The Critical Care Recovery Clinic (CCRC)
The Critical Care Recovery Clinic (CCRC) was launched by the Institute for Critical Care Medicine (ICCM) as an initiative dedicated to addressing the multifaceted recovery needs of individuals who have survived a critical illness as well as to fill essential gaps in care after hospital discharge.
A common consequence of critical illness is post intensive care syndrome. Known as PICS, the condition describes the spectrum of health concerns that remain from a critical illness after a patient is discharged from the hospital. These may be of the physical domain such as muscle weakness or difficulty sleeping, the cognitive domain such as memory and concentration issues, and the psychological domain such as anxiety and post-traumatic stress disorder.
PICS can present as early as when the patient is in the intensive care unit (ICU) to as late as after the patient returns home. Patients and families often lack understanding and context of their critical illness, resources to assist with life at home, information about what recovery is expected to involve, and awareness of PICS. Many patients will not make a full recovery following their critical illness. However, deficits that cannot be reversed still need to be identified, explained, and reconciled.
By using evidence-based practice, the CCRC works to mitigate the neuropsychological, mental health, physical, and practical challenges among survivors of critical illness in the months and years after discharge. Our CCRC provides assessment for PICS symptoms, consultation with a critical care physician with PICS expertise, review of the ICU course, and connection to appropriate support services. Psychiatry, cognitive, physical and occupational therapy, medication education, and reconciliation with a pharmacist are available. Continued assistance obtaining medical equipment; behavioral health consultations for sleep, pain, stress management, and smoking cessation; resources and support for caregivers and family members; and spiritual care are other available services.
The main goals of CCRC is to create awareness about PICS and post intensive care syndrome in families (PICS-F). We help patients and families embark on the best possible trajectory of recovery; address important gaps in care after discharge from the ICU; and collaborate with national and international scientific organizations to understand the longitudinal impact of critical care on patients and families.
Patients who are seen in the CCRC are individuals with complex medical conditions and multiple comorbidities who were admitted to the ICU for seven days or longer. These patients had a wide variety of critical care illnesses and often required mechanical ventilation, renal replacement therapy, mechanical circulatory support, emergency and complex surgeries, transplants, and neurosurgical interventions. Because the CCRC is part of ICCM, the ICU survivors that come through this clinic are patients who were admitted to the different sub-specialty ICUs throughout the Mount Sinai Health System.
The clinical team is composed of critical care physicians, critical care pharmacists, critical care advance practitioners, ICU social workers, physiatrists, spiritual care, research coordinators, and administrative staff. Under the co-direction of critical care medicine specialists Neha S. Dangayach, MD and Miguel Martillo, MD, the CCRC started its operations on Feb 11, 2020, and is entirely funded by ICCM. The clinic collaborates nationally and internationally and is an active member of The Critical and Acute Illness Recovery Organization (CAIRO), a global collaborative of multidisciplinary groups dedicated to improving outcomes for ICU survivors and their families. From its inception, the CCRC has seen approximately 40 ICU survivors.
As a leading health care provider, Mount Sinai offers modern and comprehensive outpatient facilities with state of the art medical equipment. The CCRC operates within the Center for Advanced Medicine at Mount Sinai. Patients from different ethnicities, economic statuses, and socio-cultural backgrounds come to our facilities for world-class outpatient care. The clinic accepts Medicaid, Medicare, as well as a host of managed care and commercial insurance plans. The CCRC shares clinic space with Internal Medicine Associates, and is designated a waiting area, check-in desk, one room for vitals to be taken, and three exam rooms with computer access. The clinic also has access to one shared video remote interpreting device.
The CCRC team selects patients who are at risk of developing PICS while they are in the ICU. Our doctor’s identify patients by screening for common critical care conditions that have been evidenced to be associated with PICS. Patients who come to the clinic were in the ICU for more than seven days and commonly were diagnosed with sepsis, and septic shock, delirium, acute respiratory distress syndrome, and required mechanical ventilation.
Patients who are identified to be at risk for PICS or referred by an intensivist are scheduled to have an appointment within a month of hospital discharge. Critical care advanced practice practitioners who are part of the CCRC call patients after 48 hours of hospital discharge for an introductory and educational conversation about PICS. Subsequently, the CCRC team continues to have contact with patients two and three weeks after hospital discharge. During these check-in phone calls, the CCRC team provides emotional support to the patients and families. Before the appointment day, patients are emailed forms that assess the cognitive, emotional, and physical domain of PICS.
During the appointment, the patient first has vital signs taken; then, an intensivist meets with the patient to review the ICU course and related medical problems. The clinician also screens for depression, anxiety, and post-traumatic stress disorder. The doctor will also perform a cognitive and physical assessment, and address all of the patient's concerns.
Subsequently, the patient meets with a critical care pharmacist for medication reconciliation and education. Next, the patient and family talk with a social worker who assists in obtaining medical equipment and ambulatory devices. A spiritual care worker may speak with the patient and family at the end of the visit to provide spiritual support. Lastly, the clinic team will summarize the clinic visit with instructions for patients and primary care doctors, which often includes referrals to other services, counseling on medication compliance, and reminders for follow-up appointments.