Is (ICU) Graduation Day Really All That It Could Be?

For people who work in EDs and ICUs, the day our patients leave the ICU can feel like a triumph. It validates our training, it makes the late nights worthwhile, and sometimes it even makes us want to come back for more.

But do our patients feel the same way? Increasingly, we’re learning about the costs of the care we provide, and that cost isn’t just in dollars. The recently-published Intensive Care Outcomes Network (ICON) study¹ was the latest addition to a litany of work that is uncovering the toll that critical illness takes on our patients’ lives. The ICON study collected data from patients hospitalized in the ICUs of 39 institutions in the UK between 2006 and 2013. They collected nearly 5000 surveys to measure the prevalence of anxiety, depression, and post-traumatic stress disorder (PTSD) in ICU survivors. 

The results are staggering. Among respondents, over 55% met their definitions for one of the three diagnoses. PTSD afflicted nearly 1 in 4 ICU survivors, which agrees with previous estimates.² Perhaps most surprising, those patients with post-ICU depression had 50% higher post-discharge mortality than other patients.

This report isn’t the first time that we’ve heard that our patients may do poorly when they leave our care. The Post Intensive Care Syndrome (PICS) has now been well described to include psychiatric illness, physical weakness, and cognitive impairment.³ Increasingly, we understand that delirium prevention plays a significant role, and the ABCDEF bundle has been one strategy that has been shown to improve clinical outcomes.⁴  We are also learning that even among patients who are not recognized to have PICS, mortality may remain high, perhaps because of disordered immune function or accelerated cardiovascular disease.⁵

So where does that leave us in EM/CCM? Delirium screening and recognition in the ED is growing, but we have a long way to go in understanding what role our care may play in long-term neurocognitive outcomes.⁶ How does prolonged ED boarding influence long-term outcomes among survivors of critical illness?  Should we be implementing ED-based strategies to prevent hospital-recognized complications?  Does our sedation prescription in the ED or early in the ICU affect our patients long-term? Can our interventions help to prevent the physical and cognitive failures associated with post-ICU disability and recovery?

EPs and intensivists have done pivotal work to learn how the care we provide can contribute to ICU survival, but maybe that isn’t enough. Maybe we need to change how we think about our role in the health care system and how we counsel our patients. Hopefully someday soon, we will start thinking of ICU graduation not as the end of the journey, but rather as just the beginning.

References

1. Hatch R, Young D, Barber V, et al. Anxiety, depression and post traumatic stress disorder after critical illness: a UK-wide prospective cohort study. Crit Care. 2018 Nov 23;22(1):310.
2. Nikayin S, Rabiee A, Hashem MD, et al. Anxiety symptoms in survivors of critical illness: a systematic review and meta-analysis. Gen Hosp Psychiatry. 2016 Nov-Dec;43:23-9.
3. Rawal G, Yadav S, Kumar R. Post-intensive Care Syndrome: an overview. J Transl Int Med. 2017 Jun 30;5(2):90-2.
4. Marra A, Ely EW, Pandharipande PP, et al. The ABCDEF Bundle in Critical Care. Crit Care Clin. 2017 Apr;33(2):225-43.
5. Prescott HC, Osterholzer JJ, Langa KM, et al. Late mortality after sepsis: propensity matched cohort study. BMJ. 2016 May 17;353:i2375.
6. Nagaraj G, Burkett E, Hullick C, et al. Is delirium the medical emergency we know least about? Emerg Med Australas. 2016 Aug;28(4):456-8.

Nicholas Mohr, MD