By Elaine Chen, MD
Assistant Professor, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Section of Palliative Medicine, Rush University Medical Center, Chicago
Dr. Chen reports no financial relationships relevant to this field of study.
SYNOPSIS: Three months after surviving critical illness due to respiratory failure or shock, more than 60% of survivors experienced a decrease in employment. At 12 months, almost half of survivors still experienced a decrease in employment.
SOURCE: Norman BC, et al. Employment outcomes after critical illness: An analysis of the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors cohort. Crit Care Med 2016;44:2003-2009.
Critical care use is increasing, and ICU survival rates are improving. Survivors of critical illness may experience post-intensive care syndrome, characterized by impaired cognitive, physical, and psychological function. Returning to employment marks an important milestone in recovery.1 An earlier study of health-related quality of life of general ICU survivors reported that approximately half of patients returned to school or work one year after discharge.2 This prospective cohort study is nested within a larger study, the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors (BRAIN-ICU) study at Vanderbilt University and Saint Thomas Hospital. Subjects were adults admitted to an ICU with respiratory failure, cardiogenic shock, or septic shock. Patients were evaluated via survey for employment level at three and 12 months after discharge. Primary independent risk factors examined included in-hospital duration of delirium and cognitive function at follow-up. The primary outcome was self-reported decrease in employment level compared with prior employment level. Decrease was defined as going from full-time employment to unemployed or part-time employment, or part-time employment to unemployed. Physical health status, depressive symptoms, and severity of illness were measured with well-validated tools. Of 636 patients in the three-month follow-up cohort, 113 were identified as employed prior to illness. Of these, 100 (88%) were employed full time, and 13 (12%) were employed part time. At three months, 67 (58%) were unemployed, nine (8%) were employed part time, and 39 (34%) were employed full time; of these, 70 (62%) reported decreased employment. At 12-month follow-up, available data on 94 patients revealed that 45 patients remained unemployed (47%), 7% were employed part time, and 45% had returned to full-time employment. Overall, 46 patients (49%) reported a decrease in employment at 12 months. Adjustment for covariates revealed no association with duration of in-hospital delirium, cognitive function at three months, or severity of illness. However, better cognitive function at 12 months was marginally associated with lower odds of decreased employment at 12 months.The authors cited three key findings. First, rates of unemployment for survivors of critical illness remained high at one year after discharge. Second, there was no significant relationship between delirium during hospitalization or cognitive function with decreased employment at three months. Third, better cognitive function at 12 months was associated with a trend toward lower odds of decreased employment (P = 0.07).
As intensivists, we don’t always know how our patients fare after they leave our care. Some return to the ICU repeatedly. Those who improve and stabilize often don’t return to our clinics after their ICU stay, but rather return to their primary care providers. Many studies have evaluated physical, psychological, and cognitive function but fewer have evaluated employment. One longitudinal study of acute respiratory distress syndrome (ARDS) survivors found that six years after discharge, approximately 25% of patients remained unemployed due to health conditions, with high rates of cognitive dysfunction and disability.3 This study reported that at one year, about half of ICU survivors will be working at a decreased level of employment compared to before their illness. In this article, the authors proposed that at three months, the physical and clinical factors related to the ICU still play a stronger role than cognition in decreasing re-entrance into the workforce, but at 12 months those factors have largely resolved. I am reminded of two patients who experienced prolonged ICU stays due to critical illness who have returned for follow-up with me over the past three years. The first patient is a 30-year-old woman who was hospitalized with a lupus flare and subsequently developed severe ARDS and sepsis. At her three-month follow-up visit, she could not walk from her wheelchair to the examining table and required oxygen at rest. After about one year, she returned to work part time and now works full time while caring for two children. The second patient is a bone marrow transplant recipient who was cured of his hematologic malignancy but suffered from a severe central nervous system infection. He experiences residual cognitive deficits, and while his physical function is nearly back to baseline, he has been unable to return to work after three years.
These two patients left a profound impression on me, and have led me to question what is the “normal” trajectory after ICU survival? The ideal would be to recover to baseline function rapidly, such that the sequelae of illness are not significantly noticeable. A friend of mine who received therapeutic hypothermia after a post-surgical cardiac arrest returned to full function and employment as a pharmacist within one year. Although this article will not change practice, it spurs reflection for critical care providers.
Although this study focused on delirium and cognition, other factors in the database potentially could be studied with regard to their effects on recovery. This study can help us counsel our younger, previously very functional patients and their families during their time of critical illness that regardless of how sick they are now, if they survive, long-term outcomes can be very positive.
- Anderson BJ, Mikkelsen ME. The road to recovery: Turning the tide on losses incurred after critical illness. Crit Care Med 2016;44:2111-2112.
- Myhren H, et al. Health-related quality of life and return to work after critical illness in general intensive care unit patients: A 1-year follow-up study. Crit Care Med 20101;38:1554-1561.
- Rothenhausler HB, et al. The relationship between cognitive performance and employment and health status in long-term survivors of the acute respiratory distress syndrome: Results of an exploratory study. Gen Hosp Psychiatry 2001;23:90-96.