Surviving the CICU: Discussion With Andrea Thompson, MD
In the medical intensive care literature, there has been significant discussion of post-intensive care syndrome – the physiologic and psychologic sequelae of critical care treatment.
This discussion has been highlighted in the nonmedical world through a novel written by the Brigham and Women physician, Daniela Lamas, MD, titled You Can Stop Humming Now, as well as Brigham's After the ICU stories. Different institutions have created systems involving consultation by critical care providers to manage post-critical care transitions to the outpatient setting.
The question is, can and should cardiologists provide the same care for cardiac intensive care unit (CICU) survivors?
Andrea Thompson, MD, Fellow in Training at the University of Michigan, has developed a post-CICU discharge clinic to address the transition of care issues particular to cardiac critical care patients. Patients are referred to a clinic after an admission to the CICU more than 48 hours, if they were not discharged to hospice, and if they are without a preexisting LVAD or heart transplant.
The following article is a discussion of Thompson's experience developing this novel clinic.
How did you come up with the idea to have a post-CCU discharge clinic?
The idea was born out of observations during my first year as a cardiology fellow. The patients that I saw in follow-up were the ones that returned to the hospital. I observed the difficulties they had when they transitioned to the outpatient clinic. They had a lot of different providers and many were trying to establish care in cardiology.
A lot of times, this transition is not as smooth as we hope it to be. This observation lead to the thought of having a clinic dedicated to them, designed to not only meet their cardiology needs but also their medical needs, and help them navigate the health care system in the short period post-discharge.
What services did you think were important to provide?
I started by talking to the different providers that take care of these patients both as inpatients and outpatients. We ultimately decided that it would be useful to have a medication review, including barriers to taking medications by the pharmacist, which we did by telephone.
We also decided to do a social work visit for all patients, which involved not only a social work assessment but also screening for cognitive impairment and depression, as these can be real barriers for patients getting the care they need after leaving the hospital.
In terms of the cardiology follow-up, the biggest piece was understanding our role. For patients with an already-established provider, we set up a way to coordinate with their long-term provider: the CT – surgeons, primary pulmonary hypertension specialists and heart failure specialists. For patients establishing care, we took a more active role in managing their cardiac issues until they established care with a long-term provider.
Were there any common post discharge issues?
By far the most common discharge issues are with medications, including cost of medications and side effects. We are also checking for cognitive impairment and depression, and have noticed that cognitive impairment is present in the early post-discharge period for a number of patients.
Anxiety was probably the most unexpected thing that we were not screening for, but we noticed it was an issue for many patients.
In particular, there is anxiety around what is safe to do in terms of activity level. One of the most striking examples I can remember is of a very functional athlete who went home unsure if it was safe for him to do anything aside from sitting on the couch.
As an inpatient, he had delirium and was receiving a lot of information, so it was a pressing question addressed in clinic.
How did you get the key players involved?
One of the more inspiring things about putting this together was the enthusiasm demonstrated for this population among everyone involved. The inpatient pharmacist was excited about helping with this transition. The outpatient social worker had an interest in depression and was already embedded in the cardiology clinic, so it was natural for her to start seeing this population.
In terms of the attendings, they had clinic at the same time, so it was natural for them to add on a couple of patients in a fellow-staffed clinic.
One of the attendings was a general cardiologist who had experience with patients leaving the ICU who were seen in follow-up, so he immediately saw the value of this.
The other attending was a heart failure specialist who does time in the ICU and thought it would be a way to positively impact patient care.
How have these patients benefited?
One of the greatest benefits of this clinic is patient education – having increased time with a social worker and physician. We are able to review what happened during their ICU stay and explain what they can expect going forward.
This conversation has a positive impact on not only their understanding but also their ability to participate in their health in a positive way.
This article was authored by Jessica Fleitman, MD, Fellow in Training (FIT) at the University of Pennsylvania in Philadelphia, PA.