UMEM Educational Pearls

Post-Intensive Care Syndrome (PICS) is an increasingly recognized phenomenon of impairment of physical, cognitive, and/or mental health after intensive care admission.  Even more recently, similar deficits in caregivers of patients admitted to the ICU, often called Post-Intensive Care Syndrome Family (PICS-F) is increasingly recognized.  A study recently published by Watland et al in Critical Care Medicine looking at reducing PICS-F through a “caregiver pathway” got me wondering if there's any literature out there about reducing PICS-F via interventions in the emergency department.  Patients' treatment course in the ED is a highly stressful and uncertain time for both the patient and family members, so it stands to reason this is an impactful period where intervention may help, and even in patients where their condition is too advanced for us to make a medical difference, our actions could have a positive impact on long term outcomes for the family members.

The short answer is no, to this author's knowledge and based on my review of the literature, there is no good evidence for reducing PICS-F by ED interventions (hint, hint: if anyone's looking for a good area to study…)  Based on evidence from the critical care realm, the following are probably reasonable approaches that would translate well to the ED:

1. Recognize, especially when you have a patient who likely has a very poor prognosis, that for our critical patients it is important to treat the family, as well as the patient.  
2. Update the family early and often.  Uncertainty is a key contributor to PICS-F.  
3. Consider developing a brochure for family of critically ill patients at your facility.  Basic information such as where to park, how to get into the hospital, where their loved one may go after the ED, where they can get food, what visiting hours are allowed, whom to contact with questions, etc seem exceptionally simple to us but are often early points of stress for family.  
4. Consider screening family members for PICS-F (probably better left to the ICU, but could be considered for longer ED stays or if patient prognosis is extremely poor).  There are multiple validated screening tools available.
5. Consider encouraging patient (if they are able) or family to keep a diary.  ICU diaries have been shown to decrease incidence of both PICS and PICS-F.  See also icu-diary.org
6. If feasible, consider follow up with family members at high risk of PICS-F.  Could be done as a joint venture between the ED and inpatient services or as a hospital-wide initiative.  
7. Engage ancillary services such as pastoral care, palliative care, integrative medicine, and others early and often to foster a multi-disciplinary approach.  Also, make sure to communicate well with your nursing team, who are at the bedside and often more in tune with family signs of future PICS-F.

References

Watland, Solbjørg RN, MS1,,2,3; Solberg Nes, Lise LP, PhD1,,3,,4; Ekeberg, Øivind MD, PhD5; Rostrup, Morten MD, PhD2,,6; Hanson, Elizabeth RN; PhD7,,8; Ekstedt, Mirjam RN, PhD7,,9; Stenberg, Una PhD10,,11; Hagen, Milada PhD12; Børøsund, Elin RN, PhD1,,13. The Caregiver Pathway Intervention Can Contribute to Reduced Post-Intensive Care Syndrome Among Family Caregivers of ICU Survivors: A Randomized Controlled Trial. Critical Care Medicine ():10.1097/CCM.0000000000006546, December 24, 2024. | DOI: 10.1097/CCM.0000000000006546 

https://www.fortunejournals.com/articles/approaches-to-postintensive-care-syndrome-nursing-point-of-view.html

https://icu-diary.org/

Shirasaki K, Hifumi T, Nakanishi N, Nosaka N, Miyamoto K, Komachi MH, Haruna J, Inoue S, Otani N. Postintensive care syndrome family: A comprehensive review. Acute Med Surg. 2024 Mar 11;11(1):e939. doi: 10.1002/ams2.939. PMID: 38476451; PMCID: PMC10928249.