hudson

Respiratory Therapist

Scott Marlow, RRT, AE-C

Project Manager
Marianne Mitri, MBA

Program Coordinator

Alexa Graziolli

Program Manager

Francesca Caporossi

Appointments & Locations