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opinion: covid-19 shows that we can't care for icu survivors

fuschia howard: people who get out of intensive care suffer physical, cognitive and psychological complications.

by fuchsia howard & greg haljan

oct 21 2020

4 minute read

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covid-19 shows that we can't care for those who survive the icu

fuschia howard

as canadians, we have so far escaped the worst of the calamity of covid-related suffering and death.

yet for many people, a return to normal will remain an unrealistic dream. the 20 per cent of hospitalized patients who develop severe conditions requiring ventilation and care in an intensive care unit (icu) will shoulder a significant and ongoing burden of disease including cognitive impairment, debilitating muscle aches and pains, lung problems, and crushing anxiety.

while covid-specific long-term problems are only recently emerging, recent research has revealed the long-term complications of all critical illnesses. covid has further illuminated and magnified a pre-existing gap in the healthcare system — that of critical illness survivorship.

with all eyes now on the healthcare system and icus specifically, the pandemic offers an opportunity for meaningful innovation that shifts the focus from simply preventing death to enabling survivors to thrive.

tremendous strides in the treatment of life-threatening conditions like respiratory failure and sepsis have resulted in rapidly growing numbers of critical illness survivors. adult canadians treated in an icu now outnumber those who receive a new diagnosis of cancer or heart disease.

more than 80 per cent of icu patients survive, and yet there is a remarkable cost associated with treatment. much like an arm or leg that withers inside a cast, the most basic muscles of breathing and posture weaken considerably when a patient is immobilized in a bed on a ventilator. this leaves patients too weak to sit up or even breathe independently.

up to half of icu patients suffer a constellation of physical, cognitive and psychological complications called post-intensive care syndrome (pics). lung impairment, neuromuscular complications, and pain and weakness impair daily life. cognitive impairment, symptoms of depression, anxiety and post-traumatic stress disorder are common. rates of symptoms of post-traumatic stress rival those found in soldiers returning from combat.

back at home, family members become caregivers, shouldering their own physical and emotional burdens, known collectively as pics-family. loss of employment and financial strain can follow. most unsettling is that family satisfaction of patients who survive critical illness is significantly lower than family satisfaction of patients who die. this reveals a profound caregiver burden and gap in critical illness survivorship care.

survivors quickly discover that they are discharged alive but disconnected from their primary care teams and pre-existing support networks. their post-treatment care is complex, and often without a formal personalized plan, if it exists at all. critical illness survivors are regularly lost in transition from hospital to community care and rarely have access to programs and professionals that have expertise in treating pics.

often, this leads to many hospital readmissions that are costly to the well-being of survivors and their families, and costly to the sustainability of the healthcare system. canadian studies have shown that almost half of icu survivors are re-hospitalized within a year, with a large majority readmitted multiple times, and almost half go into an emergency department within the first six months. on average, the daily cost per patient on a general hospital ward is $1,135, and three times higher, $3,592, in an icu. the cost of saving one day in the icu can pay for an entire course of 60 hours of home-based pulmonary rehabilitation.

the formidable legacy of critical illness survivorship — and now covid survivorship — demands immediate attention. we now have an opportunity for rapid healthcare system redesign in canada and beyond that ultimately improves both patient and family outcomes.

a significant number of icu survivors living in the community are in desperate need of support, yet the support they want and need is not known nor available. it is past time for a comprehensive research-informed clinical program for pics patients that will outlast the pandemic.

emerging evidence suggests that such programs include a multidisciplinary team to address complex medical, mental health and rehabilitation needs that seamlessly extends from icu into the community. the rigorous evaluation and tailoring of such programs to survivor-specific needs –— including virtual and ehealth solutions — will be key.

but ultimately what is a priority in healthcare requires the support of the medical community, amplification of voices of patients and their families, and a clear statement of support from senior leaders in healthcare.

this is possible and attainable as the recover program in toronto has shown. this program addresses care gaps and challenges related to transitions from post-icu, through inpatient rehabilitation, to follow-up at home and in the community.

a tremendous first step could be bringing together the research and clinical expertise of the patchwork of post-icu clinics across the country to forge a national standard and agenda.

covid could represent a turning point in health care such that those who require life-sustaining intervention and therapy not only survive, but eventually thrive.

dr. fuchsia howard, phd, rn, is an assistant professor at the ubc school of nursing and a michael smith foundation for health research scholar. her research examines the health service needs of survivors of acute life-threatening illness to contribute to patient-centred solutions that are responsive to the long-term burden of illness.

dr. greg haljan, md, frcpc, is a clinical associate professor at the ubc faculty of medicine, local department head of critical care at surrey memorial hospital, and the regional medical director of the department of evaluation and research services for the fraser health authority.

opinion: covid-19 shows that we can't care for icu survivors

fuschia howard: people who get out of intensive care suffer physical, cognitive and psychological complications.

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opinion: covid-19 shows that we can't care for icu survivors

fuschia howard: people who get out of intensive care suffer physical, cognitive and psychological complications.

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