Digital solutions and the future of recovery after critical illness

Purpose of review Digital technologies may address known physical and psychological barriers to recovery experienced by intensive care survivors following hospital discharge and provide solutions to care fragmentation and unmet needs. The review highlights recent examples of digital technologies designed to support recovery of survivors of critically illness. Recent findings Despite proliferation of digital technologies supporting health in the community, there are relatively few examples for intensive care survivors. Those we identified included web-based, app-based or telemedicine-informed recovery clinics or pathways offering services, including informational resources, care planning and navigation support, medication reconciliation, and recovery goal setting. Digital interventions supporting psychological recovery included apps providing adaptive coping skills training, mindfulness, and cognitive behavioural therapy. Efficacy data are limited, although feasibility and acceptability have been established for some. Challenges include difficulties identifying participants most likely to benefit and delivery in a format easily accessible to all, with digital exclusion a resultant risk. Summary Digital interventions supporting recovery comprise web or app-based recovery clinics or pathways and digital delivery of psychological interventions. Understanding of efficacy is relatively nascent, although several studies demonstrate feasibility and acceptability. Future research is needed but should be mindful of the risk of digital exclusion.


INTRODUCTION
Survivors of an ICU admission experience numerous physical, psychological, and cognitive sequalae collectively known as post intensive care syndrome (PICS) that are highly prevalent and persistent [1 && ]. Furthermore, fragmentation of healthcare services during recovery from critical illness is a common phenomenon [2]. This results in a mismatch between healthcare services needed and those received, information loss, treatment omissions, and hospital readmission [3][4][5]. In some countries such as the UK, clinical services to support recovery from critical illness are reasonably well established [6]. However, patients generally do not receive ICU recovery clinic services until 2-3 months after hospital discharge, if at all. This results in multiple unmet needs, including timely provision of assistive devices, access to services to support mental health, appropriate medication management, assistance with government and community health and social care programmes, and access to rehabilitation therapies [7 & ,8 & ]. Multiple unmet needs result in a challenging experience for patients and families that negatively influences recovery potential as well as time to recovery.
Digital technologies comprise electronic tools (cameras, sensors), systems and platforms (software, mobile apps), devices (tablets, smartphones), and resources (websites) that generate, store, or process data. These technologies may provide a solution to care fragmentation and unmet needs immediately following hospital discharge, enabling individualized patient and family-centred care. Digital solutions may improve patient access to appropriate care providers in a timely and cost-effective manner. Although digital technologies as a part of telemedicine and telerehabilitation services have been used extensively in the management of chronic diseases such as Chronic Obstructive Pulmonary Disease (COPD) and congestive heart failure [9], we are only just starting to see examples that facilitate rehabilitation and recovery from critical illness. In this brief review, we will outline recent examples of the use of digital technologies to support both physical and psychological recovery of ICU survivors.

Digital technology-based interventions to promote physical recovery
The COVID-19 pandemic has significantly accelerated the adoption of digital technologies throughout the world and across many patient diseases and conditions. Although there are some examples of digital recovery clinics or programmes that predated the pandemic, many existing ICU recovery clinic services were forced by necessity to adapt to virtual service delivery by video conferencing due to social distancing mandates aimed at reducing virus transmission. Kovaleva et al. [10] described a telemedicine ICU recovery clinic in the USA commencing in 2019 that comprised video conferenced clinic visits at 3 and 12 weeks with a team, including a pharmacist, ICU physician, and a neuropsychologist. These visits focused on medication reconciliation and counselling, remote medical examination, an ICU debrief, and cognitive and mental health screening. Qualitative data indicated recipients found this approach to be acceptable, convenient, time-saving, and to facilitate thorough discussions. Another example of a web-based recovery program, ICUTogether, was developed by Ewens et al. [11]. This program is accessible via smart devices or computer and provides a range of informational resources, including those relating to exercise, sleep, and nutrition tailored to data provided by a patient on their current symptoms. Symptom data are also reviewed to ascertain if further interventions are needed. A randomized controlled trial (RCT) of this program is currently underway in Australia.
The USA-based STAR program for sepsis survivors [12] uses a centrally based sepsis nurse navigator who provides individualized support for care planning, self-management, follow up, and engagement until 30 days after hospital discharge. Although communication between the nurse navigator and the patient was predominantly by telephone, video conferencing and the electronic medical record were also used to enable coordination and monitoring of patients. In a RCT of 691 participants, the STAR program reduced 30-day mortality or hospital readmission compared with routine transition support and outpatient care [13 && ]. During the pandemic, our group Life Lines (https://www.kingshealthpartners.org/our-work/ lifelines/information-for-families/information-onthe-digital-icu-recovery-pathway) designed and implemented an ICU digital recovery pathway into a large ICU recovery service in a tertiary centre in the UK. The pathway is hosted in the e-platform aTouchAway (Aetonix, Canada) and comprises eforms for the assessment of baseline status and barriers to recovery; setting of individualized recovery goals; patient self-reported e-monitoring of goal achievement with automated reminders; provision of e-resources tailored to recovery barriers; patient recovery e-diary; tailored activity reminders; note function enabling the recovery coordinator to document patient encounters with optional electronic medical record upload; and (8) two-way digitally secure text, audio, and video communication between the patient, nominated family members, and the recovery coordinator ( Fig. 1). Selection of goals is based on Goal Attainment Scaling (GAS) [14]. It includes discussion and documentation of what goal achievement would look like and the patient's perceptions of goal importance, difficulty, and ability to attain the goal. Initial evaluation of the pathway indicates the pathway is feasible to deliver and has good acceptability ratings [15 & ].

KEY POINTS
Digital technologies may help to address known barriers to recovery experienced by intensive care survivors following hospital discharge, and provide solutions to care fragmentation and unmet needs.
Despite proliferation in the use of digital technologies for many diseases and conditions that support physical and mental health in the community, there are relatively few examples for intensive care survivors.
Those within the evidence base include web-based, app-based, or telemedicine-informed recovery clinics or pathways, use of smart devices, and self-accessed mobile apps that deliver psychological interventions focused on coping, mindfulness, or cognitive behavioural therapy.
Data on the efficacy of interventions using digital technology to support physical and psychological recovery are limited, although feasibility of deliverability and acceptability of use has been established for some.
Telemedicine and telerehabilitation programmes also have been introduced for COVID-19 survivors, many of whom have experienced an ICU admission. In an Italian study, Bernocchi et al. [16] reported on the adaptation of their existing telemedicine services for patients with COPD or chronic heart failure to meet the needs of COVID-19 survivors. Their 3-month programme comprises a standardized interview to assess the patient's clinical condition followed by tailored advice by telephone or video conferencing. Patients are also provided with a pulse oximeter on hospital discharge to monitor their oxygen saturation during rest and exercise. Evaluation of the programme in 130 patients demonstrated a reduction in symptoms, improvement in the physical aspect of health-related quality of life, and high programme satisfaction.
Capin et al. [17] developed a comprehensive multicomponent app-facilitated telerehabilitation programme for COVID-19 survivors, including those with an ICU admission. This includes provision of a tablet, Fitbit, automated blood pressure cuff, pulse oximeter, ankle weights and resistance bands with 12 individualized exercise, coaching and motivational interviewing sessions via video, and access to the Health in Motion app. An initial assessment of feasibility demonstrated excellent adherence despite the intensive nature of this intervention. Hunter et al. [18 & ] have used smartwatches to measure step count and heart rate for up to 1 year in a cohort of 50 ICU survivors who had severe COVID-19 recruited from eight centres. In one centre, the smartwatch data were provided for a multiprofessional team review. Data demonstrated an increase in step count and a reduction in resting heart rate from baseline to 1 year, with good fidelity and positive perceptions in terms of the influence of the smartwatch on their recovery.

Digital technology-based interventions to promote self-management of psychological recovery
The stresses of critical illness promote psychological distress symptoms, including depression [19], anxiety [20], and posttraumatic stress disorder (PTSD) [21] that are common and persistent. However, there are several challenges to delivering interventions to address psychological symptoms of ICU survivors. Routine screening is uncommon, access to mental healthcare is challenging and geographically inconsistent (particularly for people from racially and ethnically minoritized groups [22,23]), and therapy frequently includes medications or inperson therapist visits [24]. In contrast, approaches that patients generally prefer includes easily accessible therapy available from home, content that reflects their individual experiences, and nonpshrmacological interventions due to concerns about polypharmacy and side effects [25].
As yet, there are few examples of effective interventions that alleviate ICU survivor distress. Rigorously conducted trials demonstrate no effect on PTSD, depression, or anxiety symptoms using either ICU-based interventions (e.g., music therapy [26], nurse-led preventive psychological intervention [27], or ICU diaries [28] (now available in digital formats) or interventions following hospital discharge (e.g., aforementioned follow-up clinics/ service [29]). Challenges include difficulties associated with directing an intervention towards those who are most likely to benefit, recognizing that some patients may be too ill and some perhaps too well. Another challenge is delivering an intervention in an easily accessible format with the risk of introducing digital exclusion. Such exclusion may be due to demographic, socioeconomic, or illness circumstances that prevent access to technology or lack of familiarity or comfort with its use. These challenges were encountered during a multicentre RCT examining a telephone-based adaptive coping skills intervention. On average, only half the calls were completed thereby limiting the intervention dose, with substantial dropout due to illness [30].
Although there are numerous more generalized digital interventions promoting self-management of psychological distress symptoms, there are few examples designed specifically for ICU survivors following hospital discharge (Fig. 2). One example is an adaptive coping skills training intervention called the Blueprint mobile app that evolved from the aforementioned telephone-based intervention. Blueprint is a self-directed, month-long programme with unique content arranged in four thematic weeks accessed using any digital device. Content includes short videos by ICU survivors describing coping strategies, videos in which clinicians normalize the recovery process and provide context for adaptive coping, and interactive exercises illustrating each week's coping skills (Fig. 3). A pilot RCT [31 & ] comparing the Blueprint mobile app intervention to usual care found good adherence, with participants experiencing improvements in depression and anxiety symptoms at 3 months. An efficacy-focused trial is now required before broader adoption.
Another example of a digital intervention to address psychological distress of ICU survivors is the month-long, self-directed mobile app-based mindfulness Lift intervention. In a pilot RCT [32] with 80 participants, the Lift mobile app reduced psychological distress symptoms compared to a control group receiving a web-based critical illness education programme. Importantly, 85% of participants randomized to the Lift app received 100% of the intervention dose. Currently, there is a multicentre trial underway [33] that compares eight different versions of Lift. To determine which version is optimal, these differ in terms of varying configurations of dose, response to increasing symptoms over time, and presence or absence of a therapist kick-off call.
Other recent trials of digital technology-based interventions to promote psychological recovery include virtual reality and internet-based cognitive behavioural therapy. Vlake et al. [34 & ] found no effect on psychological distress in a trial (89 participants) of a 14-min informational video exposing the patient to the ICU environment with voice-over explanations delivered using virtual reality during an ICU recovery clinic visit. Gawlytta et al. [35] conducted a trial targeting dyads of sepsis survivors with a presumptive PTSD diagnosis and their spouse. They found no effect of an internet-based, therapist-led partner-assisted cognitive-behavioural writing therapy comprising two 50 min internet-based writing assignments/week/5 weeks but were only able to recruit 25 dyads of the planned 98. Although these interventions have not demonstrated efficacy in decreasing psychological distress, they are likely under-powered and do however provide important data informing understanding of the acceptability of these digital interventions.

CONCLUSION
Survivors of an ICU admission experience numerous physical, psychological, and cognitive sequalae for which digital technologies may offer alternate interventions and delivery methods to traditional in-person recovery clinics. These in-person clinics in themselves are not offered consistently across regions or countries, if at all. Digital interventions described in the evidence base primarily comprise web or app-based recovery clinics or pathways addressing a range of ICU survivor needs; digital delivery of psychological interventions such as coping, mindfulness, or cognitive behavioural therapy; and use of virtual reality. Evidence in relation to the efficacy of such interventions is relatively nascent although several studies demonstrate feasibility and acceptability. Future research is needed to establish efficacy of digital technologies in supporting ICU survivor recovery but should also be mindful of the associated risk of digital exclusion.

REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as: