Post-Intensive Care Syndrome (PICS)

Podcast Transcript

Raed Dweik, MD:

Hello and welcome to the Respiratory Exchange podcast. I'm Raed Dweik, Chairman of the Respiratory Institute at Cleveland Clinic.

This podcast series of short digestible episodes is intended for healthcare providers and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary critical care, sleep, infectious disease, and related disciplines.

We will share information that will help you take better care of your patients today, as well as the patients of tomorrow. I hope you enjoy today's episode.

Hassan Khouli, MD:

Good morning. Today our podcast is gonna go over the management of patients and really, overall, post-intensive care, syndrome.

I want to welcome Dr. Michelle Biehl, MD, who is gonna be our guest today. Dr. Biehl is staff in the department of critical care medicine and pulmonary medicine in the Respiratory Institute at the Cleveland Clinic and she's the director for our post-intensive care recovery program here at the Cleveland Clinic. Welcome, Michelle.

Michelle Biehl, MD:

Thank you for having me here, Dr. Khouli.

Hassan Khouli, MD:

I am Dr. Hassan Khouli, I'm the department chair for critical care medicine in the Respiratory Institute at the Cleveland Clinic.

So, Michelle, maybe we can start with the first question that I have on my mind, which is, what is post-intensive care syndrome?

Michelle Biehl, MD:

Yes. So, post-intensive care syndrome is a term that was created by the Society of Critical Care Medicine between 2010 and 2012. And that is more of a term rather than biological for the syndrome.

So, the syndrome is an umbrella of symptoms, new or worsening, that patients have after a critical illness. So, patients who have been in the intensive care unit, or in the ICU, after that they may develop, and it's quite common under three main domains, physical impairments, emotional or mental health impairments, and cognitive impairments. And those impairments can last months to years, and it is quite common after a critical illness.

Hassan Khouli, MD:

Thank you, Michelle. Yeah, you're right, we see this syndrome, more manifestations of it in our patients. You know, we tend to work often in the intensive care unit, so we may not really see it, as patients are leaving the ICU, survivors of, you know, critical illness. But nevertheless, when you encounter them later or when they come back to us as a readmission, we see that quite common and then it's good to see that it's now a well described, well-defined syndrome in the literature.

Why is it important to define this syndrome and to be aware of it, even for our clinician or healthcare providers?

Michelle Biehl, MD:

Yeah, thank you, that's a great question and I think awareness is really key here. So, as we have evolved in ICU care over the years, there is many more ICU survivors in the past several decades. And then we have seen that these patients, after they leave the ICU and eventually go home, they develop, and it's quite common between these group of patients, develop these symptoms, these impairments. And if they go unrecognized, we can't help them in their recovery.

So that's, you know, one of the main things is really to create awareness and that's why the term was created so we know what PICS is, post-intensive care syndrome is, and how we need to recognize, so go over signs and symptoms and certain screening tools, so we can, when we see these patients, after they have been discharged, when they are home, or even if they are already in places before home, like a long-term acute care facility, or a nursing facility, a rehab facility, that we can screen for those symptoms. Recognize is the first step to then treat or refer to specific specialties to help these patients in their recovery and in, which is, you know, it can be a long journey.

Hassan Khouli, MD:

Right. You know, recognition is really such an important area and, you know, recognition starts by us thinking of this, being mindful of such syndrome, and be aware of it, too.

Who are the type of patients that, from your experience, that tend to be affected by PICS?

Michelle Biehl, MD:

There are several risk factors that have been described in the literature that are quite common for these patients to then develop PICS. And so, I like to go in, divide in before they are ICU stay, during ICU stay, and after. So, before ICU stay, patients who are frail, who have already certain physical disabilities, or have a mental health condition, they are at higher risk to develop PICS after being in the ICU.

During their ICU stay, the main risk factors are sepsis, mechanical ventilation, prolonged ICU stay, ARDS, or acute respiratory distress syndrome, and certain medications like benzodiazepines have also been linked to PICS.

After the ICU stay, if patients have early symptoms of anxiety, depression, PTSD, those tend to be higher risk for prolonged PICS, or post-intensive care syndrome.

Hassan Khouli, MD:

Thank you, Michelle. You know, I can imagine that considering, being aware how the population in the U.S. and in the entire world is aging because of the advancement in healthcare, that people are living longer and that we're seeing this type of patients who are more frail, they have more comorbidities, are at a higher risk coming, you know, coming in.

And at the same time, as we're better and better at making patients live, and survive their ICU stay, what I can imagine is that there's gonna be more and more patients who, lucky to survive, but at the same time be impacted and at risk of developing post-intensive care syndrome. So, there is a lot of work that needs to be done there.

Michelle Biehl, MD:

Yes, and if I can mention, that I think we didn't touch yet on, what are exactly, or maybe some examples of the physical impairments, the mental health, and the cognitive impairments.

Hassan Khouli, MD:

That would be great, yes, please.

Michelle Biehl, MD:

Okay, great. So, physical impairments, which are extremely common, the literature varies from 50 to 80 percent of patients, and those go from dyspnea, chronic respiratory failure, like oxygen use or even ventilators, generalized weakness or ICU-acquired weakness that can vary from polyneuropathy to myopathies. Dysphasia from, you know, being intubated, difficulties performing basic activities like ADLs or IADLs. The patients have to learn how to walk again, how to swallow again. Fine motor skills can be affected, joint contractures, and that, you know, so on. And I think these can affect profoundly patients' lives.

From the mental health perspective, which is quite common, and those mental health goals for, like, psychological, emotional aspects, anxiety, depression, and PTSD, or post-traumatic stress disorder are also extremely common. And we can see the ICU stay is really a traumatic event for certain patients like similar to patients who were in a war, for example. Patients might have frightening memories of their ICU stay, they don't know what's real, what's not, and they can have nightmares, and they can be quite worried about even coming back to the hospital, to a clinic to see physicians or healthcare professionals.

And then from the cognitive aspect, it's very common, also. So, memory difficulties, attention deficit, lack of word finding, and, you know, to even more worsening levels, like patients, very similar to patients who have traumatic brain injury, patients can have cognitive impairment similar to those, and those can improve over time. Some patients need cognitive rehabilitation, other patients may have it for lifelong unfortunately.

Hassan Khouli, MD:

You know, I mean you describe such a broad range of symptoms and experiences, that these patients, you know, tend to have. You know, they are, and I like the term that you used, this is such a life-changing, it can be a life-changing experience that people are gonna have to relearn things that they took for granted and stresses out how important it is for us to be aware of it and do what, you know, whatever we can to, to prevent it.

So, this is a good segue to ask you a question. What can we do to prevent such a devastating or potentially really significant, life-changing event?

Michelle Biehl, MD:

Yes. So, there are interventions that can be done during the ICU stay to prevent the development of PICS, which, for example, the ABCDF bundle, which each letter corresponds to a bundle of care that is in- in the ICU to prevent PICS and that can go from assessment of the type of sedation, assessment of pain and treatment of pain. From rehabilitation and, like, the F components family, which means for engagement and empowerment of the family.

Those things are done in the ICU and also some of those can be done after patients go to direct, the nursing floor. But after they are discharged at home, there are things that have been tried for these patients and potentially helped mitigate and treat PICS, like early rehabilitation, physical rehab, psychological, early psychological intervention, nutritional aspect that is extremely important. From, as well as post ICU recovery centers or clinics that have been also, being developed in these last years to help, these patients to recover, as well as peer support groups for example.

Hassan Khouli, MD:

You know what I like about the F, is, acknowledging the role, the important role the families really play in our ICUs, in the care of patients, their loved one who admitted to the ICU, and at the same time, acknowledging how they can be, themselves, impacted by this. And, you know, as we focus our interventions, you know, we're including them into that, including them in the, as part of the solution and including them as part of the, you know, being impacted and what we can do to, you know, to support them there, so, thank you for reflecting on that too. I think this is really a good advancement in the awareness and the role for families in our intensive care units.

Michelle Biehl, MD:

Yeah, yes. We see that when families are part of the team, I'll say when they are at bedside of the patients, that patients have much less confusion or delirium, they have, in the, in the future, less PTSD, less anxiety, less depression. And, also, participating in the decision-making when we are deciding very important things for the patient next steps, where to go, procedures, interventions, having the family there representing the patient's wishes, when the patient cannot verbalize their wishes when they are, you know, mechanically intubated or under sedation, have the family there is extremely important. So we can honor patient's wishes, we can treat that patient how he would like to be treated, some patients, they would like to have everything, you know, done for them, others, might differ, so families are extremely important to be there.

Hassan Khouli, MD:

Right. And, you know, I can, you know, think of how family can normalize the environment for the patients. It's a familiar person, it's a person that advocates for them, it's their loved one too and as you're describing how PICS and how patients, experience a life-threatening, event being in the ICU, that I'm sure, you know, is a helpful way to include them there too.

So, you talked about the post-intensive care recovery programs, so maybe you can elaborate a little bit more on that. You know, you lead our program at the Cleveland Clinic, here and it's a program that has been growing nicely and has been impactful. Maybe you can take us through this and then maybe also share some data on what else is available across the country in this area.

Michelle Biehl, MD:

Sure. So, post-ICU recovery clinics, initially started in U.K. in the 1980s and those programs were developed with the aim of assessing patients after an ICU stay, after critical illness, assess, what impairments they had, and help to treat those patients.

As, I think, things evolved, this, it started, also, these programs started coming to the United States. And in the two, 2010, 2011 is when the first program was opened at, in the U.S. And after 10, you know, years, or 15 years, other programs opened and in, with the COVID pandemic, pretty much the number of programs doubled.

And so, we have seen a lot more awareness of ICU survivorship and what happens to these patients. Also, I think there was the silver lining of the pandemic is that the public, in general, and healthcare systems, become much more aware of what patients can go through after they have been in the ICU, after they had a critical illness or a significant disease.

So several other programs are open and these programs are really developed to help patients in their journey to recovery, going over several of the patients' impairments that they might have, recognizing that, helping the participant understand that they are not alone, that this is quite common to happen to them and to patients who survive the ICU, and help them, to refer them to, specialties that might be needed in their recovery and help as well, families to understand what the patient is going through.

Hassan Khouli, MD:

That's wonderful. I like about, using the word recovery in this, because this is a journey. After an experience in the intensive care unit and the survivors to look at it, and it's gonna take some time, but that positive aspect that we can help patients with, in terms of their recovery journey, there.

So maybe you can, you know, expand a little bit, Michelle, on the, on our post-intensive, care, unit recovery program. Who's on the team, how does that really work?

Michelle Biehl, MD:

Sure. So post-ICU recovery clinics in general are multidisciplinary programs or interdisciplinary that have physicians, advanced care providers, physical therapy, occupational therapy, nutrition that is, several different team members that can be part.

And at the Cleveland Clinic there was a big interest in providing continuum of care for these patients. So, after they are in the ICU, and leave the ICU, what else can we do as intensivists, as critical care providers, to help these patients in their journey to recovery, especially knowing that we understand the PICS.

And with those thoughts, a group of healthcare professionals got together with the idea to help these patients in their recovery. And one of the ways then we did was developing a post-intensive care recovery clinic, or recovery program. And after a year of work, strong work, of passionate and dedicated, healthcare professionals, we developed a clinic, we opened a clinic. That was December 2019. That was just a few months before COVID hit and the pandemic was then March 2020.

So we were, in a sense, very fortunate to have developed this program before, so we were ready when we had these, large number of patients coming to our ICUs, and surviving, and leaving with several impairments and difficulties that we could address.

So, if I could go over, then, our structure of the clinic. So, we are a multidisciplinary clinic. We have intensivists, critical care physicians, some are also pulmonologists. We have advance practice providers like physician assistants and nurse practitioners. We have a physical therapist that is part of the team that has been since the beginning and sees every patient that comes to our clinic. We have pharmacists that also assess the patients and do an extensive medication review and reconciliation, which is extremely important, and we have a respiratory therapist, who goes over oxygen needs, CPAP, BiPaP, bronchopulmonary hygiene, devices, and so on.

So, this group is the group that is, synchronous, that sees the patients when they come to our clinic. We also have specialty care pathways, that we call, that are referrals to certain specialties that are very common and needed for these patients. For example, we send these patients to pulmonary rehab, to occupational therapy, to, and acknowledge with management on our nutritional assessment for those who really lost a lot of muscle mass and need a better nutritional assessment.

Ear, nose, and throat, or ENT, those patients who have voice changes after being intubated, or need a swallowing assessment like the, you know, speech for that cognitive rehab, so we send to speech therapist or neurologist for that. So, we have developed these, specialty care paths that help patients to get there, to another provider or referral, yeah, a specialty in an easier way.

I also want to elaborate on when we see these patients and who are these patients that we see? So, we developed a system of triaging patients that have been in the ICU to then come and see us. So pretty much patients who are at high risk for PICS, those are the ones that we want to come to the clinic.

So, we developed, over time, of the clinic, we develop a dashboard in Epic, or in our internal healthcare system that helped us significantly to triage who are the patients at high risk. For example, the ARDS, as I mentioned, the patients with sepsis and septic shock, the patients with prolonged mechanical ventilation, prolonged ICU stay, and delirium. And those patients are the ones that we see come to the clinic and provide them with an appointment. And we like to see these patients two to four weeks after ICU discharge, so we can start with assessment of PICS.

Hassan Khouli, MD:

It's such a comprehensive program that requires, as you describe, an incredible amount of coordination and care efforts and to be able to see these patients, you know, by multiple, really, providers, at the same time. It must be a big advantage for such a program there.

And I want to reflect a little bit back on, the beginning, the start, the establishment of this program that it, you know, it is part of a continuum of care that you describe and outline, and it's, really a vision for us in critical care. In the department, also, the care medicine and beyond there too, so very timely and important concept and a program that really supports this very well.

You know, starting at, right before COVID, reflecting you and I back on that, to how timely that was and how helpful, that was during the COVID, you know, pandemic, an advantage that lasted even beyond there too, so thank you for leading these efforts, Michelle.

Now when you have such a major comprehensive program that requires a number of people to be involved from different backgrounds and sub-specialties, there are usually some challenges, and maybe some opportunities there. So, if you can, reflect on this and share with us your thoughts and what have we been facing in this area?

Michelle Biehl, MD:

Sure. So, a very common challenge is to starting and developing these clinics are alignment with your institution, your department vision. And I think in that sense we were aligned, and I would say we were lucky, because not all the institutions and departments see the importance of a post-ICU recovery program. So that was really imperative to have the support from you, Dr. Khouli, MD, and from the department, and our Respiratory Institute.

Some other challenges, like, space, like, having the multidisciplinary team there in that one, they, one afternoon, I know, available to see those patients is also another challenge that we took, you know, some time to really find those providers, those professionals. And we want to have professionals that are passionate about what they do, that they also see the importance. So that going back to the awareness, right, I think awareness of the importance of PICS, the importance of recognizing those impairments, and then, and then treating those patients.

Some other challenges are funding of these clinics and finding the right population to come. And, actually, if patient and family attend the clinic, one part of finding the right people. We want to get, you know, we don't want to bring patients who are actually doing extremely well, perhaps, and we want to really achieve a population that will benefit from this multidisciplinary approach, but also having patients to understand these needs and families and attend the clinic. There are barriers that may, you know, have for these patients to come basic things, like, transportation. A lot of them, they need a family member to come with them, so that family member may have to have, miss, work, or have a day off to help those patients to come.

Some patients, unfortunately, are being readmitted to the hospital before they even see us. As we all know, these patients are quite sick and there is a high rate of readmission to ICU survivors.

So, all of these are barriers that, as a group, we try to overcome to really implement and have success in the clinic. And we haven't, we have had some of those, and some we have been able to overcome, others we are working on it.

Hassan Khouli, MD:

Yeah, it's a continuum of improvement and learning from our experiences there, and then this has been a wonderful journey, for sure. 

Maybe you can elaborate, Michelle, on future directions for the program and what you see really happening, you know, at the Cleveland Clinic and even beyond, nationally, where is this movement going?

Michelle Biehl, MD:

Sure. So, within our clinic, our program, what we have, one of the barriers we have seen and what we are doing to overcome that is that patient's and family's attendance to the program, depending where they have to go, that might be a barrier, so we want to actually reach to these patients and get them access to the clinic in an easier way.

So, establishing these programs in the regions, many in cities or neighborhoods that are closer to patients' homes are one of the ways. So, we are probably one of the first programs in U.S. that have developed a program that is in a different. So, we have a program in the central region at Cleveland Clinic and we also have opened this year a program in the west region.

So, in that way patients that live in the west can come much easier, have easier access. They can park easier, they can get to the clinic easier, because we have heard some patients may not want to come to the downtown of Cleveland. And in that sense, we're also developing and planning to open in the south region, for example, so this is one of the things that we are developing this year.

The other aspect is peer support groups. So, peer support groups are, as the name says, groups of peers, so people who have been through similar experiences get together and they share their experience, their struggles, their successes. And these also, have been shown that is literature that it is helpful, beneficial to survivors of intensive care, of critical illness.

So, there are, a few programs in the country, less than 10, (laughs) and we are in the process of developing a peer support group that can help these patients normalize their experience, understand that this is quite common, and that they are not alone, and help, just sharing experiences with others that are there. Maybe someone that has been, you know, an ICU survivor for two years can share how, you know, what barriers, what struggles they had, what successes they have had in their journey with someone who has been out of the unit for two months, so that is one of the areas.

And in terms of development of post-ICU programs and peer support groups, and in general in the sense of ICU survivorship in the, there is an organization that is called CAIRO, or C-A-I-R-O, which stands for Critical and Acute Illness Recovery Organization that is, actually not just in the United States, but worldwide to have, we have, healthcare professionals from Australia, from New Zealand, from UK, from Europe.

And this program is part of several healthcare professionals, not only physicians, but several that meet on a monthly basis and have collaboration, research scholar activities, have discussions, brainstorming, how we can better support our patients, and what struggles they are having in their clinics. And we, then, notice that we are not the only ones that have certain struggles, certain barriers, what others did to overcome, what we did to overcome. So, we share in our knowledge and is extremely helpful for the improvement for the development on that people even are starting programs, they can hear from others.

And I think this group has been extremely helpful for, not only our program, but others. And we are also planning to have, like, in-person meetings, for example, in the next society, ATS, so we can develop next steps, for the, for this organization.

Hassan Khouli, MD:

It's, you know, it's great to hear, to see that all the collaborative efforts that are taking place, that, many places and people recognize and acknowledge the importance of this, and I think this is gonna, you know, allow, that awareness to be spread, farther and farther, and then more investigative efforts, and then, outcomes that will, continue to advance this.

So, Michelle, maybe, you know, you can share with us what would you like to leave our audience with as a, you know, a final message to this conversation here?

Michelle Biehl, MD:

Yeah, so to me awareness is really the key, it's understanding that these patients when they survive such a stressful event, like a critical illness, they are gonna have several impairments that are quite common. So, creating awareness for our colleagues within pulmonary critical care, other clinicians, that this is common. And how, when they see these patients in their clinics, or in the hospital when these patients are after ICU or readmitted, how can, you know, how important it is to assess, to screen, and to provide, then, the services that they need. And one of the services is post-ICU recovery programs that we can help them, you know, with these resources. So, I think, really, awareness and, educating not only, professionals, but the population about this.

Hassan Khouli, MD:

Yeah. Well thank you very much, Michelle, this concludes our podcast today. My guest today is Dr. Michelle Biehl, she is the director of the post, intensive, care recovery, program at the Cleveland Clinic. I'm Hassan Khouli, MD, the department chair for critical medicine, at the Cleveland Clinic. Thank you.

Michelle Biehl, MD:

Thank you so much for having me.

Raed Dweik, MD:

Thank you for listening to this episode of the Respiratory Exchange podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter at raeddweikmd.