RECOVER

The RECOVER Program: A Patient- and Family-Centred International Practice Standard for Follow-up Care after Critical Illness and Canadian ICU-outcomes Educational Program.

An episode of critical illness and treatment in an Intensive Care Unit (ICU) results in medical complexity and promotes multimorbidities.  This promotes large numbers of ICU survivors with new multiorgan system dysfunction including neuromuscular injury, neurocognitive and psychiatric dysfunction that contribute to profound, often irreversible functional impairment, inability to return to work, and reduced quality of life. Family caregivers develop new and often severe mood disorders affecting caregivers’ health and wellbeing.

Our research group has made landmark contributions to the international ICU outcomes literature over the past 20 years through a 5-year outcomes project in survivors of ARDS (Herridge et al. N Engl J Med 2003;348(8):683-93; Herridge et al. N Engl J Med 2011;364(14):1293-304) and a 1-year outcomes project in survivors of SARS and their caregivers (Tansey et al. Arch Intern Med 2007;167(12):1312-20). We are committed to optimizing patient and family outcomes after critical illness.

Currently, there is no systematic follow-up care or formal educational platform on outcomes after critical illness for patients or families. This is an urgent international public health issue.

Since 2007, and in close collaboration with the Canadian Critical Care Trials Group, we have established the RECOVER Program to address the gaps in the healthcare transitions and promote a seamless care continum for this complex and vulnerable population of patients and caregivers after critical illness. The Program consists of three phases:
• Phase I: Towards RECOVER
• Phase II: RECOVER program pathway feasibility and implementation
• Phase III: RECOVER national educational program

RECOVER Program (Phase I - Towards RECOVER (NCT00896220)- Co-PI Dr. Jill Cameron) is the first and largest international medical and surgical ICU patient (n=800) and family caregiver (n=500) parallel cohort, mixed-methods, multi-centre prospective study of outcomes after critical illness. Detailed in-person follow-up assessments to 2 years after ICU discharge were completed in 10 sites across Canada to elucidate the impact of critical illness and the caregiving situation on patients' and caregivers' long-term physical function and mental health. The study received support from CIHR and AHSC AFP Innovation Fund and also from families who participated in the RECOVER Program (The Gail and John MacNaughton Family, Don and Jane Luck Family and the Jason Tham and Andrea Chan Family). These results have were published in May of 2016 in the New England Journal of Medicine (caregiver and patient cohort- N Engl J Med. 2016 May 12; 374(19):1831-41) and the American Journal of Respiratory and Critical Care Medicine (patient cohort- Am J Respir Crit Care Med. 2016 Oct 1; 194(7):831-844). The Towards RECOVER cohort study enables us to understand that critically ill patients who require a minimum of 7 days of mechanical ventilation in the ICU and their family caregivers may be stratified into discrete groups characterized by increasing risk for functional disability and mood disorders after ICU discharge. These risk groups are independent of admitting diagnosis and ICU severity of illness and determine recovery trajectories, pattern of healthcare resource use and mortality to 1 year after ICU discharge. These data have significant implications for patient- and family-centered longitudinal care after an episode of critical illness.

The RECOVER Program is using this information to construct a novel patient- and family-centred care pathway that integrates care across health transitions: from ICU, acute care through inpatient rehab and ambulatory follow-up to primary care and community integration. Phase II: RECOVER program pathway feasibility and implementation - is grounded in new knowledge (Phase I: Towards RECOVER study), patient and caregiver engagement and multidisciplinary and interprofessional healthcare partnerships. This aims to establish:

i) a multidisciplinary and interprofessional team-based approach to complex care delivery and the first high acuity inpatient rehabilitation program based on disability risk groupings;
ii) a parallel psychoeducational instrument to promote literacy and self-efficacy in healthcare for patients and families;
iii) the Navigator role to facilitate care transitions and family- and patient-provider communication across the care continuum;
iv) a knowledge transfer and exchange program on outcomes during and after critical illness for patients and families, the multidisciplinary and interprofessional team, policy makers and the lay public as a foundation for the future RECOVER national educational program (Phase III).

The Phase II: implementation and feasibility is currently undergoing testing across University Health Network, Mount Sinai Hospital and Toronto Rehabilitation Institute as part of a wider national rollout to other RECOVER collaborating sites. An episode of critical illness transforms the life of the patient and family and we hope that the RECOVER Program will set a new international standard of practice across the recovery continuum.

Susan Abbey, Neill Adhikaru, Andrew Baker, Ian Ball, Mark Dr. Bayley, Jane Batt, karen Bosma, John gordon Boyd, Laurent Brochard, Karen Burns, Jill Cameron, Cecila Chaparo, Chung-Wai Chow, Brian Cuthbertson, Marcelo Cypel, Deborah Cook, Lorenzo Delsorbo, Claudia Dos Santos, Eddy Fan, Niall Ferguson, Geoff Fennie, John Flannery, Rob Fowler, Alison Fox-Robichaud, Jan Friedrich, John Granton, Paul Hébert, Jamie Hutchison, Shaf Keshavjee, Vincent Lo, John Marshall, Claudio Martin, David Maslove, Sunita Mathur, Andrea Matte, Victoria McCredie, Scott McIntaggart, Lauralyn McIntyre, Hilary Meggison, Angetta Metha, Michelle Kho, Denise Morris, Laveena Munshi, John Muscedere, Matteo Parotto, Dhar Preeti, Darlene, Reid, Jill Rudkowski, Damom Scales, Lianne Singer, Tax Sinuff, Yoanna Skrobik, Marat Slessarev, Arthur, Slutski, Orla Smith, Andrienne Tan, Claire Thomas, George Tomlinson, 

University Health Network (TWH), Mount Sinai, St-Michel's Hospital, St-Jopseph Hospital, St-Paul's Hospital, Sunnybrook Health Sciences Centre, The Ottawa Hospital - Civic Campus, Centre hospitlaier de l'Université de Sherbrooke, Hôpital Maisonneuve-Rosemont