Nice review. Just as critical illness is often, itself, a multi-organ process, PICS follows suit. Having tried to pull together an appropriately multi-disciplinary PICS clinic in my own institution, it is easy to see why there are only 35 that you can readily identify. Who was interested? The intensivist. Rehab, neurology, speech, etc. not so much. Why? There was no mechanism for billing for their specialty work. Take rehab medicine, for example. CMS will pay for post-trauma care, post-stroke care, post-neurosurgical care, post-orthopedic care, even post-MI care, but there is no code for post-ICU general care, i.e. it is not recognized. Any administrator can see that the above named conditions impair function in specific ways. What insurance company or CMS administrator understands the generalized impairment that comes from a broad variety of critical illnesses? Hence, my colleagues, not being able to bill for anything in particular, chose not to participate. Multi-organ failure led to multi-specialty breakdown.
Something worth pointing out is that there is now an ICD-CM code for post-sepsis syndrome, Z51.A. Even though there are no specific diagnostic criteria, other than having had sepsis. Sepsis, by the way, like COVID-19, need not involve ICU care to result in long-lasting neurocognitive and physical deficits. Given that sepsis-induced delirium or encephalopathy is one of the most frequently encountered organ dysfunctions, this should not be surprising. (BTW, a pet peeve is when even gerontologists say "old people get delirious with infection" - yes, they do when they have infection-induced CNS dysfunction. It should be our business to determine why older brains are particularly susceptible to dysfunction, for heaven's sakes.) Having ranted, I'll return to the key point of the paragraph - infections don't rely on having put you into an ICU in order to engender PICS-type impairment.
Finally, I'll point out a conundrum. It's intensivists who are most aware of PICS. Yet it is intensivists who are perhaps least prepared for treating it. Knowing how to care for shock and knowing that your care leads to post-ICU impairments are different from having expertise at actually caring, in the long term, for patients who have those impairments. The skill sets are almost diametrically opposed, and the interest level quite possibly similar. Intensivists tackled the problem of sepsis and awareness of it among other physicians precisely because we saw the devastating downstream effects of missing it or ignoring it in its early course. It was a natural direction to go, and it kept us in the ICU. PICS would take us out of the ICU and into clinic. That stage migration (Will Rogers) effect could wind us up with both worsening ICU and clinic outcomes. Fascinating.
Love this reply — but it raises a bigger question.
Sure, intensivists might be well positioned to lead post-ICU care. But are we truly better suited than PM&R colleagues, who routinely guide patients through recovery from devastating neurologic injury, stroke, and complex medical illness? Rehabilitation medicine is built around longitudinal, function-focused recovery. That’s their core expertise.
As this excellent piece notes, post-ICU clinics are labor-intensive. You see 4-5 post-nasal drips in the time it takes to thoughtfully evaluate and support one post-ICU survivor — and the RVU structure certainly favors the former. That reality matters when thinking about scalability and sustainability.
Attended a conference presentation from someone running a post-ICU clinic. Like much of the data cited in the article, the takeaway felt less like demonstrable outcome improvement and more like, “Look at this innovative model we’re building.” (and it will help me get promoted) -- It was difficult to see compelling evidence that a 60-something pt who survived a week of mechanical ventilation for Legionella pneumonia months ago would derive meaningful benefit from a sporadically assembled multidisciplinary team whose members have competing clinical demands.
This isn’t necessarily a “call the Justice League” problem. There are already established pathways — PM&R, primary care, targeted specialty referrals, mental health services — that can meet many of these needs without building an entirely new silo of care.
The article makes an important point: prevention likely matters more than post-hoc clinic structure. Reducing delirium, minimizing deep sedation, shortening ventilator days, and accepting the labor-intensive work of awake, mobilized ICU care may ultimately do more to mitigate PICS than episodic outpatient programs.
Personally, I’ve used a midazolam drip perhaps three or four times in the past 60 weeks of ICU service. Meanwhile, I’ve seen patients handed off on multiple continuous sedative infusions as routine practice. Does a “waking and walking” ICU change long-term outcomes? We don’t yet have definitive answers — but if it’s safe, that may be the more meaningful starting point for rehabilitation. In many ways, the as-stated pre-hab begins in the ICU itself.
Perhaps am wrong — but standardizing lighter sedation, delirium prevention, and early mobility may ultimately do more to reduce PICS than building resource-intensive, sporadic post-ICU clinics.
I agree with pretty much everything you say. I've just played heck trying to get those specialists, who I think have the real expertise, interested in these patients. Also 100% agree with avoiding benzodiazepines, using standard sedation protocols, etc. As we have known for a long time, an ounce of prevention is worth a pound of cure. But we can't prevent it all, and I do think there is a role for whatever kind of doc has the wherewithal to see these folks through their long term issues.
Nice review. Just as critical illness is often, itself, a multi-organ process, PICS follows suit. Having tried to pull together an appropriately multi-disciplinary PICS clinic in my own institution, it is easy to see why there are only 35 that you can readily identify. Who was interested? The intensivist. Rehab, neurology, speech, etc. not so much. Why? There was no mechanism for billing for their specialty work. Take rehab medicine, for example. CMS will pay for post-trauma care, post-stroke care, post-neurosurgical care, post-orthopedic care, even post-MI care, but there is no code for post-ICU general care, i.e. it is not recognized. Any administrator can see that the above named conditions impair function in specific ways. What insurance company or CMS administrator understands the generalized impairment that comes from a broad variety of critical illnesses? Hence, my colleagues, not being able to bill for anything in particular, chose not to participate. Multi-organ failure led to multi-specialty breakdown.
Something worth pointing out is that there is now an ICD-CM code for post-sepsis syndrome, Z51.A. Even though there are no specific diagnostic criteria, other than having had sepsis. Sepsis, by the way, like COVID-19, need not involve ICU care to result in long-lasting neurocognitive and physical deficits. Given that sepsis-induced delirium or encephalopathy is one of the most frequently encountered organ dysfunctions, this should not be surprising. (BTW, a pet peeve is when even gerontologists say "old people get delirious with infection" - yes, they do when they have infection-induced CNS dysfunction. It should be our business to determine why older brains are particularly susceptible to dysfunction, for heaven's sakes.) Having ranted, I'll return to the key point of the paragraph - infections don't rely on having put you into an ICU in order to engender PICS-type impairment.
Finally, I'll point out a conundrum. It's intensivists who are most aware of PICS. Yet it is intensivists who are perhaps least prepared for treating it. Knowing how to care for shock and knowing that your care leads to post-ICU impairments are different from having expertise at actually caring, in the long term, for patients who have those impairments. The skill sets are almost diametrically opposed, and the interest level quite possibly similar. Intensivists tackled the problem of sepsis and awareness of it among other physicians precisely because we saw the devastating downstream effects of missing it or ignoring it in its early course. It was a natural direction to go, and it kept us in the ICU. PICS would take us out of the ICU and into clinic. That stage migration (Will Rogers) effect could wind us up with both worsening ICU and clinic outcomes. Fascinating.
Love this reply — but it raises a bigger question.
Sure, intensivists might be well positioned to lead post-ICU care. But are we truly better suited than PM&R colleagues, who routinely guide patients through recovery from devastating neurologic injury, stroke, and complex medical illness? Rehabilitation medicine is built around longitudinal, function-focused recovery. That’s their core expertise.
As this excellent piece notes, post-ICU clinics are labor-intensive. You see 4-5 post-nasal drips in the time it takes to thoughtfully evaluate and support one post-ICU survivor — and the RVU structure certainly favors the former. That reality matters when thinking about scalability and sustainability.
Attended a conference presentation from someone running a post-ICU clinic. Like much of the data cited in the article, the takeaway felt less like demonstrable outcome improvement and more like, “Look at this innovative model we’re building.” (and it will help me get promoted) -- It was difficult to see compelling evidence that a 60-something pt who survived a week of mechanical ventilation for Legionella pneumonia months ago would derive meaningful benefit from a sporadically assembled multidisciplinary team whose members have competing clinical demands.
This isn’t necessarily a “call the Justice League” problem. There are already established pathways — PM&R, primary care, targeted specialty referrals, mental health services — that can meet many of these needs without building an entirely new silo of care.
The article makes an important point: prevention likely matters more than post-hoc clinic structure. Reducing delirium, minimizing deep sedation, shortening ventilator days, and accepting the labor-intensive work of awake, mobilized ICU care may ultimately do more to mitigate PICS than episodic outpatient programs.
Personally, I’ve used a midazolam drip perhaps three or four times in the past 60 weeks of ICU service. Meanwhile, I’ve seen patients handed off on multiple continuous sedative infusions as routine practice. Does a “waking and walking” ICU change long-term outcomes? We don’t yet have definitive answers — but if it’s safe, that may be the more meaningful starting point for rehabilitation. In many ways, the as-stated pre-hab begins in the ICU itself.
Perhaps am wrong — but standardizing lighter sedation, delirium prevention, and early mobility may ultimately do more to reduce PICS than building resource-intensive, sporadic post-ICU clinics.
I agree with pretty much everything you say. I've just played heck trying to get those specialists, who I think have the real expertise, interested in these patients. Also 100% agree with avoiding benzodiazepines, using standard sedation protocols, etc. As we have known for a long time, an ounce of prevention is worth a pound of cure. But we can't prevent it all, and I do think there is a role for whatever kind of doc has the wherewithal to see these folks through their long term issues.
That was beautifully written. And I don't say "beautifully" very often - haha.