So You’ve Been Asked to See a Recovering COVID Patient in Clinic: What Do You Do?

Carla M. Sevin, MD, FCCMDirector, The ICU Recovery Center at Vanderbilt

Nashville, Tennessee

@ICU_Recovery

The Why

Iwashyna 2011 JAGS

Survival is not the end-point for patients and families

Post-Intensive Care Syndrome (PICS)

Needham et al. Crit Care Med 2012Adapted with permission from Hallie Prescott

Stressed Families DepressionAnxietyPTSD

Cognitive ImpairmentsExecutive Function

Mental Processing SpeedVisuo‐spatialMemoryAttention

Physical ImpairmentsMuscle Weakness and Loss

NeuropathiesPulmonary Function

Mental HealthDepressionAnxietyPTSD

High Burden of Chronic Health Conditions

Kamdar et al AJCC 2017

How is recovery different in COVID-19?Now add:

Increased sedationIncreased use of benzodiazepinesIncreased time on vent

mobilityfamily visitationresources and staff

Physical sequelae 6MWT

Battle et al J Crit Care 2018

Alopecia Onychomadesis

Shoulder Impairment

Gustafson et al Crit Care Med 2018

ROM

Global Cognition Scores in Survivors

Pandharipande et al NEJM 2013

MoCA

https://www.mocatest.org/remote‐moca‐testing/

Delirium is the strongest independent predictor of cognitive impairment

0 2 4 6 8 10

70

60

80

90

N=382

P=0.004 for 0 vs. 5 days of delirium

RBANS Global

Cognitive Score

Days of ICU DeliriumPandharipande et al. NEJM 2013

CAM

PTSD after critical illness

• Meta-analysis: – PTSD symptoms in 1/5– More likely in those with

• comorbid psychopathology• benzodiazepines • early memories of frightening

ICU experiences

Parker et al CCM 2015Art by Nancy Andrews

PCL‐5IES‐6HADS

Unroe et al Ann Int Med 2010

Models of post ICU care

The Vanderbilt ModelSELECTION CRITERIA:• Mechanical ventilation• Shock• Delirium

TEAM:• Respiratory therapy• Pharmacy• Critical Care• Psychology• Case management

An Interdisciplinary ICU Recovery ClinicPatient check in Patient check in 

Spirometry (RT)Spirometry (RT)

Patient in exam room

Patient in exam room

Vital signs checked  (LPN)

Vital signs checked  (LPN) 6MWT6MWT

Patient back in exam room

Patient back in exam room

Med reconciliation (pharmacist)

Med reconciliation (pharmacist)

Medical history and exam (NP)Medical history and exam (NP)

Neuropsych evaluation Neuropsych evaluation 

Case management evaluation 

Case management evaluation 

Assessment and plan discussed with patient 

Assessment and plan discussed with patient 

Patient and family feedback

Patient and family feedback

Updated med list and plan (checkout)

Updated med list and plan (checkout)

Team conferenceTeam conference

Report for primary provider prepared 

and sent

Report for primary provider prepared 

and sent

Data recordedData recorded

Minimum criterion

Sevin and Jackson Crit Care Med 2019 

Components of an ICU recovery program

McPeake et al April 2020

TelemedicineAdvantages

• Reach patients at critical time points

• Start up costs are low• Can pull in multidisciplinary 

team members from afar• See family, home environment• ”Screen and triage”

Disadvantages• Limited objective data 

gathering, physical exam, and treatments

• Still some regulatory hurdles despite COVID

Interview tips• Diagnostic: Ask very specific questions, and listen to the answers

– Patient may not want to know the answer– You may not know how to deal with the answer*

• Therapeutic: Normalize recovery problems

*This is ok. If you don’t seek you will not find.

Content: Iwashyna, Johnson, McPeake, McSparron, Prescott, SevinGraphics: Chelsea Harris @CAHarrisMD

https://litfl.com/the‐dirty‐dozen‐common‐errors‐on‐discharging‐patients‐recovering‐from‐critical‐illness/

Serial assessments

Adapted from “Timing It Right” Framework:Cameron and Gignac 2008

Anticipatory guidance

Education

Discharge planning Post ICU Clinic

Telehealth? Peer support

Weeks Months  Years?

Haines et al ICM 2019

ICU Recovery Programs

Peer support

Clinic

Both

https://www.sccm.org/MyICUCare/THRIVE/Connect‐With‐Patients‐and‐Families

Vanderbilt ICU Recovery@ICU_Recovery

@CAIROrg