Transcription:
Post-ICU Recovery Clinic

Melanie Cole (Host):  Welcome to Back to Health, your source for the latest in health, wellness and medical care; keeping you informed, so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world renowned physicians at Weill Cornell Medicine. I’m Melanie Cole and today, we’re discussing recovery from the ICU and the road ahead for patients through the post-ICU recovery clinic at Weill Cornell Medical Center. Joining me is Dr. Lindsay Lief. She’s the Director of the Medical Intensive Care Unit and the Director of the Post-ICU Recovery Clinic. She’s also an Assistant Professor of Medicine at Weill Cornell Medicine. Dr. Lief, thank you so much for being with us today. start by telling us what is Post Intensive Care Syndrome?

Lindsay Lief, MD (Guest):  So, Post Intensive Care Syndrome which is abbreviated as PICS is really a constellation of symptoms that can happen after a patient endures and ICU stay. So, those symptoms can be cognitive, emotional, or physical symptoms and now also we include social isolation and financial hardship as part of this syndrome. And all of those things are considered part of this syndrome.

Host:  Well thank you so much for telling us what that is. So, who is affected? Tell us a little bit about what you’ve seen as far as people that are in recovery and that are post-intensive care. What have you seen? Who is most affected?

Dr. Lief:  Well we can’t predict exactly who will suffer from post-intensive care syndrome, but we know certain groups are at higher risk. And those people include those who were on mechanical ventilation so on a ventilator for several days, those who required sedation while in the intensive care unit, those who experienced delirium or episodes of confusion while they were critically ill and those who had syndromes like septic shock or ARDS, acute respiratory distress syndrome; all of those patients are at higher risk of suffering from post-intensive care syndrome. Patients who we think come to the ICU for a very short stay, maybe overnight after a procedure perhaps, are at much lower risk of developing these symptoms.

Host:  Well then tell us about your holistic approach to care after the ICU. In addition to the thorough medical exam, how do screen for PICS, what kinds of tests do you conduct?

Dr. Lief:  Right so we consider a post-intensive care visit sort of on one hand like a post op visit. So, someone has a major surgery, of course they are going to check in with the surgeon a month later to make sure everything is going well, they are getting back to their life. And we draw an analogy to that. So, as opposed to going to just see the cardiologist or the ophthalmologist or someone who focuses on one particular organ or part of the body; when we see a patient in post-ICU clinic we start with a lot of open ended questions and in addition, we will tell them upfront that this is not going to be a standard 20 minute follow up visit. We see them often for one to two hours at a time. And so, we ask questions like, how are you? Are you sleeping? Are you eating? Do you remember or know what happened to you while you were in the hospital? And you would be shocked that many people have no memories and no information about what happened to them.

And so often, we start with retelling the story of their hospitalization. This is the last thing you remember coming in through the emergency department, here’s what happened next and we’ll take them day by day or week through week or complication through complication of their hospital stay until they have memories again. And then we talk about how they are recovering. What was their life like before the hospital and what is it like now? Can they take care of themselves? Do they feel like they could get back to their life whether that was being a parent, a student, a professional? And then we have more formal surveys that we do which are validated questionnaires to actually look for symptoms of emotional or psychological challenges like we screen for anxiety, depression, PTSD. We screen for sleep and insomnia challenges. We screen for ADLs which are activities of daily living. So, can people take care of themselves, do the basic things they need independently? We screen for quality of life and based on the results of those screens; we may make additional referrals to for example mental health experts. If someone looks like they have symptoms of PTSD, we would refer that person to a psychologist specializing in that.

Host:  Well then let’s follow along that line. Tell us what other providers might be involved and how important this multidisciplinary approach to wellness after illness really is for these patients.

Dr. Lief:  I mean the multidisciplinary approach is so important in the ICU and that continues after recovery or during recovery. So, when people initially started asking me a couple of years ago what are you doing in post-ICU and I would say that what I do is the least important thing. They don’t need a doctor anymore. What they need are people who can help them achieve their goals which is generally to get back to a life that’s recognizable. And so often what they need is occupation therapy and physical therapy, people to help them gain stamina back if it’s just that they are weak and debilitated and have lost muscle mass from being in the hospital or to help them overcome a new challenge they have with a new neurologic or muscular or arthritic problem that has developed. They need often speech pathology and speech therapists to help them if their swallowing has become impaired from having a breathing tube in for so long. They certainly need mental health expertise if they are having symptoms of anxiety or depression.

We have a partner in our sleep medicine practice who is a psychologist by training who helps with insomnia, nightmares and then we have partners in pharmacology from our ICU pharmacologists and our ICU dieticians who can help in people who have lost a tremendous amount of weight and are interested in how to gain back weight in a safe and healthy way and how to supplement their diets. And then our pharmacologists are invaluable because patients sometimes enter the hospital taking no medicines and may leave prescribed ten medications. And in between, those two dates they may have been many different teams taking care of the patient so they may have been in the Emergency Department, and then in Intensive Care Unit, then a Step Down Unit, then a Medical Floor, then a Rehab Facility and then home. So, that’s several steps where the patient is vulnerable where medication reconciliation or ensuring the right medicines are being continued and the right are being stopped may have happened perfectly or may not have. And so in the Post-ICU Clinic, with the help of pharmacologists, we go through those medications in detail and we make sure they are not taking one extra medicine they don’t need but on the other hand, they are taking the right ones and the ones they do need. And you’d be surprised how often patients come in having now idea why they are prescribed these medications and when you don’t know the importance of them, then of course you have no interest in taking them. Especially if they are expensive.

And so the last thing they need often is social work or case management. Someone who can help them navigate being someone who now has an illness when they are not used to it and maybe financially burdened by that. So, some of our patients have lost their jobs while they were in the hospital or lost their insurance. And now they can’t afford the one medicine that might be lifesaving. Or they used to take the subway everywhere and now they need to take a taxi because they are too weak to walk the subway stairs and they have four doctor’s appointments this week and they can’t afford four taxi rides. So, we can help with the help of social work set them up with city or governmental services that can help them not only with getting them emergency insurance but also in getting them for example, emergency transportation to help them get to their doctor’s appointments.

Host:  What an amazing comprehensive approach that is Dr. Lief. So, in this climate that we’re in now, how are you utilizing video visits as a follow up after discharge?

Dr. Lief:  Well video visits have been really life saving for us. As a practice in pulmonary, we had just started using video visits prior to the COVID pandemic and of course, after it started, we really escalated our use of them and so a few weeks ago, we started seeing our first post-ICU patients via video visits. And I’ll tell you there are so many benefits to it that I didn’t even anticipate. So, one is that we get to see the patient in their own home, their own environment which is incredible. So, if I need to ask a patient can you walk up a flight of stairs? The patient will pick up her phone and walk up a flight of stairs with me. I can see them stand up independently from a couch or they can show me why it’s a struggle for them to get in and out of their bed. So, just watching a patient navigate his or her own apartment or house is really valuable.

The second thing that’s remarkable is I do the video visits with Fellows or Pulmonary Critical Care Fellows or trainees in my office which is right behind the Medical ICU in the hospital. And so, sometimes, the patients will say oh I had this amazing nurse who cared for me and I wish I could say thank you to that nurse. And I say oh that nurse is actually working today would you like me to ask him of her to come back and say hi? And so I can actually have faculty, fellows, nurses, respiratory therapists who work in the ICU connect with these patients who want to say thank you or just say hi because they remembered seeing them everyday for three weeks in the ICU, who just come and say hi and give a little wave and get to see the patients at home.

And I think it provides value not only to the patient to feel like they were able to express gratitude but also to the staff in the ICU who so rarely get to see the patients once they have recovered, it provides a huge amount of relief and sort of validation of what they do to see their patients recovered, home and back to their lives.

Host:  It really is amazing. So, how do you see COVID-19 affecting ICU survivors and your post-ICU recovery clinic?

Dr. Lief:  Well it’s so interesting because I started this practice formally a couple of years ago and I was seeing these patients informally through my pulmonary practice prior to that. And as soon as COVID-19 started, there was a big uptick in interest in post-ICU care and to me, the biggest change is not that the patients are going to be particularly different. So, a patient who is in the hospital for three weeks on a ventilator is at high risk for having post-ICU syndrome and I think patients with COVID have the same risk. Now of course, we don’t know that yet, hopefully we’ll learn more about it. The difference is the sheer number of patients. So, in a terrible flu season, we might have a handful of patients who were on a breathing machine for weeks and suffered the kind of complications we’re seeing now.

But in the last two months, on just in the campus of our hospital, we’ve had hundreds. So, one of the big differences is the sheer number of patients that are going to be at risk for post-intensive care syndrome. And so from our end, what we’ve done is really reinforced our partnerships, with rehab medicine, with pharmacy, with dieticians, with mental health providers so that we know we have enough resources to accommodate all the patients that may need their expertise. The thing I think might be a benefit to COVID for post-ICU care is the attention it’s brought because this is not a new syndrome, it’s something we’re only learning about and I think now that people see just in one city, thousands of patients who suffered a very significant and traumatic ICU stay, a huge percentage of those people might need follow up intensive treatment and so now the public and the media are learning about post-intensive care syndrome and the value of our practice. And so I hope that it brings more attention to what we’re doing and so more people will seek help after intensive care.

Even in our practice, we don’t limit our patients to having been in one of our intensive care units. We see patients who have been in intensive care units all over the city come out, realize they have some anxiety or recurring nightmares and then are referred to us so we can do a comprehensive screen and help them get set up with the providers they need to help them get back to their lives.

Host:  So, Dr. Lief as we wrap up, tell listeners what you’d like them to know about what you see as the greatest value in a post-ICU recovery clinic at Weill Cornell Medicine, how it’s different from standard follow up appointments with a Primary Care doctor, how it helps with the emotional and cognitive needs of the patient as well. Kind of summarize and wrap it up for us what you’d like listeners to take away from this very important topic.

Dr. Lief:  I think I learned what’s so important about our practice from our patients. One of the very first few patients I saw who when I started with these sort of open ended questions that I do, how are you, are you eating, are you sleeping, are you getting gout of the house and the patient broke down in tears and said I’ve seen four doctors since I left and nobody has asked me that. And I’ll tell you I work with incredible doctors. one of the reason I stay at Weill Cornell is because we have just the most spectacular specialists. But due to the time constraints and the requirements and nature of what each specialist is trying to manage; they are often unable and don’t have the time or expertise to think about the broader challenges including emotional and cognitive. And so what we offer is that we are there to help the patient get back to who they were before or who they plan to be and if that means the entire visit is spent dealing with PTSD; that’s what we’ll do. If it means the entire visit is dealing with shortness of breath and the inability to walk up a flight of stairs when they used to be a marathon runner; that’s what we’ll do. The visit is really tailored to the patient. We screen them in a 360 degree manner about what their challenges are after the ICU, emotional, financial, physical, cognitive and then we focus on what they need to achieve their goals.

We have no agenda. The agenda is set by the patient. And I think that is very unique.

Host:  It certainly is. Thank you so much. It’s so encouraging to hear about this very comprehensive multidisciplinary approach that can help patients that have suffered a trauma and were in the ICU. Thank you again for joining us. For more information on how to manage the emotional challenges of this pandemic, please visit www.weillcornell.org/news. You’ll also learn how Weill Cornell Medicine is taking extra precautions to prioritize your patient experience in office and offering more resources via digital health on www.weillcornell.org/digital/health/services. Thank you for joining us again today. this concludes today’s episode of Back to Health. We’d like to thank our listeners and invite our audience to download, subscribe, rate and review Back to Health on Apple Podcasts, Spotify and Google Play Music. For more health tips go to www.weillcornell.org and search podcasts and parents, don’t forget to check out our kids health cast. I’m Melanie Cole.