Towards RECOVER: Interdisciplinary and molecular characterization of functional disability after critical illness and development of a family-centred rehabilitation program
Emergency and Critical Care
Determinants of one-year disability risk groups and outcomes after 7 days of mechanical ventilation(MV) in medical and surgical ICU survivors and their caregivers are unknown. Few resources are available to support patients and caregivers to survivors of critical illnes. This is an urgent issue for the Canadian public health agenda as there is no systematic post-ICU follow-up care to optimize patient and family outcomes. Also, there is no formal platform to educate on outcomes after critical illness. The RECOVER Program Phase I- Towards RECOVER study is the first international, prospective, multi-centre cohort of survivors of critical illness and their family caregivers that characterizes in detail the impact of illness and the caregiving situation on patients’ and caregivers’ long-term function and mental health. Novel findings from this diverse national cohort of medical and surgical patients enable us to understand that patients and caregivers may be divided into disability and mental health risk groups after ICU discharge that predict healthcare resource use and recovery trajectories during and after 1 year of the critical illness. These data will inform nuanced rehabilitation practice and the ultimate construction of a patient- and family-centered post-ICU follow-up care as well as a national education program on ICU outomes (RECOVER Program – Phases II and III).
In the towards RECOVER study, mechanically-ventilated ICU patients and their family caregivers were recruited from 10 sites in 6 cities across Canada. Detailed outcomes and healthcare use were assessed 7-days, 3, 6, 12, and 24-months post-ICU discharge. Risk stratification for rehabilitation was attained using recursive partitioning modeling and thematic analysis of qualitative data used to specify rehabilitation needs over time. Findings show: i) 60% of patients were unable to walk at 7 days after ICU discharge; ii) Functional independence measure (FIM) is the optimal outcome to inform a rehabilitation intervention as it captures detailed disability in a patient-centred manner regardless of the patient’s ability to walk; iii) Patients may be divided into 4 disability risk groups using age and ICU LOS and these groups predict FIM at day 7 after ICU discharge. These risk groups are independent of admitting diagnosis and severity of illness; iv) The 7-day FIM predicts the trajectory of recovery to 1 year after ICU discharge; shoulder and hip girdle weakness are the main determinants of disability with ability to bathe, climb stairs and to dress upper body and lower body being the most affected; v) Patients have prevalent depressive symptoms and PTSD which may persist to 1 year; and vi) Caregivers have an important burden of mood disorders that are related to caregiver mastery and intrinsic characteristics of the caregiver independent of patient characteristics, degree of patient post-ICU disability or presence of mood disorders. Based on this information, we have devised a multidimensional and longitudinal working model for patient- and family-centred ICU follow-up care based on disability risk and tailored to individual needs (the RECOVER Program). This is currently undergoing feasibility and implementation testing.