Telehealth-Enhanced Patient-Oriented Recovery Trajectory After Intensive Care

大约33-50%的重症监护病房（ICU）幸存者发展为长期认知障碍-阿尔茨海默病相关性痴呆（ADRD）的一种公认形式。ICU获得性ADRD患病率在急性呼吸窘迫综合征和脓毒症幸存者中尤其高，影响高达80%。这种认知能力的丧失导致独立性、就业和生活质量的丧失，并持续数月至数年。ICU获得性ADRD是被称为重症监护后综合征（PICS）的更广泛综合征的一部分，包括身体，精神和社会经济障碍。ICU恢复诊所（ICU-RC）是一种可行且有前景的干预措施，可协同解决ICU获得的ADRD和其他PICS损伤，但面对面访问有限。有必要研究使用替代交付策略扩大可用性和覆盖范围的大型队列的ICU-RC的有效性。老年（年龄≥ 45岁）感染性休克和/或急性呼吸衰竭患者存在ICU获得性ADRD和其他损害的综合风险，是首先解决这一知识缺口的理想人群。范德比尔特ICU康复中心团队拥有近10年的经验，提供跨学科的协作护理，以识别和治疗ICU获得性ADRD和ICU幸存者经历的其他PICS损伤。我们假设，协作远程医疗提供的跨学科ICU-RC干预有效地识别和改善了长期认知功能，并作为次要结果，身心健康功能，社会融合和自我管理行为与对照条件相比，随访由出院团队选择。因此，在老年感染性休克和急性呼吸衰竭幸存者的样本中，我们旨在检查远程医疗ICU-RC服务与出院团队选择的对照随访在识别和管理ICU获得性ADRD和其他PICS损伤（即，身体、心理健康、社会、自我管理功能）。我们将通过对202例患者进行对照试验来解决我们的假设和目标，这些患者按年龄分层以1：1的比例随机分配到远程医疗ICU-RC或对照组（每组101例）。远程医疗接受者将在出院后3个月内接受至少2次ICU-RC访视，如果出院到另一家机构，则返回家中，额外随访由PICS损伤的严重程度确定。我们的主要结局是6个月时的认知功能（目标1），使用来自ICU幸存者长期核心结局测量集的MoCA盲法和PROMIS认知功能。我们的次要结果是身心健康功能（目标2）和社会融合和自我管理行为（目标3）。除了6个月的测量外，我们还将评估院前功能和出院后1周的功能，以评估出院功能轨迹。这项研究将为ICU恢复计划的持续发展，实施和扩展提供科学依据。最终，这些知识可以通过减少ADRD负担来改善数百万ICU幸存者和家庭成员的生活质量。

Approximately 33-50% of intensive care unit (ICU) survivors develop long-term cognitive impairment – a well-established form of Alzheimer’s Disease Related Dementia (ADRD). ICU-acquired ADRD prevalence is especially high in acute respiratory distress syndrome and sepsis survivors, affecting up to 80%. This loss of cognition leads to loss of independence, employment, and quality of life and persists for months to years. ICU-acquired ADRD is part of a broader syndrome known as Post-Intensive Care Syndrome (PICS), including physical, mental, and socioeconomic impairments. ICU Recovery Clinics (ICU-RC) are a feasible and promising intervention to collaboratively address ICU-acquired ADRD and other PICS impairments, but in-person access is limited. There is a need to study efficacy of ICU-RCs with large cohorts using alternative delivery strategies to expand availability and reach. Older (age >=45) septic shock and/or acute respiratory failure patients are at a combined risk for ICU-acquired ADRD among other impairments, and the ideal population to first address this knowledge gap. The Vanderbilt ICU Recovery Center team has nearly 10 years of experience providing interdisciplinary, collaborative care to identify and treat ICU-acquired ADRD and other PICS impairments experienced by ICU survivors. We hypothesize that a collaborative telemedicine-delivered interdisciplinary ICU-RC intervention effectively identifies and improves long-term cognitive function, and as secondary outcomes, physical and mental health function, social integration, and self-management behaviors vs. a control condition with follow-up chosen by the discharge team. Therefore, in a sample of older septic shock and acute respiratory failure survivors, we aim to examine the efficacy of telemedicine ICU-RC services vs. control follow-up chosen by the discharge team in identifying and managing ICU-acquired ADRD and other PICS impairments (i.e., physical, mental health, social, self-management function) at 6 months after hospital discharge. We will address our hypothesis and aims by conducting a controlled trial of 202 patients randomized 1:1 with age stratification to telemedicine ICU-RC or control (101 per group). Telemedicine recipients will receive a minimum of 2 ICU-RC visits within 3 months of hospital discharge or return to home if discharged to another institution, with additional follow-up determined by the severity of PICS impairment. Our primary outcome is cognitive function (Aim 1) at 6 months using the MoCA-Blind and PROMIS Cognitive Function from the Long-term Core Outcome Measurement Set for ICU survivors. Our secondary outcomes are physical and mental health functioning (Aim 2) and social integration and self-management behaviors (Aim 3). In addition to 6-month measurements, we will assess pre-hospital function and 1-week post-discharge to assess discharge functional trajectories. This research will provide scientific justification for the continued development, implementation, and scaling of ICU recovery programs. Ultimately, such knowledge can improve the quality of life for millions of ICU survivors and family members by reducing ADRD burden.