Abstract
After intensive care and hospital-based rehabilitation, most ICU (Intensive Care Unit) survivors receive aftercare from their Primary Care Physician (PCP). This setting is characterized in many countries by a long-term doctor-patient relationship, with all health services being coordinated by a central clinician. Due to fragmentation in the care process, information on the ICU stay and knowledge about ICU sequelae are often missing in primary care. Structured discharge notes, the inclusion of PCPs in ICU follow-up programs, and the application of standardized scales and guidelines, as well as the establishment of training modules, should be implemented.
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References
Needham DM, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference. Crit Care Med. 2012;40(2):502–9.
McGovern M, McGovern C, Parker R. Survivors of critical illness: victims of our success? Br J Gen Pract. 2011;61(593):714–5.
NICE. Rehabilitation after critical illness in adults. Clinical guideline [CG83] 2009. 16.09.2019; Available from https://www.nice.org.uk/guidance/cg83.
Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457–502.
Ramsay P, et al. A rehabilitation intervention to promote physical recovery following intensive care: a detailed description of construct development, rationale and content together with proposed taxonomy to capture processes in a randomised controlled trial. Trials. 2014;15:38.
Stam HJ, Stucki G, Bickenbach J. Covid-19 and post intensive care syndrome: a call for action. J Rehabil Med. 2020;52(4):jrm00044.
Bench S, Cornish J, Xyrichis A. Intensive care discharge summaries for general practice staff: a focus group study. Br J Gen Pract. 2016;66(653):e904–12.
Gehrke-Beck S, et al. GP’s perspective and experiences in caring for patients with post-intensive care syndrome, a qualitative study. J Crit Care. 190:62. in press.
Kahn JM, Angus DC. Health policy and future planning for survivors of critical illness. Curr Opin Crit Care. 2007;13(5):514–8.
Schwarz CM, et al. A systematic literature review and narrative synthesis on the risks of medical discharge letters for patients’ safety. BMC Health Serv Res. 2019;19(1):158.
Girbes ARJ, Beishuizen A. Interfacing the ICU with the general practitioner. Crit Care (London, England). 2010;14(3):172–172.
Etesse B, et al. How the relationships between general practitioners and intensivists can be improved: the general practitioners’ point of view. Crit Care (London, England). 2010;14(3):R112–R112.
Medlock S, et al. Improved communication in post-ICU care by improving writing of ICU discharge letters: a longitudinal before-after study. BMJ Qual Saf. 2011;20(11):967–73.
Scottish Intercollegiate Guidelines Network, S.I.G.N. The SIGN discharge document. 2012. 10.09.2019; Available from https://www.sign.ac.uk/assets/sign128.pdf.
NICE. Development of a multidisciplinary post critical care clinic at guy’s & St Thomas’ NHS Foundation Trust. 2017. 08.08.2019; Available from: https://www.nice.org.uk/sharedlearning/development-of-a-multidisciplinary-post-critical-care-clinic-at-guy-s-st-thomas-nhs-foundation-trust.
Hoffman K, Thomas A, Brett S. Clinical pathways for the continuum of rehabilitation. In: Stevens RD, Hart N, Herridge MS, editors. Textbook of post-ICU medicine: the legacy of critical care: Oxford University Press; 2014. p. 546–58.
“Was-hab’-ich?”. Patientenbriefe wirken. Ergebnisbericht zum Projekt “Mehr Gesundheitskompetenz durch Patientenbrief”. 2019. 10.09.2019; Available from https://www.qualitaetskliniken.de/fileadmin/user_upload/2019-06-10_Ergebnisbericht.pdf.
Lin R, et al. Effect of a patient-directed discharge letter on patient understanding of their hospitalisation. Intern Med J. 2014;44(9):851–7.
Griffiths RD, Jones C. Seven lessons from 20 years of follow-up of intensive care unit survivors. Curr Opin Crit Care. 2007;13(5):508–13.
Marra A, et al. The ABCDEF bundle in critical care. Crit Care Clin. 2017;33(2):225–43.
Davidson JE, Harvey MA, Schuller J. Post-intensive care syndrome: what it is and how to help prevent it. Am Nurse Today. 2013;8(5):32–8.
Harvey MA, Davidson JE. Postintensive care syndrome: right care, right now...and later. Crit Care Med. 2016;44(2):381–5.
Prinjha S, Field K, Rowan K. What patients think about ICU follow-up services: a qualitative study. Crit Care. 2009;13(2):R46.
Prescott HC, Angus DC. Enhancing recovery from sepsis: a review. JAMA. 2018;319(1):62–75.
Granja C, et al. Quality of life of survivors from severe sepsis and septic shock may be similar to that of others who survive critical illness. Crit Care. 2004;8(2):R91–8.
Brown SM, Bose S, Banner-Goodspeed V, Beesley SJ, Dinglas VD, Hopkins RO, Jackson JC, Mir-Kasimov M, Needham DM, Sevin CM. Approaches to addressing post-intensive care syndrome among intensive care unit survivors. A narrative review. Ann Am Thorac Soc. 2020;16(8):947–56.
Mikkelsen M, et al. Society of Critical Care Medicine’s international consensus conference on prediction and identification of long-term impairments after critical illness. Crit Care Med. in press.
Jolley SE, Bunnell AE, Hough CL. ICU-acquired weakness. Chest. 2016;150(5):1129–40.
Marinos, E., THE ‘MUST’ REPORT – nutritional screening of adults: a multidisciplinary responsibility – development and use of the ‘Malnutrition Universal Screening Tool’ (‘MUST’) for adults, T.B.A.f.P.a.E. Nutrition, Editor. 2003. p. 127.
Ali NA, et al. Acquired weakness, handgrip strength, and mortality in critically ill patients. Am J Respir Crit Care Med. 2008;178(3):261–8.
Connolly B, et al. Exercise rehabilitation following intensive care unit discharge for recovery from critical illness. Cochrane Database Syst Rev. 2015;(6):Cd008632.
Major ME, et al. Surviving critical illness: what is next? An expert consensus statement on physical rehabilitation after hospital discharge. Crit Care (London, England). 2016;20(1):354–354.
van Zanten ARH, De Waele E, Wischmeyer PE. Nutrition therapy and critical illness: practical guidance for the ICU, post-ICU, and long-term convalescence phases. Crit Care. 2019;23(1):368.
Schmidt K, et al. Effect of a primary care management intervention on mental health-related quality of life among survivors of sepsis: a randomized clinical trial. JAMA. 2016;315(24):2703–11.
Tohara H, et al. Three tests for predicting aspiration without videofluorography. Dysphagia. 2003;18(2):126–34.
Brodsky MB, et al. Prevalence, pathophysiology, diagnostic modalities and treatment options for dysphagia in critically ill patients. Am J Phys Med Rehabil. 2020;99:1164.
Sinwar PD. Overwhelming post splenectomy infection syndrome – review study. Int J Surg. 2014;12(12):1314–6.
Granja C, et al. Patients’ recollections of experiences in the intensive care unit may affect their quality of life. Crit Care. 2005;9(2):R96–109.
Bienvenu OJ, et al. Psychiatric symptoms after acute respiratory distress syndrome: a 5-year longitudinal study. Intensive Care Med. 2018;44(1):38–47.
Greenberg N, Brooks S, Dunn R. Latest developments in post-traumatic stress disorder: diagnosis and treatment. Br Med Bull. 2015;114(1):147–55.
Schmidt KF, et al. Long-term courses of sepsis survivors: effects of a primary care management intervention. Am J Med. 2020;133(3):381–385.e5.
Schmidt K, et al. Traumafolgestörungen in der Allgemeinmedizin. Prim Hosp Care Allg Inn Med. 2018;18(12):212–6.
Mehlhorn J, et al. Rehabilitation interventions for postintensive care syndrome: a systematic review. Crit Care Med. 2014;42(5):1263–71.
Jones C. Narratives of illness and healing after the ICU. In: Stevens RD, Hart N, Heridge MS, editors. Textbook of post-ICU medicine: the legacy of critical care: Oxford University Press; 2014. p. 597–602.
Taylor AK, et al. Identification of post-traumatic stress disorder following ICU. Br J Gen Pract. 2019;69(680):154–5.
Kamdar BB, et al. Return to work after critical illness: a systematic review and meta-analysis. Thorax. 2020;75(1):17–27.
Gräfe K, et al. Screening psychischer Störungen mit dem “Gesundheitsfragebogen für Patienten (PHQ-D)”. Diagnostica. 2004;50(4):171–81.
Elliot, D. and L. Deneh, Post-ICU rehabilitation, in Textbook of post-Icu medicine: the legacy of critical care, R.D. Stevens, N. Hart, and M.S. Heridge, 2014, Oxford University Press 583-596.
Hopkins RO, et al. Neuropsychological sequelae and impaired health status in survivors of severe acute respiratory distress syndrome. Am J Respir Crit Care Med. 1999;160(1):50–6.
Kalbe E, et al. DemTect: a new, sensitive cognitive screening test to support the diagnosis of mild cognitive impairment and early dementia. Int J Geriatr Psychiatry. 2004;19(2):136–43.
Singer M, Shankar-Hari M. Sepsis, an issue of critical care clinics. E-Book. 34 1. Elsevier Health Sciences, 2017.
Schmidt M, Azoulay E. Having a loved one in the ICU: the forgotten family. Curr Opin Crit Care. 2012;18(5):540–7.
Griffiths RD. Introduction therapeutic and rehabilitation strategies in the post-ICU period. In: Stevens RD, Hart N, Heridge MS, editors. Textbook of post-ICU medicine: the legacy of critical care: Oxford University Press; 2014. p. 525–9.
Winters BD, et al. Long-term mortality and quality of life in sepsis: a systematic review. Crit Care Med. 2010;38(5):1276–83.
Murray SA, et al. Illness trajectories and palliative care. BMJ. 2005;330(7498):1007–11.
Care T.G.S.F.C.i.E.o.L. GSF Proactive Identification Guidance (PIG) 08.08.2019]; Available from www.goldstandardsframework.org.uk/PIG.
Highet G, et al. Development and evaluation of the supportive and palliative care indicators tool (SPICT): a mixed-methods study. BMJ Support Palliat Care. 2014;4(3):285–90.
Needham DM, et al. Core outcome measures for clinical research in acute respiratory failure survivors. An international modified Delphi consensus study. Am J Respir Crit Care Med. 2017;196(9):1122–30.
Rubak S, et al. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract. 2005;55(513):305–12.
Elwyn G, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361–7.
Elliott D, et al. Exploring the scope of post-intensive care syndrome therapy and care: engagement of non-critical care providers and survivors in a second stakeholders meeting. Crit Care Med. 2014;42(12):2518–26.
Mikkelsen ME, Netzer G, Iwashyna T. Post-intensive care syndrome (PICS). In: Post T, editor. UpToDate. Waltham: UpToDate; 2020. p. 1–29. Accessed on 16 June 2020.
Jones C, et al. Rehabilitation after critical illness: a randomized, controlled trial. Crit Care Med. 2003;31(10):2456–61.
Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288(14):1775–9.
Gensichen J, et al. Effect of a combined brief narrative exposure therapy with case management versus treatment as usual in primary care for patients with traumatic stress sequelae following intensive care medicine: study protocol for a multicenter randomized controlled trial (PICTURE). Trials. 2018;19(1):480.
Daly BJ, et al. Trial of a disease management program to reduce hospital readmissions of the chronically critically ill. Chest. 2005;128(2):507–17.
Douglas SL, et al. Chronically critically ill patients: health-related quality of life and resource use after a disease management intervention. Am J Crit Care. 2007;16(5):447–57.
Schofield-Robinson OJ, et al. Follow-up services for improving long-term outcomes in intensive care unit (ICU) survivors. Cochrane Database Syst Rev. 2018;(11):Cd012701.
Nelson EC, et al. Patient reported outcome measures in practice. BMJ. 2015;350:g7818.
Ali NA, et al. Acquired weakness, handgrip strength, and mortality in critically ill patients. Am J Respir Crit Care Med. 2008;178(3):261–8.
Paternostro-Sluga T, et al. Reliability and validity of the Medical Research Council (MRC) scale and a modified scale for testing muscle strength in patients with radial palsy. J Rehabil Med. 2008;40(8):665–71.
Korupolu R, et al. Rehabilitation of critically ill COVID-19 survivors. J Int Soc Phys Rehabil Med. 2020;3(2):45–52.
Ambrose A, et al. Patient and caregiver guide to managing COVID-19 patients at home. J Int Soc Phys Rehabil Med. 2020;3(2):53–68.
Enright PL. The six-minute walk test. Respir Care. 2003;48(8):783–5.
Chan KS, et al. Evaluating physical outcomes in acute respiratory distress syndrome survivors: validity, responsiveness, and minimal important difference of 4-meter gait speed test. Crit Care Med. 2016;44(5):859–68.
Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179–86.
Katz S, Akpom CA. A measure of primary sociobiological functions. Int J Health Serv. 1976;6(3):493–508.
Nikayin S, et al. Anxiety symptoms in survivors of critical illness: a systematic review and meta-analysis. Gen Hosp Psychiatry. 2016;43:23–9.
Snaith R, Zigmond A. Hospital anxiety and depression scale (HADS). In: Handbook of psychiatric measures. Washington DC: American Psychiatric Association; 2000. p. 547–8.
Kroenke K, et al. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146(5):317–25.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fifth Edition (DSM-5). Arlington; 2013.
Rabiee A, et al. Depressive symptoms after critical illness: a systematic review and meta-analysis. Crit Care Med. 2016;44(9):1744–53.
Norman SB, et al. Development and validation of an overall anxiety severity and impairment scale (OASIS). Depress Anxiety. 2006;23(4):245–9.
Plummer F, et al. Screening for anxiety disorders with the GAD-7 and GAD-2: a systematic review and diagnostic metaanalysis. Gen Hosp Psychiatry. 2016;39:24–31.
Hosey MM, Leoutsakos JS, Li X, Dinglas VD, Bienvenu OJ, Parker AM, Hopkins RO, Needham DM, Neufeld KJ: Screening for posttraumatic stress disorder in ARDS survivors: validation of the Impact of Event Scale-6 (IES-6). Crit Care 2019, 23(1):276.
Stoll C, et al. Sensitivity and specificity of a screening test to document traumatic experiences and to diagnose post-traumatic stress disorder in ARDS patients after intensive care treatment. Intensive Care Med. 1999;25(7):697–704.
Jones C. Narratives of Illness and Healing after the ICU. In: Stevens RD, Hart N, Herridge MS, editors. Textbook of post-ICU medicine: the legacy of critical care: Oxford University Press; 2014. p. 597–602.
Huang M, et al. Psychiatric symptoms in acute respiratory distress syndrome survivors: a 1-year national multicenter study. Crit Care Med. 2016;44(5):954–65.
Nasreddine D. Montreal cognitive assessment website.[cited 2020 15.08.2020]; Available from: http://www.mocatest.org/pdf_files/test/MoCA-Test-BLIND.pdf.
Desai SV, Law TJ, Needham DM. Long-term complications of critical care. Crit Care Med. 2011;39(2):371–9.
Mikkelsen M, Netzer I. Post-intensive care syndrome (PICS). Post-intensive care syndrome (PICS) 2020 [cited 2020; pages 1–29].
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Schmidt, K., Gehrke-Beck, S. (2021). Transitions to Primary Care. In: Haines, K.J., McPeake, J., Sevin, C.M. (eds) Improving Critical Care Survivorship. Springer, Cham. https://doi.org/10.1007/978-3-030-68680-2_17
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