Post-ICU Care in the Outpatient Setting

 

Am Fam Physician. 2021 May 15;103(10):590-596.

Published online February 2, 2021.

Author disclosure: No relevant financial affiliations.

More than 5 million patients in the United States are admitted to intensive care units (ICUs) annually, and an increasing percentage of patients treated in the ICU survive to hospital discharge. Because these patients require follow-up in the outpatient setting, family physicians should be prepared to provide ongoing care and screening for post-ICU complications. Risk factors for complications after ICU discharge include previous ICU admissions, preexisting mental illness, greater number of comorbidities, and prolonged mechanical ventilation or higher opioid exposure while in the ICU. Early nutritional support and mobilization in the ICU decrease the risk of complications. After ICU discharge, patients should be screened for depression, anxiety, insomnia, and cognitive impairment using standardized screening tools. Physicians should also inquire about weakness, fatigue, neuropathy, and functional impairment and perform a targeted physical examination and laboratory evaluation as indicated; treatment depends on the underlying cause. Exercise regimens are beneficial for reducing several post-ICU complications. Patients who were treated for COVID-19 in the ICU may require additional instruction on reducing the risk of virus transmission. Telemedicine and telerehabilitation allow patients with COVID-19 to receive effective care without increasing exposure risk in communities, hospitals, and medical offices.

More than 5 million patients in the United States are admitted to intensive care units (ICUs) annually.1 Mortality rates among these patients decreased by 35% between 1988 and 2012, despite increasing illness severity and increasing patient age; current mortality rates are estimated at 10% to 29%.1 Because a greater number of patients are surviving to ICU discharge and require follow-up in the outpatient setting, family physicians should be prepared to provide ongoing care and screening for post-ICU complications.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Patients should be screened for weakness after ICU discharge and referred for physical rehabilitation when appropriate.58

B

Small randomized controlled trials and professional guideline

Patients should be screened for cognitive impairment after ICU discharge.2022

C

Observational and retrospective cohort studies

Patients should be screened for depression,anxiety, and posttraumatic stress disorder after ICU discharge.5,24,25

C

Prospective cohort studies

Partners and family members of patients discharged from the ICU should be screened for depression, anxiety, and posttraumatic stress disorder.27,28

C

Prospective cohort studies


ICU = intensive care unit.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Patients should be screened for weakness after ICU discharge and referred for physical rehabilitation when appropriate.58

B

Small randomized controlled trials and professional guideline

Patients should be screened for cognitive impairment after ICU discharge.2022

C

Observational and retrospective cohort studies

Patients should be screened for depression,anxiety, and posttraumatic stress disorder after ICU discharge.5,24,25

C

Prospective cohort studies

Partners and family members of patients discharged from the ICU should be screened for depression, anxiety, and posttraumatic stress disorder.27,28

C

Prospective cohort studies


ICU = intensive care unit.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

With no universally accepted guidelines, the timing and frequency of post-ICU follow-up should be individualized and based on the patient's comorbidities and severity of illness. Although about 20 medical centers in the United States have post-ICU transition clinics,2 there is no evidence that such programs decrease readmission or mortality rates.3

Although the term post-ICU syndrome has been used to describe the various complications reported in ICU survivors (Table 14), there is no universally accepted definition for such a syndrome. Family physicians must be familiar with the complications that can occur after discharge (e.g., physical and psychological impairments), including in patients recovering from COVID-19.

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TABLE 1.

Common Complications After Discharge

The Authors

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JASON WILBUR, MD, FAAFP, is the vice chair of education and a clinical professor in the Department of Family Medicine at the University of Iowa Carver College of Medicine, Iowa City....

JESSICA ROCKAFELLOW, MD, is a clinical assistant professor in the Department of Family Medicine at the University of Iowa Carver College of Medicine.

BRIAN SHIAN, MD, is a clinical associate professor in the Department of Family Medicine at the University of Iowa Carver College of Medicine.

Address correspondence to Jason Wilbur, MD, University of Iowa Carver College of Medicine, 200 Hawkins Dr., Iowa City, IA 52242 (email: jason-wilbur@uiowa.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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