Rehab in the ICU

Published in Hopkins Medicine - Summer 2020

Patients with COVID-19 are staying for weeks in the ICU, putting them at great risk of developing post-intensive care syndrome (PICS): physical, cognitive and psychological changes that occur after surviving an illness or injury that requires ICU treatment. 

The syndrome can affect a person’s ability to perform activities of daily living, driving and work, and impact family members who must adjust to their loved ones’ new normal, notes Dale Needham, a Johns Hopkins critical care physician who is renowned for advancing PICS research. 

When a patient is in an unfamiliar environment, under sedation and working overtime to fight infection or recover from an injury, delirium can set in, says Joe Bienvenu, a Johns Hopkins psychiatrist who studies survivors of critical illnesses and intensive care. He describes delirium as a brain malfunction that makes it hard for patients to interpret what is going on around them. Their bodies seem to know that something is terribly wrong, but their brains can misinterpret what that is. Patients often describe frightening, nightmarelike experiences, sometimes with themes of betrayal by doctors and nurses, sometimes even loved ones.  

The prevalence of delirium in patients with COVID-19 in the ICU is especially high, likely due to the amount of sedation needed to keep patients on ventilators for an extended period of time, says Megan Hosey, a rehabilitation psychologist in the ICU at The Johns Hopkins Hospital. 

Unfortunately, the effects of delirium can linger. “Even after it resolves,” Bienvenu says, “the memories can lead to mental health effects downstream: increased symptoms of anxiety, depression or post-traumatic stress disorder. Patients find themselves wanting to avoid hospitals and becoming very fearful that they will get sick again.”  

Because delirium can also cause cognitive changes in attention, thinking and memory that last beyond hospitalization, Hosey talks to patients about getting in touch with a mental health provider who understands PICS.  

In addition, in an effort to help patients with COVID-19 manage their health in the ICU as early as possible, many physical, speech and occupational therapists from Johns Hopkins rehabilitation facilities have been reassigned to The Johns Hopkins Hospital. “Very few ICUs in the country provide patients with the amount and intensity of early rehabilitation that we provide at Hopkins,” says Hosey.  

Needham agrees. “We’ve got an extraordinary program that routinely provides psychological help and physical, occupational and speech therapy on top of medical care in the ICU. During the pandemic, this program continues.”  

Soon, patients recovering from COVID-19 will have a convenient resource to report and monitor their health, including PICS. Ann Marie Parker is creating a virtual clinic for COVID-19 survivors.