Skip to main content
SpringerLink
Log in

Transitions to Primary Care

  • Chapter
  • First Online:
Book cover Improving Critical Care Survivorship

Abstract

After intensive care and hospital-based rehabilitation, most ICU (Intensive Care Unit) survivors receive aftercare from their Primary Care Physician (PCP). This setting is characterized in many countries by a long-term doctor-patient relationship, with all health services being coordinated by a central clinician. Due to fragmentation in the care process, information on the ICU stay and knowledge about ICU sequelae are often missing in primary care. Structured discharge notes, the inclusion of PCPs in ICU follow-up programs, and the application of standardized scales and guidelines, as well as the establishment of training modules, should be implemented.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 159.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Needham DM, 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.

    Article  PubMed  Google Scholar 

  2. McGovern M, McGovern C, Parker R. Survivors of critical illness: victims of our success? Br J Gen Pract. 2011;61(593):714–5.

    Article  PubMed  PubMed Central  Google Scholar 

  3. NICE. Rehabilitation after critical illness in adults. Clinical guideline [CG83] 2009. 16.09.2019; Available from https://www.nice.org.uk/guidance/cg83.

  4. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457–502.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Ramsay P, et al. A rehabilitation intervention to promote physical recovery following intensive care: a detailed description of construct development, rationale and content together with proposed taxonomy to capture processes in a randomised controlled trial. Trials. 2014;15:38.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Stam HJ, Stucki G, Bickenbach J. Covid-19 and post intensive care syndrome: a call for action. J Rehabil Med. 2020;52(4):jrm00044.

    Article  PubMed  Google Scholar 

  7. Bench S, Cornish J, Xyrichis A. Intensive care discharge summaries for general practice staff: a focus group study. Br J Gen Pract. 2016;66(653):e904–12.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Gehrke-Beck S, et al. GP’s perspective and experiences in caring for patients with post-intensive care syndrome, a qualitative study. J Crit Care. 190:62. in press.

    Google Scholar 

  9. Kahn JM, Angus DC. Health policy and future planning for survivors of critical illness. Curr Opin Crit Care. 2007;13(5):514–8.

    Article  PubMed  Google Scholar 

  10. Schwarz CM, et al. A systematic literature review and narrative synthesis on the risks of medical discharge letters for patients’ safety. BMC Health Serv Res. 2019;19(1):158.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Girbes ARJ, Beishuizen A. Interfacing the ICU with the general practitioner. Crit Care (London, England). 2010;14(3):172–172.

    Google Scholar 

  12. Etesse B, et al. How the relationships between general practitioners and intensivists can be improved: the general practitioners’ point of view. Crit Care (London, England). 2010;14(3):R112–R112.

    Google Scholar 

  13. Medlock S, et al. Improved communication in post-ICU care by improving writing of ICU discharge letters: a longitudinal before-after study. BMJ Qual Saf. 2011;20(11):967–73.

    Article  PubMed  Google Scholar 

  14. Scottish Intercollegiate Guidelines Network, S.I.G.N. The SIGN discharge document. 2012. 10.09.2019; Available from https://www.sign.ac.uk/assets/sign128.pdf.

  15. NICE. Development of a multidisciplinary post critical care clinic at guy’s & St Thomas’ NHS Foundation Trust. 2017. 08.08.2019; Available from: https://www.nice.org.uk/sharedlearning/development-of-a-multidisciplinary-post-critical-care-clinic-at-guy-s-st-thomas-nhs-foundation-trust.

  16. Hoffman K, Thomas A, Brett S. Clinical pathways for the continuum of rehabilitation. In: Stevens RD, Hart N, Herridge MS, editors. Textbook of post-ICU medicine: the legacy of critical care: Oxford University Press; 2014. p. 546–58.

    Google Scholar 

  17. “Was-hab’-ich?”. Patientenbriefe wirken. Ergebnisbericht zum Projekt “Mehr Gesundheitskompetenz durch Patientenbrief”. 2019. 10.09.2019; Available from https://www.qualitaetskliniken.de/fileadmin/user_upload/2019-06-10_Ergebnisbericht.pdf.

  18. Lin R, et al. Effect of a patient-directed discharge letter on patient understanding of their hospitalisation. Intern Med J. 2014;44(9):851–7.

    Article  CAS  PubMed  Google Scholar 

  19. Griffiths RD, Jones C. Seven lessons from 20 years of follow-up of intensive care unit survivors. Curr Opin Crit Care. 2007;13(5):508–13.

    Article  PubMed  Google Scholar 

  20. Marra A, et al. The ABCDEF bundle in critical care. Crit Care Clin. 2017;33(2):225–43.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Davidson JE, Harvey MA, Schuller J. Post-intensive care syndrome: what it is and how to help prevent it. Am Nurse Today. 2013;8(5):32–8.

    Google Scholar 

  22. Harvey MA, Davidson JE. Postintensive care syndrome: right care, right now...and later. Crit Care Med. 2016;44(2):381–5.

    Article  PubMed  Google Scholar 

  23. Prinjha S, Field K, Rowan K. What patients think about ICU follow-up services: a qualitative study. Crit Care. 2009;13(2):R46.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Prescott HC, Angus DC. Enhancing recovery from sepsis: a review. JAMA. 2018;319(1):62–75.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Granja C, et al. Quality of life of survivors from severe sepsis and septic shock may be similar to that of others who survive critical illness. Crit Care. 2004;8(2):R91–8.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Brown SM, Bose S, Banner-Goodspeed V, Beesley SJ, Dinglas VD, Hopkins RO, Jackson JC, Mir-Kasimov M, Needham DM, Sevin CM. Approaches to addressing post-intensive care syndrome among intensive care unit survivors. A narrative review. Ann Am Thorac Soc. 2020;16(8):947–56.

    Article  Google Scholar 

  27. Mikkelsen M, et al. Society of Critical Care Medicine’s international consensus conference on prediction and identification of long-term impairments after critical illness. Crit Care Med. in press.

    Google Scholar 

  28. Jolley SE, Bunnell AE, Hough CL. ICU-acquired weakness. Chest. 2016;150(5):1129–40.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Marinos, E., THE ‘MUST’ REPORT – nutritional screening of adults: a multidisciplinary responsibility – development and use of the ‘Malnutrition Universal Screening Tool’ (‘MUST’) for adults, T.B.A.f.P.a.E. Nutrition, Editor. 2003. p. 127.

    Google Scholar 

  30. Ali NA, et al. Acquired weakness, handgrip strength, and mortality in critically ill patients. Am J Respir Crit Care Med. 2008;178(3):261–8.

    Article  PubMed  Google Scholar 

  31. Connolly B, et al. Exercise rehabilitation following intensive care unit discharge for recovery from critical illness. Cochrane Database Syst Rev. 2015;(6):Cd008632.

    Google Scholar 

  32. Major ME, et al. Surviving critical illness: what is next? An expert consensus statement on physical rehabilitation after hospital discharge. Crit Care (London, England). 2016;20(1):354–354.

    Google Scholar 

  33. van Zanten ARH, De Waele E, Wischmeyer PE. Nutrition therapy and critical illness: practical guidance for the ICU, post-ICU, and long-term convalescence phases. Crit Care. 2019;23(1):368.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Schmidt K, et al. Effect of a primary care management intervention on mental health-related quality of life among survivors of sepsis: a randomized clinical trial. JAMA. 2016;315(24):2703–11.

    Article  CAS  PubMed  Google Scholar 

  35. Tohara H, et al. Three tests for predicting aspiration without videofluorography. Dysphagia. 2003;18(2):126–34.

    Article  PubMed  Google Scholar 

  36. Brodsky MB, et al. Prevalence, pathophysiology, diagnostic modalities and treatment options for dysphagia in critically ill patients. Am J Phys Med Rehabil. 2020;99:1164.

    Article  PubMed  Google Scholar 

  37. Sinwar PD. Overwhelming post splenectomy infection syndrome – review study. Int J Surg. 2014;12(12):1314–6.

    Google Scholar 

  38. Granja C, et al. Patients’ recollections of experiences in the intensive care unit may affect their quality of life. Crit Care. 2005;9(2):R96–109.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Bienvenu OJ, et al. Psychiatric symptoms after acute respiratory distress syndrome: a 5-year longitudinal study. Intensive Care Med. 2018;44(1):38–47.

    Article  PubMed  Google Scholar 

  40. Greenberg N, Brooks S, Dunn R. Latest developments in post-traumatic stress disorder: diagnosis and treatment. Br Med Bull. 2015;114(1):147–55.

    Article  PubMed  Google Scholar 

  41. Schmidt KF, et al. Long-term courses of sepsis survivors: effects of a primary care management intervention. Am J Med. 2020;133(3):381–385.e5.

    Article  PubMed  Google Scholar 

  42. Schmidt K, et al. Traumafolgestörungen in der Allgemeinmedizin. Prim Hosp Care Allg Inn Med. 2018;18(12):212–6.

    Google Scholar 

  43. Mehlhorn J, et al. Rehabilitation interventions for postintensive care syndrome: a systematic review. Crit Care Med. 2014;42(5):1263–71.

    Article  PubMed  Google Scholar 

  44. Jones C. Narratives of illness and healing after the ICU. In: Stevens RD, Hart N, Heridge MS, editors. Textbook of post-ICU medicine: the legacy of critical care: Oxford University Press; 2014. p. 597–602.

    Google Scholar 

  45. Taylor AK, et al. Identification of post-traumatic stress disorder following ICU. Br J Gen Pract. 2019;69(680):154–5.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Kamdar BB, et al. Return to work after critical illness: a systematic review and meta-analysis. Thorax. 2020;75(1):17–27.

    Article  PubMed  Google Scholar 

  47. Gräfe K, et al. Screening psychischer Störungen mit dem “Gesundheitsfragebogen für Patienten (PHQ-D)”. Diagnostica. 2004;50(4):171–81.

    Article  Google Scholar 

  48. Elliot, D. and L. Deneh, Post-ICU rehabilitation, in Textbook of post-Icu medicine: the legacy of critical care, R.D. Stevens, N. Hart, and M.S. Heridge, 2014, Oxford University Press 583-596.

    Google Scholar 

  49. Hopkins RO, et al. Neuropsychological sequelae and impaired health status in survivors of severe acute respiratory distress syndrome. Am J Respir Crit Care Med. 1999;160(1):50–6.

    Article  CAS  PubMed  Google Scholar 

  50. Kalbe E, et al. DemTect: a new, sensitive cognitive screening test to support the diagnosis of mild cognitive impairment and early dementia. Int J Geriatr Psychiatry. 2004;19(2):136–43.

    Article  CAS  PubMed  Google Scholar 

  51. Singer M, Shankar-Hari M. Sepsis, an issue of critical care clinics. E-Book. 34 1. Elsevier Health Sciences, 2017.

    Google Scholar 

  52. Schmidt M, Azoulay E. Having a loved one in the ICU: the forgotten family. Curr Opin Crit Care. 2012;18(5):540–7.

    Article  PubMed  Google Scholar 

  53. Griffiths RD. Introduction therapeutic and rehabilitation strategies in the post-ICU period. In: Stevens RD, Hart N, Heridge MS, editors. Textbook of post-ICU medicine: the legacy of critical care: Oxford University Press; 2014. p. 525–9.

    Google Scholar 

  54. Winters BD, et al. Long-term mortality and quality of life in sepsis: a systematic review. Crit Care Med. 2010;38(5):1276–83.

    Article  PubMed  Google Scholar 

  55. Murray SA, et al. Illness trajectories and palliative care. BMJ. 2005;330(7498):1007–11.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Care T.G.S.F.C.i.E.o.L. GSF Proactive Identification Guidance (PIG) 08.08.2019]; Available from www.goldstandardsframework.org.uk/PIG.

  57. Highet G, et al. Development and evaluation of the supportive and palliative care indicators tool (SPICT): a mixed-methods study. BMJ Support Palliat Care. 2014;4(3):285–90.

    Article  PubMed  Google Scholar 

  58. Needham DM, et al. Core outcome measures for clinical research in acute respiratory failure survivors. An international modified Delphi consensus study. Am J Respir Crit Care Med. 2017;196(9):1122–30.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Rubak S, et al. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract. 2005;55(513):305–12.

    PubMed  PubMed Central  Google Scholar 

  60. Elwyn G, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361–7.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Elliott D, et al. Exploring the scope of post-intensive care syndrome therapy and care: engagement of non-critical care providers and survivors in a second stakeholders meeting. Crit Care Med. 2014;42(12):2518–26.

    Article  PubMed  Google Scholar 

  62. Mikkelsen ME, Netzer G, Iwashyna T. Post-intensive care syndrome (PICS). In: Post T, editor. UpToDate. Waltham: UpToDate; 2020. p. 1–29. Accessed on 16 June 2020.

    Google Scholar 

  63. Jones C, et al. Rehabilitation after critical illness: a randomized, controlled trial. Crit Care Med. 2003;31(10):2456–61.

    Article  PubMed  Google Scholar 

  64. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288(14):1775–9.

    Article  PubMed  Google Scholar 

  65. Gensichen J, et al. Effect of a combined brief narrative exposure therapy with case management versus treatment as usual in primary care for patients with traumatic stress sequelae following intensive care medicine: study protocol for a multicenter randomized controlled trial (PICTURE). Trials. 2018;19(1):480.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Daly BJ, et al. Trial of a disease management program to reduce hospital readmissions of the chronically critically ill. Chest. 2005;128(2):507–17.

    Article  PubMed  Google Scholar 

  67. Douglas SL, et al. Chronically critically ill patients: health-related quality of life and resource use after a disease management intervention. Am J Crit Care. 2007;16(5):447–57.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Schofield-Robinson OJ, et al. Follow-up services for improving long-term outcomes in intensive care unit (ICU) survivors. Cochrane Database Syst Rev. 2018;(11):Cd012701.

    Google Scholar 

  69. Nelson EC, et al. Patient reported outcome measures in practice. BMJ. 2015;350:g7818.

    Article  PubMed  Google Scholar 

  70. Ali NA, et al. Acquired weakness, handgrip strength, and mortality in critically ill patients. Am J Respir Crit Care Med. 2008;178(3):261–8.

    Article  PubMed  Google Scholar 

  71. Paternostro-Sluga T, et al. Reliability and validity of the Medical Research Council (MRC) scale and a modified scale for testing muscle strength in patients with radial palsy. J Rehabil Med. 2008;40(8):665–71.

    Article  PubMed  Google Scholar 

  72. Korupolu R, et al. Rehabilitation of critically ill COVID-19 survivors. J Int Soc Phys Rehabil Med. 2020;3(2):45–52.

    Article  Google Scholar 

  73. Ambrose A, et al. Patient and caregiver guide to managing COVID-19 patients at home. J Int Soc Phys Rehabil Med. 2020;3(2):53–68.

    Article  Google Scholar 

  74. Enright PL. The six-minute walk test. Respir Care. 2003;48(8):783–5.

    PubMed  Google Scholar 

  75. Chan KS, et al. Evaluating physical outcomes in acute respiratory distress syndrome survivors: validity, responsiveness, and minimal important difference of 4-meter gait speed test. Crit Care Med. 2016;44(5):859–68.

    Article  PubMed  PubMed Central  Google Scholar 

  76. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179–86.

    Article  CAS  PubMed  Google Scholar 

  77. Katz S, Akpom CA. A measure of primary sociobiological functions. Int J Health Serv. 1976;6(3):493–508.

    Article  CAS  PubMed  Google Scholar 

  78. Nikayin S, et al. Anxiety symptoms in survivors of critical illness: a systematic review and meta-analysis. Gen Hosp Psychiatry. 2016;43:23–9.

    Article  PubMed  PubMed Central  Google Scholar 

  79. Snaith R, Zigmond A. Hospital anxiety and depression scale (HADS). In: Handbook of psychiatric measures. Washington DC: American Psychiatric Association; 2000. p. 547–8.

    Google Scholar 

  80. Kroenke K, et al. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146(5):317–25.

    Article  PubMed  Google Scholar 

  81. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fifth Edition (DSM-5). Arlington; 2013.

    Google Scholar 

  82. Rabiee A, et al. Depressive symptoms after critical illness: a systematic review and meta-analysis. Crit Care Med. 2016;44(9):1744–53.

    Article  PubMed  PubMed Central  Google Scholar 

  83. Norman SB, et al. Development and validation of an overall anxiety severity and impairment scale (OASIS). Depress Anxiety. 2006;23(4):245–9.

    Article  PubMed  Google Scholar 

  84. Plummer F, et al. Screening for anxiety disorders with the GAD-7 and GAD-2: a systematic review and diagnostic metaanalysis. Gen Hosp Psychiatry. 2016;39:24–31.

    Article  PubMed  Google Scholar 

  85. Hosey MM, Leoutsakos JS, Li X, Dinglas VD, Bienvenu OJ, Parker AM, Hopkins RO, Needham DM, Neufeld KJ: Screening for posttraumatic stress disorder in ARDS survivors: validation of the Impact of Event Scale-6 (IES-6). Crit Care 2019, 23(1):276.

    Google Scholar 

  86. Stoll C, et al. Sensitivity and specificity of a screening test to document traumatic experiences and to diagnose post-traumatic stress disorder in ARDS patients after intensive care treatment. Intensive Care Med. 1999;25(7):697–704.

    Article  CAS  PubMed  Google Scholar 

  87. Jones C. Narratives of Illness and Healing after the ICU. In: Stevens RD, Hart N, Herridge MS, editors. Textbook of post-ICU medicine: the legacy of critical care: Oxford University Press; 2014. p. 597–602.

    Google Scholar 

  88. Huang M, et al. Psychiatric symptoms in acute respiratory distress syndrome survivors: a 1-year national multicenter study. Crit Care Med. 2016;44(5):954–65.

    Article  PubMed  PubMed Central  Google Scholar 

  89. Nasreddine D. Montreal cognitive assessment website.[cited 2020 15.08.2020]; Available from: http://www.mocatest.org/pdf_files/test/MoCA-Test-BLIND.pdf.

  90. Desai SV, Law TJ, Needham DM. Long-term complications of critical care. Crit Care Med. 2011;39(2):371–9.

    Article  PubMed  Google Scholar 

  91. Mikkelsen M, Netzer I. Post-intensive care syndrome (PICS). Post-intensive care syndrome (PICS) 2020 [cited 2020; pages 1–29].

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Departments of General Practice and Family Medicine, Charité University Hospital Berlin and Jena University Hospital, Berlin and Jena, Germany

    Konrad Schmidt

  2. Department of General Practice and Family Medicine, Charité University Hospital Berlin, Berlin, Germany

    Sabine Gehrke-Beck

Authors
  1. Konrad Schmidt
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sabine Gehrke-Beck
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Konrad Schmidt .

Editor information

Editors and Affiliations

  1. Department of Physiotherapy, Western Health, Melbourne, VIC, Australia

    Kimberley J. Haines

  2. Glasgow Royal Infirmary, NHS Greater, Glasgow and Clyde, Glasgow, UK

    Joanne McPeake

  3. Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA

    Carla M. Sevin

Rights and permissions

Reprints and permissions

Copyright information

© 2021 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Schmidt, K., Gehrke-Beck, S. (2021). Transitions to Primary Care. In: Haines, K.J., McPeake, J., Sevin, C.M. (eds) Improving Critical Care Survivorship. Springer, Cham. https://doi.org/10.1007/978-3-030-68680-2_17

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-68680-2_17

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-68679-6

  • Online ISBN: 978-3-030-68680-2

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation