Post-intensive Care Syndrome (PICS): an American Association for the Surgery of Trauma Critical Care Committee Consensus Guideline – Defining, Recognizing, and Managing PICS Associated Physical Impairment, Cognitive Dysfunction, and Thromboinflammatory Dysregulation

Introduction

Post-intensive care syndrome, often called PICS, refers to a set of impairments that can affect a person’s body, mind, or emotions after they leave the intensive care unit (ICU). These issues may include new or worsening physical limitations, difficulties with memory or cognition, and mental health challenges such as anxiety or depression. It is important to recognize PICS because a patient’s recovery and quality of life can be significantly impacted after discharge from the ICU. The Society of Critical Care Medicine (SCCM) recommends that healthcare providers start screening for PICS within 2–4 weeks after a patient leaves the ICU, with further evaluations at 3 months, 6 months, and 1 year.¹ This recommended timeline ensures that issues are identified and addressed early.

In this Clinical Consensus Guideline created by the Critical Care Committee of the American Association for the Surgery in Trauma (AAST), we will discuss how to recognize, diagnose, and manage the cognitive and physical effects of PICS in patients who have undergone surgery or major trauma and require ICU admission. Additionally, we will expand our discussion of PICS to encompass the long-term morbidity and mortality associated with thromboinflammatory dysregulation, which represents a central mechanism underlying the cognitive, physical, and psychological impairments that define this syndrome, and we will examine the potential role of structured outpatient follow-up and the development of dedicated PICS clinics in addressing these enduring sequelae. By outlining these key areas, our goal is to increase awareness of PICS in the trauma and surgical populations and to provide pragmatic guidance and support for healthcare professionals caring for these patients after critical illness.

Methods

The AAST Critical Care Committee selected PICS as a clinically significant topic for review in the context of surgical critical care patients. To facilitate this work, a dedicated working group was formed from the committee’s membership. Each member of the working group was assigned a specific subtopic and conducted a targeted literature search using databases such as PubMed and Embase. Searches were restricted to English-language publications and focused on studies involving adult surgical ICU patients (aged ≥16 years). Priority was given to randomized controlled trials, large observational studies, and societal guidelines when available; other studies were included only if they provided unique, important, or non-replicated findings.

Studies were identified and selected based on their relevance to the assigned subtopics, and each working group member appraised the quality and applicability of the evidence at their own discretion. The methodology did not follow the iterative selection or appraisal processes characteristic of a systematic review; instead, the search and selection strategies were determined by individual authors.

The recommendations formulated from the reviewed literature were subsequently presented to the entire AAST Critical Care Committee for evaluation. Consensus was defined as agreement among at least 80% of committee members during structured discussions. In cases where disagreements arose, further discussion was encouraged to reach a resolution; any points for which consensus could not be achieved were recorded as ‘no consensus’ in the final document.

It is important to clarify that this work represents a consensus of expert opinion rather than a comprehensive systematic review. The recommendations apply to adult surgical and trauma patients who experienced ICU stays and should be interpreted in the context of the committee’s expertise and the available evidence. However, most of the studies that are referenced in this consensus document were not performed in surgical and/or trauma patients; thus, we are extrapolating studies from mixed population critical care environments to surgical critically ill patients. In subsequent sections, each recommendation explicitly states its strengths and limitations to guide both interpretation and clinical application.

Disclaimer from the AAST Critical Care Committee

This work reflects the expert opinion and recommendations of the AAST Critical Care Committee. These recommendations support, but do not replace individualized clinical decision-making. Healthcare professionals should rely on their expertise and consider the unique circumstances of each patient when making treatment choices. The recommendations do not address every possible approach to prevention, diagnosis, or treatment. The AAST is not responsible for any harm or damage resulting from the use of this information.

What is PICS in surgical and trauma patients?

Recommendation

PICS is defined as a new physical, cognitive, or psychological impairment that develops and persists after ICU admission and hospital discharge. In addition to these domains, we recommend the explicit inclusion of persistent thromboinflammatory dysregulation and sustained organ dysfunction due to recent evidence demonstrating persistent alterations in immunity associated with prolonged ICU stays and organ failure, which are directly linked to post-discharge morbidity and mortality.²

Discussion

Our framework for diagnosing and managing PICS in surgical patients aligns closely with the definition from the SCCM: after critical illness, survivors may experience new or worsening physical, cognitive, and mental health impairments. These impairments constitute PICS, which represents a response to prolonged critical illness that can last from as little as 2 days to much longer periods after ICU discharge. Patients may display symptoms from one or multiple domains as these phenotypes often overlap.

Based on the SCCM definition and the presence of altered thromboinflammatory function, we further categorize PICS in surgical patients as follows:

• Physical impairment: includes ICU-acquired weakness, muscle and bone loss, impaired sleep, chronic pain, fatigue, swallowing dysfunction, and ongoing physical inflammation.

• Cognitive dysfunction: includes impairments in memory, concentration, and organizational skills, and higher executive function.

• Psychological impairment: includes the development of depression, anxiety, and/or post-traumatic stress disorder.

• Persistent thromboinflammatory dysregulation and sustained organ dysfunction: includes maladaptive activation of thrombotic and immune-inflammatory pathways and sustained impairment of one or more organ systems after ICU discharge that contribute to long-term morbidity and mortality.

PICS should be considered in any patient with a recent ICU admission who develops new or worsening impairments in one or more of these domains. These changes result from the interplay between the patient’s baseline health and the treatments commonly used in the surgical ICU including immobility, mechanical ventilation, nutrition, medications, analgesia, and sedation. The purpose of evaluating for PICS is to determine which ongoing effects stem from the underlying illness and which are consequences of their critical care condition. It is also essential to distinguish PICS from pre-existing or underlying disease processes.

It is critical to state that the thromboinflammatory dysfunction and sustained organ failure after discharge has been previously termed persistent inflammation, immunosuppression, and catabolism syndrome (also abbreviated as PICS). However, for clarity in this document, we will refer to this sustained dysregulated immune and catabolic state as ‘thromobinflammatory dysfunction’. This condition is classically defined as an ICU stay of at least 14 consecutive days, elevated C-reactive protein (CRP), reduced total lymphocyte count, protein catabolism, and other laboratory abnormalities such as decreased serum albumin or body mass index, which typically results in discharge to a long-term acute care facility.^{3 4} The early development of this condition is not self-limited; instead, it persists well beyond ICU discharge, often for weeks, months, or even years, resulting in long-term cognitive, physical, and psychological impairments as well as ongoing organ dysfunction that contributes to late complications and increased mortality. The acronym PICS within this document, therefore, refers to the specific cognitive, physical, psychological, and thromboinflammatory impairments patients experience after ICU discharge.

Evidence from surgical and trauma populations underscores the significance of PICS. A 2009 study of adults with surgical ICU stays of 10 or more days found that 49% of patients previously employed had returned to work or school at a median of 3.3 years after discharge, whereas 25% had long-term disability.⁵ A 2021 study of general surgery and trauma patients (excluding severe traumatic brain injury) who spent more than 72 hours in the ICU showed that 95.7% met at least one criterion for PICS—physical, psychiatric, or cognitive symptoms—at follow-up visits up to 24 weeks after discharge.⁶ Additionally, a number of recent studies have demonstrated that the development of chronic critical illness and thromboinflammatory dysfunction is associated with a mortality rate at 1 year approaching 25% to 30%.^{7 8}

Which evaluations are most useful for diagnosing cognitive impairment in PICS in Surgical and Trauma patients?

Recommendation

We recommend in-person administration of the Montreal Cognitive Assessment (MoCA) in patients suspected of having PICS to identify cognitive deficits. When an in-person follow-up is not feasible, we recommend a remote validated exam, such as the Telephone Interview of Cognitive Status (TICS), until an in-person MoCA can be performed.

Discussion

Cognitive impairment is a common manifestation of PICS, affecting approximately 30% to 50% of survivors of critical illness.⁹ Presentations range from mild deficits in short-term memory and attention to substantial impairments in executive function. Trauma patients may be at particularly high risk due to the increased prevalence of traumatic brain injury. Currently, no single diagnostic tool or consensus panel of tests exists for identifying cognitive impairment specific to PICS. However, a Delphi consensus conducted by Nakanishi et al identified the MoCA, Mini-Mental State Examination (MMSE), and Short Memory Questionnaire (SMQ) as the most commonly recommended tools for screening cognitive function in this population.¹⁰ The MoCA, a 10-minute screening tool for mild cognitive impairment, has demonstrated greater sensitivity for detecting subtle deficits compared with the MMSE.^{11 12} Furthermore, the MoCA has been successfully used and demonstrated greater sensitivity in patients with traumatic brain injury.¹³ The SMQ, a 14-item instrument, has been validated in populations with vascular dementia but has not been specifically evaluated in PICS.¹⁴

Both the MoCA and MMSE require in-person administration, although remote alternatives exist. The TICS, which has been validated against the MMSE, has been used for remote assessment in PICS populations.^{15 16} Additionally, the MoCA-Blind/Telephone version, scored out of 22 points, is designed for telephone use or for individuals with visual impairments.¹⁷

A persistent limitation is the scarcity of validated tools for non-English-speaking populations. Analysis of the MIMIC-III database revealed that approximately 15% of ICU patients report a primary language other than English. These patients experienced longer emergency department wait times and higher mortality rates.¹⁸ Given the variability in language demographics across institutions, the availability of validated cognitive assessments in multiple languages remains a critical need in ensuring equitable post-ICU care.

Which evaluations are most useful for diagnosing physical impairment in PICS in Surgical and Trauma patients?

Recommendation

In patients with concerns for PICS, we recommend clinicians consider evaluating for changes in function and structure, activity limitations, and participation restrictions. As no single test has been validated for all domains, we recommend clinicians use available resources and the tests described in this section, ensuring an individualized approach that considers the surgical cause of the ICU stay.

Discussion

There are three primary domains of physical impairment in PICS: change in body function and structure, activity limitations, and participation restriction.19,21 Several tests have been described to assess each of these domains, although no universally validated test is available to determine if a person has physical impairment after PICS. Importantly, tests should be individualized as patients may have very different functional baselines and surgical/injury limitations that preclude certain tests from being performed.

The first domain, changes in function and structure, can be tested by assessing inspiratory muscle strength, knee extension strength, limb strength, and handgrip strength.²² The WHO’s international classification of functioning, disability, and health framework noted that impairments in pulmonary function in patients with ARDS at 6 months after critical illness, and PFTs were reduced to 65% to 88% of predicted normal values.²³ Patients had mild to moderate impairments in diffusion capacity, and inspiratory muscle strength was reduced to 15% below predicted normal values at 12 months. Deficits in handgrip strength have been reported at 3 months, 6 months, and 12 months after critical illness.²² These tests all have their individual limitations and must be used at the clinician’s discretion when determining which test to use on an individual patient.

Activity limitations are assessed using tests that measure a patient’s ability to perform a specific activity in a specified time. These tests include the Timed Up and Go test (TUG),²⁴ the 30-second or 1-minute sit-to-stand test,^{25 26} and the 2-minute and 6-minute walk tests.^{27 28} Overall, we think the 30-second sit-to-stand test and the 2-minute walk test are the easiest to perform in a limited time setting.

In the TUG test, patients start by sitting in a chair, standing up, walking nine feet to a marked turnaround, and then walking back.²⁴ There are published norms for age for the TUG,^{29 30} and any patient beyond these norms should be considered for a potential PICS diagnosis. The 30-second and 1-minute sit-to-stand test is similar but does not require walking.²⁵ In this test, a patient starts by sitting in a chair, and then the patient must stand from sitting as many times as possible within 30 seconds or 1 min. There are norms for age and sex for this test.³¹ The 2-minute and 6-minute walk tests determine how far a person can walk in these allotted times.³² Of course, all these tests in a trauma patient may not be as useful due to extremity injuries and/or immobility, and thus a lower score on these tests may not reflect PICS.

The third domain, participation restriction, uses historical data, physical tests, or surveys to assess impairment.^{33 34} Clinicians evaluating an ICU stay survivor have used participant recall of preadmission status to determine participation restriction.1923 35,38 Conversely, others have used patient physical tests and activity levels versus a predicted value.39,45 Finally, clinicians may opt to use surveys that have been developed to assess the change in participation.^{33 46 47} For example, the Health-Related Quality of Life questionnaire EQ 5D can be used to assess activity limitations and participation restrictions. This survey can even be repeated over time to assess improvements in activity restrictions.^{48 49} Regardless of the tool used, it is important to determine premorbid functional status to assess for the presence of PICS in appropriate patients.

What laboratory or genomic assessments can be done to supplement the evaluation of thromboinflammatory dysfunction and persistent organ failure for PICS in surgical and trauma patients?

Recommendation

Considering that no single laboratory or genomic test currently can confirm or exclude thromboinflammatory dysfunction and persistent organ failure, both clinical and adjunctive biomarkers should be considered in the diagnosis.

Discussion

Critical care providers now have tools to evaluate survivors of critical illness and injury using both clinical and biochemical assessments. The SCCM recommends that selected patients be assessed for PICS early (eg, 2 weeks to 4 weeks after discharge), serially, with priority given to high-risk patients, and during important health or life changes.¹

There are many overlapping features between the clinical manifestations of PICS and the subsequent development of thromboinflammatory dysfunction and persistent organ failure. For the latter, several surrogate markers have been proposed and can be extrapolated to define this altered immunologic state. These include: CRP >1.5 mg/L, total lymphocyte count <0.80 × 10⁹/L, serum albumin <3.0 g/dL, serum prealbumin <10 mg/dL, creatinine height index <80%, weight loss >10%, BMI <18 kg/m² during hospital admission, and retinol-binding protein <10 µg/dL.⁵⁰ Other associated markers include reduced CD3, CD4, CD8, and CD20 lymphocyte subsets, anemia, thrombocytopenia, and elevated neutrophil-to-lymphocyte ratio. Inflammatory cytokines such as procalcitonin, Interleukin (IL)-6, IL-8, and IL-10 are frequently abnormal.^{51 52} Exploratory markers include IL-1β, metallopeptidase-9, glucagon-like peptide (GLP)-1, tumor necrosis factor-α, interferon-γ, granulocyte-macrophage colony stimulating factor (GM-CSF), vascular endothelial growth factor (VEGF), toll-like receptor (TLR)-3, and insulin-like growth factor binding protein (IGFBP).⁵²

Beyond routine laboratory assessments, genomic and transcriptomic analyses are emerging as valuable adjuncts for risk stratification and understanding the mechanisms underlying this condition. Whole-blood transcriptomic studies have demonstrated a reproducible ‘genomic storm’ after severe trauma, with large-scale upregulation and downregulation of innate and adaptive immune genes that correlate with clinical outcomes.⁵³ Longitudinal analyses show that patients progressing to chronic critical illness, defined as persistent organ failure and ICU admission of greater than 14 days, exhibit sustained inflammatory and myeloid activation patterns alongside suppression of adaptive immune pathways, distinguishing them from rapid-recovery trajectories.54,56

Previous investigations have also demonstrated that early elevations in circulating cytokines such as IL-6 and IFN-γ after severe injury are associated with subsequent organ failure and poor outcomes.^{57 58} These findings illustrate how molecular signals can identify patients at risk of poor recovery and persistent dysfunction, and they support the integration of molecular profiling into the broader evaluation of at-risk ICU survivors.

For clinicians, the utility of these genomic approaches currently lies in research and prognostication rather than direct diagnosis. Their value is maximized when combined with clinical assessments, patient-reported outcomes, and structured follow-up, as described elsewhere in this document.^{59 60} Laboratory and genomic markers should therefore be viewed as complementary to clinical evaluation, helping to identify patients at the highest risk for ongoing morbidity and mortality, and guiding enrollment in multidisciplinary follow-up programs or precision medicine trials.

What conditions in Surgical and Trauma patients can produce a physical and cognitive decline that can mimic PICS, and how do we distinguish those conditions from each other?

Recommendation

There is significant overlap between PICS and many diseases that clinicians will encounter in the surgical ICU, especially patients with diseases impacting multiple organ systems. Table 1 provides a partial list of conditions and their common presentations that are prominent in recovering surgical and trauma patients after intensive care admission. Please refer to the online supplemental material for a more comprehensive list of conditions that may mimic components of PICS. A clinical presentation explained by a new or existing pathological findings as determined at surgical follow-up does not invite the diagnosis of PICS. However, when the pattern of recovery does not fit with expected clinical progress, PICS needs to be considered.

Table 1. Conditions with presenting symptoms that overlap may PICS and their differentiating features.

Condition	Physical impact	Cognitive impact	Psychological impact	Overlap with PICS	Differentiating features
Traumatic brain injury	Motor deficits: paralysis, speech/swallowing issues, seizures, pain	Memory, attention, executive dysfunction, slowed thinking	Depression, irritability, personality changes	Physical and cognitive deficits mimic PICS; mood overlap71	Acute onset with known head trauma, focal neurological signs, abnormal imaging
Sepsis (post-sepsis syndrome)	Weakness, cachexia, ICU-acquired myopathy	Delirium, memory loss, executive dysfunction	Anxiety, depression, PTSD	All PICS domains present in many survivors72	History of critical infection; inflammatory/organ dysfunction; elderly at higher risk72
Delirium	Variable—may be hypo/hyperactive	Acute confusion, disorientation that fluctuates	Fear, emotional lability	Acute cognitive disturbance mimics PICS early71 73	Fluctuating, reversible; short duration; reversible once treat underlying cause73
Hypoxic brain injury	Motor impairments, autonomic signs	Severe cognitive dysfunction, memory loss	Mood swings, depression, anxiety	Cognitive and emotional overlap71 74	Antecedent hypoxic event (eg, cardiac arrest); Imaging shows diffuse injury; coma or vegetative state phases may have occurred.
Chronic fatigue syndrome	Post-exertional malaise, fatigue	Significant short-term memory/ concentration problems	Anxiety, panic, depression	Fatigue and cognitive/mood symptoms resemble PICS75 76	Not ICU-related; chronic fatigue diagnosis; post-exertional worsening
Stroke	Hemiparesis, dysphagia, vision loss	Memory, executive function, attention deficits	Depression, anxiety	Focal neurological and cognitive deficits65 71 74	Acute onset with focal findings; neuroimaging shows infarct/hemorrhage; vascular risk factors
Hypothyroidism	Fatigue, cold intolerance, bradycardia	Cognitive slowing, memory loss	Depression, apathy	Lethargy, cognitive fog resembles PICS77 78	TSH/T4 abnormalities; slow, insidious onset; treatable with thyroxine
Hyperthyroidism	Tremors, weight loss, palpitations	Poor concentration, distractibility	Anxiety, irritability, insomnia	Anxiety/fatigue can mimic PICS77 78	Thyroid function abnormal; sympathetic overdrive signs
Vitamin B12 deficiency	Paresthesia, ataxia, weakness	Memory loss, confusion, slow processing	Irritability, apathy	Neurologic/cognitive overlap77 79	Macrocytic anemia; low B12; reversible with supplementation
Anemia	Fatigue, pallor, dyspnea	Decreased attention, mental fatigue	Low mood, irritability	Fatigue, cognitive slowing similar to PICS77 80	Confirmed by CBCt; treatable; unrelated to ICU stay
Cancer	Variable: pain, fatigue, cachexia	Chemo brain: attention/memory deficits	Depression, PTSD, anxiety	Fatigue, cognitive/mood issues resemble PICS77 79 81	Malignancy signs; treatment-related; non-ICU cause
Dementia	Falls, gait change, incontinence	Progressive memory and functional decline	Depression, paranoia, apathy	Cognitive symptoms overlap PICS71 74 80 82	Chronic course; not ICU-triggered; imaging/neuro testing confirms
Generalized anxiety disorder	Muscle tension, headaches, insomnia	Distractibility, poor concentration	Excessive worry, hyperarousal	Anxiety symptoms common to PICS83	Predates or is independent of any ICU event; DSM-5 criteria
Depression	Fatigue, sleep/appetite changes	Poor focus, slowed thinking	Sadness, guilt, suicidal ideation	Mood overlaps with PICS depression1 65 76 84	May predate ICU; no triad unless comorbid issues
Schizophrenia/ schizoaffective disorder	Neglect, motor inactivity	Disorganized thought, hallucinations	Psychosis, mood swings	Cognitive/psych overlap with ICU psychosis59 65 85	Chronic course; hallucinations/ delusions present; DSM-5 criteria
Substance use disorder	Variable: fatigue, weakness, withdrawal signs (eg ataxia, seizure, arrhythmia)	Attention, memory deficits, executive functioning deficits	Irritability, paranoia, depression, insomnia, emotional lability	Withdrawal delirium mimics ICU psychosis65 77 86	History of substance use; toxicology; response to detox
Failure to thrive	Cachexia, malnutrition, immobility	Decreased alertness in elderly; poor memory	Depression, apathy, social withdrawal	Frailty may resemble PICS physical impact65 77 84 87	Predates ICU; geriatric syndrome; nutritional aid helpful1 88
Neuromuscular disorders (eg, multiple sclerosis, ALS)	Variable: weakness, muscle atrophy, spasticity, and hyper-reflexia. Bulbar involvement causes dysarthria/dysphagia.	Cognitive impairment can be seen if frontotemporal involvement	Depression, anxiety, emotional lability (pseudobulbar affect) may occur	Profound weakness, cognitive/behavioral changes can overlap with PICS findings88 89	Timing is key for various diagnoses; EMG diagnostic; normal brain imaging; Pattern of spread and respiratory decline differentiates from PICS89
Post-hospital syndrome	Fatigue, frailty, falls post discharge	Transient confusion or disorientation, especially in elderly	Adjustment reaction, anxiety, frustration, low mood	Similar short-term fatigue and stress59 90	Transient (days–weeks); not persistent like PICS; does not include all three PICS domains90
PTSD	Insomnia, fatigue, muscle tension	Memory, concentration impairment	Recurrent intrusive memories, flashbacks, nightmares, hypervigilance	Similar intrusive thoughts, sleep disturbance, emotional dysregulation76 83	Linked to trauma, not ICU-specific; DSM-5 criteria may predate ICU or persist independently

ALS, Amyotrophic Lateral Sclerosis; CBC, Complete Blood Count; DSM, Diagnostic and Statistical Manual of Mental Disorders; EMG, Electromyography; ICU, intensive care unit; PICS, post-intensive care syndrome; PTSD, Post-traumatic stress disorder.

Discussion

The presentation of PICS may vary, and it can be difficult to distinguish between other disease processes. A key feature is newly recognized or worsening symptoms after a critical illness.^{61 62} Physical symptoms may present with generalized weakness or a more focal neurological deficit. The risk of ICU-associated weakness is increased with female sex, sepsis, catabolic state, multiorgan failure, systemic inflammatory response syndrome, long duration of mechanical ventilation, immobility, and neuromuscular blocking agents.⁶³ Cognitive symptoms may present with confusion, agitation, or memory loss. Hypoglycemia, hyperglycemia, delirium, and in‐hospital acute stress symptoms have been identified as possible risk factors for persistent cognitive impairment after critical illness.^{16 64 65} Mental health symptoms may present with anxiety, depression, or other psychiatric symptoms. Pre‐existing depression, anxiety, PTSD, lower education level, and alcohol abuse increase the risk of ICU‐acquired mental illness.⁶¹ For each of these categories, it is important to rule out exacerbation of chronic illnesses, new structural sources, and/or metabolic sources. Providers should suspect PICS if the presenting symptoms do not improve after initiation of treatment or if the workup does not reveal a causative source.⁶²

What is a PICS clinic and what is the minimum recommended personnel for establishing a PICS clinic?

Recommendation

A PICS clinic is a specialized multidisciplinary outpatient program that provides comprehensive evaluation, longitudinal follow-up, and coordinated management of PICS across its four core domains, including physical, cognitive, mental health, and social functioning. We recommend the development of a dedicated PICS clinic to support structured recovery and continuity of care; however, we recognize that implementation may not be feasible in all institutions because of resource and infrastructure limitations. When establishing a PICS clinic, we recommend inclusion of a dedicated provider champion, ideally with expertise in critical care and PICS, in addition to nursing, physical therapy, clinical psychology, and social work. Based on local resources and patient population needs, we further recommend incorporation of pharmacy, dietetics, speech-language pathology, occupational therapy, and case management services to promote comprehensive and patient-centered care.

Discussion

There are multiple models of PICS clinics that have been established worldwide. These can be broken down into in-person clinics, telehealth clinics, or a hybrid approach in which both models are combined to meet the needs of the patient. However, a key concept of post-ICU clinics is the idea of ‘humanizing survivorship’.⁶⁶ Human, personal connections between provider and patient are important in these clinics as providers want to build rapport and a sense of safety with this unique patient population. As such, in-person clinics are preferred whenever feasible, keeping in mind the ultimate needs of the patient. Of note, timed walk tests, a recommended, validated tool for physical function as a component of PICS, require in-person testing. However, it should be noted that telemedicine models of post-ICU care increase rates of recruitment, success of interventions, and retention, though the impact on clinical outcomes is unclear.⁶⁷ Despite the recognized benefits of structured post-ICU follow-up, the creation of a dedicated PICS clinic may not be universally feasible. Financial limitations, institutional priorities, workforce availability, and competing resource demands may limit the ability of some centers to develop or sustain a formal program. In such settings, adaptation of existing outpatient infrastructure or incorporation of PICS-focused assessments into established clinics may represent a pragmatic alternative. Health system resources, funding, space availability, telemedicine licensure, and the ability of patients (and caregivers) to physically come to a clinic space will dictate the optimal type of ‘clinic’ for each individual patient. Because of resource constraints, in-person follow-up in a PICS clinic should be reserved for patients with high risk of exhibiting PICS.

In terms of personnel, groups should define a provider champion who can lead interdisciplinary teams and who is capable of navigating obstacles including funding mechanisms.⁶⁶ Ideally, this individual should be involved in societies active in PICS care to be current with this evolving practice. Clinics should have a multidisciplinary approach with core subspecialists available for common issues associated with PICS, such as physicians, pharmacists, nurses, social workers, case managers, physical therapists, advanced practice providers, clinical psychologists, dietitians, and speech-language therapists.⁶⁸ The physicians do not necessarily need to be intensivists; however, we would recommend the integration of an intensivist who is able to help review modifiable risk factors to mitigate the development of PICS in their critical care environments. In a UK survey of PICS clinics, physicians, nursing, and physical therapy providers were present in 74% of outpatient services providing PICS care.⁶⁹ Finally, PICS clinics should also have an integrated pathway for referrals to primary care providers.⁶⁸ We have found that primary care physicians often carry the burden of navigating patients through their post-ICU discharge, and a strong relationship between primary care providers and PICS clinics should be encouraged. The initial PICS clinic assessment should include a complete medication reconciliation, evaluation of new or lingering symptoms, screening for health maintenance gaps, and careful review of the ICU stay. There should also be a robust discussion with the patient regarding the expected course of recovery and placement of indicated referrals.⁶⁸

Regarding testing, we do not recommend any additional testing aside from that described above to diagnose PICS or specific testing recommended by consulting services to improve patient outcomes regarding their physical, cognitive, or psychological deficiencies. However, any further testing that is pursued should be done within the PICS framework. Tests should be done by the appropriate personnel in the clinic, and when an impairment is diagnosed, the patient should be seen by a specialist who can best treat their impairment. For instance, a patient with a significantly prolonged 30-second sit-to-stand test who is suspected of having PICS should be referred to a physical therapist for ongoing treatment.

Currently, there may be multiple barriers to establishing a PICS clinic, and this has limited the widespread adoption and standardization of these clinics nationally. The first barrier is deciding which providers should own the diagnosis and follow-up of patients suspected of having PICS. Intensivists do not necessarily have their own clinic or dedicated time for staffing clinics; primary surgeons are not often experienced in PICS; physical medicine and rehabilitation physicians seem like a reasonable option; however, many patients with mild impairments may not meet criteria to be referred to rehabilitation. Funding is another of the largest barriers for these clinics, and thus institutional PICS programs are rare. To date, there is no support for PICS follow-up by national health insurance systems in any country. Therefore, these clinics require institutional funding, which is often limited. Another barrier is the fact that there is insufficient evidence for the efficacy of PICS follow-up. High-quality clinical trials are needed to understand the association of PICS screenings and interventions with outcomes. An additional barrier is a lack of recognition of PICS by both critical care and non-critical care providers, outpatient care teams, and patients themselves. The lack of recognition and understanding of this overall condition places patients directly at risk for long-term complications and late mortality. Thus, although the establishment and standardization of a formal PICS clinic would be ideal, we recommend clinicians work within the current framework of their local institution until further evidence and funding mechanisms emerge to establish a national standard for the establishment of PICS clinics. If the building of a formal PICS clinic or program is not possible at one’s local institution, critical care leaders should work with and educate inpatient and outpatient clinicians to increase awareness of PICS. In doing so, they will be able to help integrate components of PICS evaluations into their post ICU discharge care.⁶⁸

Which patients should be referred to a PICS clinic and what is the recommended follow-up?

Recommendation

Patients who are in a critical care environment for more than 48 hours or deemed at high risk by the treating physicians should ultimately be evaluated prior to discharge for consideration of referral to a PICS clinic. We recommend follow-up in a PICS clinic approximately 2 to 4 weeks after discharge from the hospital and thereafter at the discretion of the PICS clinic.

Discussion

PICS clinic referrals should be based on validated screening tools. These tools do not predict PICS but rather identify patients at high risk for long-term cognitive, physical, psychological, and thromboinflammatory impairments after a critical care stay. Ideally, critical care providers should assess and document the patient’s pre-ICU functional abilities as part of their admission history and physical. As hospital discharge approaches, providers should perform a brief, standardized functional assessment and compare it to the pre-ICU assessment documented in the health record. This has been termed ‘functional reconciliation’.¹ This workflow will allow for the proper placement of postdischarge appointments for patients deemed at risk for PICS and inform postdischarge placement decisions.

These assessments should align with planned and unplanned patient-centered events (ie, hospital discharge, termination of paid medical leave, and changes or plateaus in functional and cognitive abilities). Renner et al recommend screening and assessing all critically ill patients with lengths of stay >48 hours during their critical care stay, after hospital discharge, during and at the end of rehab, and in the outpatient setting.⁷⁰ The assessment should be made predischarge from institutions (hospital, rehabilitation, and/or skilled nursing facility) so that follow-up appointments for PICS can be made. Serial assessments for those at risk for PICS should begin 2 to 4 weeks after hospital discharge with subsequent visits after significant health and life changes with the initial follow-up at 6 weeks to 12 weeks after hospital discharge.¹ It is common for patients to follow-up in a PICS clinic at intervals of 3 months, 6 months, and 12 months.¹⁰ As discussed previously, ideally, PICS follow-up would occur in person. However, we recognize that there may be physical, social, or financial limitations for patients coming to in-person follow-up. In these instances, we recommend a hybrid approach with both in-person and telehealth evaluation for evaluation of PICS. Finally, broad education is essential to improve recognition of this condition and potential interventions that could minimize the long-term impacts to individual patients.

These assessments should align with planned and unplanned patient-centered events (ie, hospital discharge, termination of paid medical leave, and changes or plateaus in functional and cognitive abilities). Renner et al recommend screening and assessing all critically ill patients with lengths of stay >48 hours during their critical care stay, after hospital discharge, during and at the end of rehab, and in the outpatient setting.⁷⁰ The assessment should be made predischarge from institutions (hospital, rehabilitation, and/or skilled nursing facility) so that follow-up appointments for PICS can be made. Serial assessments for those at risk for PICS should begin 2 weeks to 4 weeks after hospital discharge with subsequent visits after significant health and life changes with the initial follow-up at six to 12 weeks after hospital discharge.¹ It is common for patients to follow-up in a PICS clinic at intervals of three, six, and 12 months.¹⁰ As discussed previously, ideally, PICS follow-up would occur in person. However, we recognize that there may be physical, social, or financial limitations for patients coming to in-person follow-up. In these instances, we recommend a hybrid approach with both in-person and telehealth evaluation for evaluation of PICS. Finally, broad education is essential to improve recognition of this condition and potential interventions that could minimize the long-term impacts to individual patients.