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The Need for Continuity of Care in Neurocritical Care and Recovery

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Abstract

Purpose of review

After discharge from the Neurological Intensive Care Unit (NICU), patients often have new functional limitations and comorbidities requiring ongoing supportive care. In this review, we discuss the current state across the care continuum and identify opportunities for improvement.

Recent findings

Patients often transition through multiple care settings after discharge from the NICU. Disposition to SNF (skilled nursing facility) and IRF (inpatient rehabilitation facility) varies significantly based on insurance coverage and geography. Opportunities for improvement in care transitions from the hospital to rehabilitative care include enhanced communication with patients and their caregivers to facilitate optimal rehabilitation location and services for long-term support. Standardized communication tools can reduce medical errors with early discharge planning. Early supported discharge can be considered to provide patients with coordinated community or home-based rehabilitation.

Summary

After discharge from the NICU, patients need close outpatient follow-up for medication management, prevention, and management of medical and neuropsychiatric complications. Engagement of ICU providers in long-term outpatient follow-up as part of an organized post-ICU recovery clinic could help them learn about long-term patient experience and recovery, influence sensitivity to managing and preventing neuropsychiatric complications, help guide communication with patients and families, and may reduce provider burnout.

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References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: •  Of importance

  1. Thompson LR, Ifejika NL. The transition from the hospital to an IRF setting for neurologic patients. Nurs Clin North Am. 2019;54(3):357–366. (In eng). https://doi.org/10.1016/j.cnur.2019.04.004.

  2. Benjamin EJ, Muntner P, Alonso A, et al. Heart disease and stroke statistics-2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56–e528. (In eng). https://doi.org/10.1161/cir.0000000000000659.

  3. Hall MJ, Levant S, DeFrances CJ. Hospitalization for stroke in US hospitals, 1989–2009: US Department of Health and Human Services, Centers for Disease Control and …, 2012.

  4. • Woo D, Comeau ME, Venema SU, et al. Risk factors associated with mortality and neurologic disability after intracerebral hemorrhage in a racially and ethnically diverse cohort. JAMA Network Open. 2022;5(3):e221103–e221103. https://doi.org/10.1001/jamanetworkopen.2022.1103. This article offers an understanding of risk factors that contribute to neurologic disability and mortality in addition to traditional vascular risk factors after intracerebral hemorrhage in a large cohort study. Novel risk factors identified included older age, pre-ICH modified Rankin score, and presence of infection in addition to size and location of ICH. These additional characteristics can be utilized to identify patients at greater risk of neurological disability and mortality for targeted transitional care interventions.

  5. • Ifejika NL, Vahidy FS, Reeves M, et al. Association between 2010 Medicare reform and IRF access in people with intracerebral hemorrhage. J Am Heart Assoc. 2021;10(16):e020528. (In eng). https://doi.org/10.1161/jaha.120.020528. Considering the impact of earlier neurological recovery for intracerebral hemorrhage compared to ischemic stroke is an important consideration in the neurocritical care continuum for rehabilitation goals. This article examines the impact of Centers for Medicare and Medicaid Services 2010 prospective payment system on discharges to inpatient rehabilitation facilities. They found fewer discharges to inpatient rehabilitation among patients with intracerebral hemorrhage. This suggests that health policy does affect access to intensive post-acute rehabilitations. In order to improve health care across the neurocritical care continuum, facilitating health policities must be instituted for sustainable impact.

  6. Schepers VP, Ketelaar M, Visser-Meily AJ, de Groot V, Twisk JW, Lindeman E. Functional recovery differs between ischaemic and haemorrhagic stroke patients. J Rehabil Med. 2008;40(6):487–9. (In eng). https://doi.org/10.2340/16501977-0198.

  7. Broderick JP, Abir M. Transitions of care for stroke patients: opportunities to improve outcomes. Circ Cardiovasc Qual Outcomes. 2015;8(6 Suppl 3):S190–2. (In eng). https://doi.org/10.1161/circoutcomes.115.002288.

  8. Higashida R, Alberts MJ, Alexander DN, et al. Interactions within stroke systems of care. Stroke. 2013;44(10):2961–84. https://doi.org/10.1161/STR.0b013e3182a6d2b2.

    Article  PubMed  Google Scholar 

  9. Commission MPA. March 2022 report to the congress: Medicare payment policy. Washington, DC: Medicare Payment Advisory Commission. 2022. https://www.medpac.gov/document/march-2022-report-to-the-congress-medicare-payment-policy/.

  10. Beaulieu CL, Dijkers MP, Barrett RS, et al. Occupational, physical, and speech therapy treatment activities during IRF for traumatic brain injury. Arch Phys Med Rehabil. 2015;96(8 Suppl):S222–34.e17. (In eng). https://doi.org/10.1016/j.apmr.2014.10.028.

  11. Deutsch A, Granger CV, Heinemann AW, et al. Poststroke rehabilitation: outcomes and reimbursement of IRF facilities and subacute rehabilitation programs. Stroke. 2006;37(6):1477–82.

    Article  PubMed  Google Scholar 

  12. Hong I, Goodwin JS, Reistetter TA, et al. Comparison of functional status improvements among patients with stroke receiving postacute care in IRF vs SNFs. JAMA Netw Open. 2019;2(12):e1916646. (In eng). https://doi.org/10.1001/jamanetworkopen.2019.16646.

  13. Belagaje SR, Sun C-HJ, Nogueira RG, et al. Discharge disposition to SNF after endovascular reperfusion therapy predicts a poor prognosis. J Neurointerv Surg. 2015;7(2):99–103.

  14. Greenberg SM, Ziai WC, Cordonnier C, et al. 2022 Guideline for the management of patients with spontaneous intracerebral hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke. 2022;53(7):e282–361. https://doi.org/10.1161/STR.0000000000000407.

    Article  CAS  PubMed  Google Scholar 

  15. Langhorne P, Baylan S. Early supported discharge services for people with acute stroke. Cochrane Database Syst Rev. 2017;7(7):Cd000443. (In eng). https://doi.org/10.1002/14651858.CD000443.pub4.

  16. Lichtman JH, Leifheit-Limson EC, Jones SB, Wang Y, Goldstein LB. Preventable readmissions within 30 days of ischemic stroke among Medicare beneficiaries. Stroke. 2013;44(12):3429–35. https://doi.org/10.1161/STROKEAHA.113.003165.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Rahman M, McHugh J, Gozalo PL, Ackerly DC, Mor V. The contribution of SNFs to hospitals’ readmission rate. Health Serv Res. 2017;52(2):656–75. https://doi.org/10.1111/1475-6773.12507.

    Article  PubMed  Google Scholar 

  18. Tyler DA, Gadbois EA, McHugh JP, Shield RR, Winblad U, Mor V. Patients are not given quality-of-care data about SNFs when discharged from hospitals. Health Aff (Millwood). 2017;36(8):1385–1391. (In eng). https://doi.org/10.1377/hlthaff.2017.0155.

  19. Rahman M, Gozalo P, Tyler D, Grabowski DC, Trivedi A, Mor V. Dual eligibility, selection of SNF, and length of Medicare paid postacute stay. Med Care Res Rev. 2014;71(4):384–401. (In eng). https://doi.org/10.1177/1077558714533824.

  20. Blouin AS. Improving hand-off communications: new solutions for nurses. J Nurs Care Qual. 2011;26(2):97–100.

    Article  PubMed  Google Scholar 

  21. Commission J. Joint Commission Center for Transforming Healthcare. Joint Commission Resources hot topics in health care-transitions of care: the need for a more effective approach to continuing patient care. https://www.pwrnewmedia.com/2013/joint_commission/transitions_of_care/downloads/TOC_Issue_2.pdf. Updated 2012.

  22. Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80(12):1094–1099. https://journals.lww.com/academicmedicine/Fulltext/2005/12000/Lost_in_Translation__Challenges_and_Opportunities.5.aspx.

  23. King BJ, Gilmore-Bykovskyi AL, Roiland RA, Polnaszek BE, Bowers BJ, Kind AJ. The consequences of poor communication during transitions from hospital to SNF: a qualitative study. J Am Geriatr Soc. 2013;61(7):1095–102.

    Article  PubMed  Google Scholar 

  24. Hill CE, Varma P, Lenrow D, Price RS, Kasner SE. Reducing errors in transition from acute stroke hospitalization to IRF. Front Neurol. 2015;6:227.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Ifejika NL, Okpala MN, Moser HA, Watkins JN, Noser EA. Rehab MATRIX: content validity of a nursing-led patient assignment algorithm. J Neurosci Nurs. 2019;51(1):33–6. https://doi.org/10.1097/jnn.0000000000000418.

    Article  PubMed  Google Scholar 

  26. Camicia M, Black T, Farrell J, et al. The essential role of the rehabilitation nurse in facilitating care transitions: a white paper by the Association of Rehabilitation Nurses. Rehabilitation Nurs J. 2014;39(1):3–15. https://doi.org/10.1002/rnj.135.

    Article  Google Scholar 

  27. Lutz BJ, Young ME, Creasy KR, et al. Improving stroke caregiver readiness for transition from IRF to home. Gerontologist. 2017;57(5):880–9.

    PubMed  Google Scholar 

  28. Bakas T, Clark PC, Kelly-Hayes M, King RB, Lutz BJ, Miller EL. Evidence for stroke family caregiver and dyad interventions. Stroke. 2014;45(9):2836–52. https://doi.org/10.1161/STR.0000000000000033.

    Article  PubMed  Google Scholar 

  29. Vloothuis JD, Mulder M, Veerbeek JM, et al. Caregiver‐mediated exercises for improving outcomes after stroke.  Cochrane Database Syst Rev. 2016(12).

  30. Sevin CM, Bloom SL, Jackson JC, Wang L, Ely EW, Stollings JL. Comprehensive care of ICU survivors: development and implementation of an ICU recovery center. J Crit Care. 2018;46:141–8. https://doi.org/10.1016/j.jcrc.2018.02.011.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Biffi A, Anderson CD, Battey TW, et al. Association between blood pressure control and risk of recurrent intracerebral hemorrhage. JAMA. 2015;314(9):904–12.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Xavier D, Liu L, Zhang H, Chin S, Rao-Melacini P. INTERSTROKE investigators: risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet. 2010;376(9735):112–23.

    Article  PubMed  Google Scholar 

  33. Zahuranec DB, Wing JJ, Edwards DF, et al. Poor long-term blood pressure control after intracerebral hemorrhage. Stroke. 2012;43(10):2580–5.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Wang C, Redgrave J, Shafizadeh M, Majid A, Kilner K, Ali AN. Aerobic exercise interventions reduce blood pressure in patients after stroke or transient ischaemic attack: a systematic review and meta-analysis. Br J Sports Med. 2019;53(24):1515–25.

    Article  PubMed  Google Scholar 

  35. Agarwal S, Birk JL, Abukhadra SL, et al. Psychological distress after sudden cardiac arrest and its impact on recovery. Curr Cardiol Rep. 2022;24(10):1351–1360. (In eng). https://doi.org/10.1007/s11886-022-01747-9.

  36. Christensen MC, Mayer SA, Ferran J-M, Kissela B. Depressed mood after intracerebral hemorrhage: the FAST trial. Cerebrovasc Dis. 2009;27(4):353–60.

    Article  PubMed  Google Scholar 

  37. LaBuzetta JN, Rosand J, Vranceanu AM. Review: post-intensive care syndrome: unique challenges in the neurointensive care unit. Neurocrit Care. 2019;31(3):534–545. (In eng). https://doi.org/10.1007/s12028-019-00826-0.

  38. Jourdan C, Bayen E, Pradat-Diehl P, et al. A comprehensive picture of 4-year outcome of severe brain injuries. Results from the PariS-TBI study. Ann Phys Rehabil Med. 2016;59(2):100–6. (In eng). https://doi.org/10.1016/j.rehab.2015.10.009.

  39. Eriksson M, Glader E-L, Norrving B, Asplund K. Poststroke suicide attempts and completed suicides: a socioeconomic and nationwide perspective. Neurology. 2015;84(17):1732–8.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Kutlubaev MA, Hackett ML. Part II: predictors of depression after stroke and impact of depression on stroke outcome: an updated systematic review of observational studies. Int J Stroke. 2014;9(8):1026–36.

    Article  PubMed  Google Scholar 

  41. Cai W, Mueller C, Li Y-J, Shen W-D, Stewart R. Post stroke depression and risk of stroke recurrence and mortality: a systematic review and meta-analysis. Ageing Res Rev. 2019;50:102–9.

    Article  PubMed  Google Scholar 

  42. Van De Port IG, Kwakkel G, Van Wijk I, Lindeman E. Susceptibility to deterioration of mobility long-term after stroke: a prospective cohort study. Stroke. 2006;37(1):167–71.

    Article  PubMed  Google Scholar 

  43. Power KN, Gramstad A, Gilhus NE, Engelsen BA. Adult nonconvulsive status epilepticus in a clinical setting: semiology, aetiology, treatment and outcome. Seizure. 2015;24:102–6. https://doi.org/10.1016/j.seizure.2014.09.007.

    Article  PubMed  Google Scholar 

  44. Patel M, Coshall C, Rudd AG, Wolfe CD. Natural history of cognitive impairment after stroke and factors associated with its recovery. Clin Rehabil. 2003;17(2):158–66.

    Article  PubMed  Google Scholar 

  45. Benedictus MR, Hochart A, Rossi C, et al. Prognostic factors for cognitive decline after intracerebral hemorrhage. Stroke. 2015;46(10):2773–8.

    Article  CAS  PubMed  Google Scholar 

  46. Scott RB, Eccles F, Molyneux AJ, Kerr RS, Rothwell PM, Carpenter K. Improved cognitive outcomes with endovascular coiling of ruptured intracranial aneurysms: neuropsychological outcomes from the International Subarachnoid Aneurysm Trial (ISAT). Stroke. 2010;41(8):1743–7.

    Article  PubMed  Google Scholar 

  47. Presciutti A, Newman MM, Sawyer KN, Agarwal S, Perman SM. Gaps in the provision of cognitive and psychological resources in cardiac arrest survivors with good neurologic recovery. Ther Hypothermia Temp Manag. 2022;12(2):61–67. (In eng). https://doi.org/10.1089/ther.2021.0003.

  48. Presciutti A, Sobczak E, Sumner JA, et al. The impact of psychological distress on long-term recovery perceptions in survivors of cardiac arrest. J Crit Care. 2019;50:227–233. (In eng). https://doi.org/10.1016/j.jcrc.2018.12.011.

  49. Wade DM, Mouncey PR, Richards-Belle A, et al. Effect of a nurse-led preventive psychological intervention on symptoms of posttraumatic stress disorder among critically ill patients: a randomized clinical trial. Jama. 2019;321(7):665–675. (In eng). https://doi.org/10.1001/jama.2019.0073.

  50. Allida S, Cox KL, Hsieh CF, Lang H, House A, Hackett ML. Pharmacological, psychological, and non‐invasive brain stimulation interventions for treating depression after stroke.  Cochrane Database Syst Rev. 2020(1).

  51. Wang S-B, Wang Y-Y, Zhang Q-E, et al. Cognitive behavioral therapy for post-stroke depression: a meta-analysis. J Affect Disord. 2018;235:589–96.

    Article  CAS  PubMed  Google Scholar 

  52. Edmondson D, Birk JL, Ho VT, Meli L, Abdalla M, Kronish IM. A challenge for psychocardiology: addressing the causes and consequences of patients’ perceptions of enduring somatic threat. Am Psychol. 2018;73(9):1160–1171. (In eng). https://doi.org/10.1037/amp0000418.

  53. Smits JA, Berry AC, Tart CD, Powers MB. The efficacy of cognitive-behavioral interventions for reducing anxiety sensitivity: a meta-analytic review. Behav Res Ther. 2008;46(9):1047–54. (In eng). https://doi.org/10.1016/j.brat.2008.06.010.

  54. Gibson E, Koh CL, Eames S, Bennett S, Scott AM, Hoffmann TC. Occupational therapy for cognitive impairment in stroke patients. Cochrane Database Syst Rev. 2022;3(3):Cd006430. (In eng). https://doi.org/10.1002/14651858.CD006430.pub3.

  55. Hwang DY. Mitigating postintensive care syndrome among patients and caregivers via a dyadic intervention. JAMA Netw Open. 2020;3(10):e2021014–e2021014. https://doi.org/10.1001/jamanetworkopen.2020.21014.

    Article  PubMed  Google Scholar 

  56. Roberts MK, Stewart KA, Tessore NM, et al. Experiences of family caregivers after an acute neurological event. Neurocrit Care. 2021;34(1):45–53. (In eng). https://doi.org/10.1007/s12028-020-00973-9.

  57. Hwang DY, Yagoda D, Perrey HM, et al. Anxiety and depression symptoms among families of adult intensive care unit survivors immediately following brief length of stay. J Crit Care. 2014;29(2):278–82. (In eng). https://doi.org/10.1016/j.jcrc.2013.11.022.

  58. Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference. Crit Care Med. 2012;40(2):502–9. https://doi.org/10.1097/CCM.0b013e318232da75.

    Article  PubMed  Google Scholar 

  59. Davidson JE, Jones C, Bienvenu OJ. Family response to critical illness: postintensive care syndrome–family. Crit Care Med. 2012;40(2):618–24. https://doi.org/10.1097/CCM.0b013e318236ebf9.

    Article  PubMed  Google Scholar 

  60. Kuehn BM. Clinics aim to improve post-ICU recovery. JAMA. 2019;321(11):1036–8.

    Article  PubMed  Google Scholar 

  61. Lasiter S, Oles SK, Mundell J, London S, Khan B. Critical care follow-up clinics: a scoping review of interventions and outcomes. Clin Nurse Spec. 2016;30(4):227–37. (In eng). https://doi.org/10.1097/nur.0000000000000219.

  62. Bakas T, McCarthy M, Miller ET. Update on the state of the evidence for stroke family caregiver and dyad interventions. Stroke. 2017;48(5):e122–5. https://doi.org/10.1161/STROKEAHA.117.016052.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Bannon S, Lester EG, Gates MV, et al. Recovering together: building resiliency in dyads of stroke patients and their caregivers at risk for chronic emotional distress; a feasibility study. Pilot Feasibility Stud. 2020;6(1):75. https://doi.org/10.1186/s40814-020-00615-z.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Vranceanu A-M, Bannon S, Mace R, et al. Feasibility and efficacy of a resiliency intervention for the prevention of chronic emotional distress among survivor-caregiver dyads admitted to the neuroscience intensive care unit: a randomized clinical trial. JAMA Netw Open. 2020;3(10):e2020807–e2020807.

    Article  PubMed  PubMed Central  Google Scholar 

  65. Haines KJ, Sevin CM, Hibbert E, et al. Key mechanisms by which post-ICU activities can improve in-ICU care: results of the international THRIVE collaboratives. Intensive Care Med. 2019;45(7):939–47. https://doi.org/10.1007/s00134-019-05647-5.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Haines KJ, McPeake J, Hibbert E, et al. Enablers and barriers to implementing ICU follow-up clinics and peer support groups following critical illness: the Thrive Collaboratives. Crit Care Med. 2019;47(9):1194.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Naqvi IA, Strobino K, Kuen Cheung Y, et al. Telehealth after stroke care pilot randomized trial of home blood pressure telemonitoring in an underserved setting. Stroke. 2022 (In eng). https://doi.org/10.1161/strokeaha.122.041020.

  68. Kress JP, Gehlbach B, Lacy M, Pliskin N, Pohlman AS, Hall JB. The long-term psychological effects of daily sedative interruption on critically ill patients. Am J Respir Crit Care Med. 2003;168(12):1457–61.

    Article  PubMed  Google Scholar 

  69. Figueroa-Ramos MI, Arroyo-Novoa CM, Lee KA, Padilla G, Puntillo KA. Sleep and delirium in ICU patients: a review of mechanisms and manifestations. Intensive Care Med. 2009;35:781–95.

    Article  PubMed  Google Scholar 

  70. Van Mol MM, Kompanje EJ, Benoit DD, Bakker J, Nijkamp MD. The prevalence of compassion fatigue and burnout among healthcare professionals in intensive care units: a systematic review. PLoS ONE. 2015;10(8): e0136955.

    Article  PubMed  PubMed Central  Google Scholar 

  71. Becker KJ, Baxter A, Cohen W, et al. Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology. 2001;56(6):766–72.

    Article  CAS  PubMed  Google Scholar 

  72. Parker AM, Sricharoenchai T, Raparla S, Schneck KW, Bienvenu OJ, Needham DM. Posttraumatic stress disorder in critical illness survivors: a metaanalysis. Crit Care Med. 2015;43(5):1121–9.

    Article  PubMed  Google Scholar 

  73. Hwang DY, Yagoda D, Perrey HM, et al. Assessment of satisfaction with care among family members of survivors in a neuroscience intensive care unit. The Journal of neuroscience nursing: journal of the American Association of Neuroscience Nurses. 2014;46(2):106.

    Article  PubMed  Google Scholar 

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Funding

Agarwal reports grants from the National Institute of Health (R01HL153311, R01NS127959). Naqvi reports support from the Columbia University Vagelos College of Physicians, Doris Duke Charitable Foundation COVID-19 Fund to Retain Clinical Scientists, and the American Heart Association grant # 923718.

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  1. Department of Neurology, Vagelos College of Physicians and Surgeons, The Neurological Institute of New York, Columbia University, New York, NY, USA

    Jeremy Ader MD, MBA, Sachin Agarwal MD, MPH & Imama A. Naqvi MD, MS

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  1. Jeremy Ader MD, MBA
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Correspondence to Imama A. Naqvi MD, MS.

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Ader, J., Agarwal, S. & Naqvi, I.A. The Need for Continuity of Care in Neurocritical Care and Recovery. Curr Treat Options Neurol 25, 455–467 (2023). https://doi.org/10.1007/s11940-023-00768-1

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