{'fraction_non_alphanumeric': 0.040477734543882406, 'fraction_numerical': 0.01691526156506701, 'mean_word_length': 5.3964742481852745, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Characteristics of Post-ICU and Post-COVID Recovery Clinics in 29 U.S. Health Systems

OBJECTIVES: The multifaceted long-term impairments resulting from critical illness and COVID-19 require interdisciplinary management approaches in the recovery phase of illness. Operational insights into the structure and process of recovery clinics (RCs) from heterogeneous health systems are needed. This study describes the structure and process characteristics of existing and newly implemented ICU-RCs and COVID-RCs in a subset of large health systems in the United States. DESIGN: Cross-sectional survey. SETTING: Thirty-nine RCs, representing a combined 156 hospitals within 29 health systems participated. PATIENTS: None. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: RC demographics, referral criteria, and operating characteristics were collected, including measures used to assess physical, psychologic, and cognitive recoveries. Thirty-nine RC surveys were completed (94% response rate). ICU-RC teams included physicians, pharmacists, social workers, physical therapists, and advanced practice providers. Funding sources for ICU-RCs included clinical billing (n = 20, 77%), volunteer staff support (n = 15, 58%), institutional staff/space support (n = 13, 46%), and grant or foundation funding (n = 3, 12%). Forty-six percent of RCs report patient visit durations of 1 hour or longer. ICU-RC teams reported use of validated scales to assess psychologic recovery (93%), physical recovery (89%), and cognitive recovery (86%) more often in standard visits compared with COVID-RC teams (psychologic, 54%; physical, 69%; and cognitive, 46%). CONCLUSIONS: Operating structures of RCs vary, though almost all describe modest capacity and reliance on volunteerism and discretionary institutional support. ICU- and COVID-RCs in the United States employ varied funding sources and endorse different assessment measures during visits to guide care coordination. Common features include integration of ICU clinicians, interdisciplinary approach, and focus on severe critical illness. The heterogeneity in RC structures and processes contributes to future research on the optimal structure and process to achieve the best postintensive care syndrome and postacute sequelae of COVID outcomes.

C ritical illness and COVID-19 infection are associated with prolonged clusters of cognitive, physical, and psychologic impairments identified as postintensive care syndrome (PICS) and postacute sequelae of severe acute respiratory syndrome coronavirus 2 infection (PASC; i.e., long COVID), respectively. As many as 65% of ICU survivors experience some combination of executive function impairment or memory impairment, depression, and physical disability (1). Similarly, PASC, including cognitive dysfunction (e.g., brain fog), fatigue, and postexertional malaise are experienced by up to 70% of patients hospitalized with COVID-19 (2,3). There are striking similarities between PICS and PASC.
Long-term impairments following critical illness and/or COVID-19 infection burden public health and society by increasing healthcare utilization, creating new disability, and impacting financial health and return to work, among others (1,(4)(5)(6). The multifaceted long-term impairments resulting from critical illness and COVID-19 can be addressed via interdisciplinary management approaches to follow-up assessments. ICU recovery clinics (ICU-RCs) serve to screen, diagnose, refer, and manage critical illness survivors and have been operational in a subset of U.S. health systems with a modest adoption rate prior to the COVID-19 pandemic (7,8). Amid COVID-19, many ICU-RCs adapted to the care of COVID-19 survivors. Additionally, several COVID-19 recovery clinics (COVID-RCs) were initiated de novo, often built on the framework of interdisciplinary outpatient care that characterizes ICU-RCs.
The Critical and Acute Illness Recovery Organization (CAIRO) Post-ICU Clinic Collaborative, a successor to the Society of Critical Care Medicine Thrive Post ICU Clinic Collaborative, is a global collaborative of interdisciplinary clinicians. CAIRO members collaborate to analyze and address critical and acute illness recovery outcomes, cultivate best practices and exemplars for critical illness survivor recovery care, and disseminate information to inform uptake of post-acute recovery care programs. The work of the collaborative has resulted in descriptions of the structure and process for RC operations and delivery of services (9), which can guide processes for new clinics and inform RC best practices. The purpose of this cross-sectional study is to describe the structure and process characteristics of existing and newly implemented ICU-RCs and COVID-RCs in CAIRO Collaborative sites in the United States.

MATERIALS AND METHODS
We conducted a cross-sectional descriptive study using quantitative survey methods in accordance with Strengthening the Reporting of Observational studies in Epidemiology guidelines (10). Institutional Review Board (IRB) exemption status was obtained from The University of Texas at Austin IRB (2019-05-0132).

Setting and Sample
Participants were recruited from the CAIRO Collaborative (11), which includes global membership from seven countries representing 39 health systems operating an ICU-RC and/or COVID-RC, including 31 health systems in the United States. Only U.S. site results are included. Health systems engaged in CAIRO span every region of the United States, are largely academic, and operate at least one Post-ICU or Post-COVID-RC. Key clinic personnel from each collaborative site were asked to complete one survey for each RC in their institution. Responses from CAIRO Collaborative members within the United States are reported.

Variables and Measures
A 36-item investigator-developed web-based survey was designed to characterize Post-ICU and COVID-RCs. Survey items were developed by CAIRO leaders and RC directors within the collaborative through an iterative process of pilot testing, discussion, deliberation, and consensus with representation spanning critical care medicine, critical care nursing, critical care pharmacy, respiratory care, and health services administration. The survey solicits structure and process measures, including clinic start dates, patient referral sources, patient eligibility criteria, and an assessment of tools and measures used by RC teams to assess functional, psychologic, and cognitive recoveries as well as caregiver and quality-of-life assessments (Supplemental Table 1, http://links.lww.com/CCX/A945).

Procedures
The voluntary survey was sent to CAIRO collaborative members in March 2021 via emailed electronic survey link. One reminder e-mail was sent 1 week following initial survey distribution. Study data were collected and managed via the Research Electronic Data Capture tools hosted at Vanderbilt University (12).

Analysis
Responses from health systems and hospitals were analyzed descriptively to summarize RC demographics, operating structures, and clinical practice processes. Frequency distributions were used to summarize nominal and ordinal data. We reported responses to each question as the proportion of total U.S. sites.
Proportions are computed on known values; thus, missing data are removed from denominators. We used the chi-square or Fisher test, where appropriate, for comparing proportions and Wilcoxon rank-sum test to compare distributions. We summarized continuous variables using median values and interquartile range. All tests were two-sided with p values of less than 0.05 for significance.

RESULTS
A total of 39 RC surveys were completed by 29  systems, and responses from COVID-RC sites represent 84 hospitals in 13 health systems. The operational capacity for participating RCs is presented in Table 2. The majority (69%) of RCs are in large metropolitan areas. However, 80% of RCs reported offering telehealth clinic visits, thus extending the geographic reach beyond these large metropolitan hubs. Most RC sites (73%) serve health systems that include both large academic medical centers and smaller community hospitals (range, 2-26 hospitals per health system), suggesting that one clinic serves both urban and rural populations for that health system.

ICU-RC Demographics and Operating Structures
The number of ICU-RCs affiliated with the CAIRO Collaborative has increased steadily since 2016, with the highest number of new center members joining in 2020 ( Figs. 1 and 2). In 2020, 10 participating ICU-RCs were started in direct response to the COVID-19 pandemic. The most common ICU-RC referral criteria are critical illness requiring an ICU stay and, specifically, target patients who received mechanical ventilation (Table 1). Eighty-five percent of ICU-RCs offer telehealth-enabled access to patients ( Table 2). The most common services in the ICU-RC were physical assessment (100%), global needs assessment (85%), behavioral health referral (85%), cognitive assessment (77%), ICU debrief (77%), and communication with primary care (77%).

COVID-RC Demographics and Operating Structures
In COVID-RCs, internal medicine physicians (54%) were prominent members of the clinic team in combination with other disciplines (8-31%) to support a screen-and-refer model. In contrast to services in ICU-RCs, the most common COVID-RC services, after medication reconciliation, were immunization review (54%), care coordination (54%), physical assessment (46%), and sleep/pulmonary referral (46%). As of March 2021, 41% (n = 11) of participating U.S.-based CAIRO member health systems were concurrently supporting both an ICU-RC and COVID-RC. In contrast to ICU-RCs, 92% (n = 12) of COVID-RC operations were funded by clinical billing, with only 38% (n = 5) funded by institutional staff/space support and 31% (n = 4) from volunteer staff support. Clinic appointments were offered an average of 4 days per month with most available for 4-8 hours per clinic day. COVID-RC visits tended to be shorter in duration with the majority being less than or equal to 60 minutes (n = 8, 62%).

Assessments and Measures Used Within Recovery Clinics
ICU-RC teams reported use of validated tools and scales (Supplemental Table 2, http://links.lww.com/ CCX/A946) to assess psychologic recovery (93%), physical recovery (89%), and cognitive recovery (86%) more often in standard visits compared with COVID-RC teams (psychologic, 54%; physical, 69%; and cognitive, 46%). Tools and scales to assess quality of life and/or care coordination are more prevalent as part of ICU-RC processes compared with those used in COVID-RCs (50% vs 15%).
The Patient Health Questionnaire-9 (PHQ-9) was the most reported psychologic measure in both ICU-RC (57%) and COVID-RC (46%). Assessment and measure of physical recovery included functional exercise capacity (6-min walk test), Activities of Daily Living, and breathlessness (dyspnea scale). The most used cognitive recovery assessment tool was the Montreal Cognitive Assessment (MoCA) or the MoCA-Blind, used by 82% of ICU-RC teams and 38% of COVID-RC teams.
Almost half of participating centers (n = 42%, n = 11) used quality-of-life measures in the context of an ICU-RC, with most sites (42%) using the European Quality of Life Five Dimension. Psychometrically validated measures for caregiver assessment (Zarit burden interview; Hospital Anxiety and Depression Scale [HADS] for caregiver) were not systematically embedded within COVID-RCs but were present in a subset of ICU-RCs (14%).

DISCUSSION
New sepsis guidelines (13), international PICS consensus recommendations (14), and rapidly emerging COVID-19 recovery insights (2,4,15) contribute to the urgency and scope of demand for evidence-based implementation and operation of RCs. Health systems operating ICU-RCs to assess and treat community-dwelling ICU survivors with clusters of cognitive, physical, and psychologic impairments have largely served as a care delivery model for newly created COVID-RCs in the United States (15). Both ICU-RCs and COVID-RCs are structured with interdisciplinary teams that include ICU clinicians, are generally offered once per week, and have some reliance on volunteer staff and institutional support to operate. However, ICU-RC and COVID-RC respondents report different approaches to team structure and assessments for physical, psychologic, and cognitive recoveries during visits. In partnership with contextual considerations,  our descriptive survey can contribute to best practice determinations and scaling of critical care resources for RCs (16). For example, there are capacity constraints inherent to clinic models supported with discretionary institutional funding of support services and operating with modest 1 day per week availabilities, compared with self-sustaining models tied to clinical billing enabling teams to operate according to patient volumes.
This sample represents RC leaders linked via a collaborative built for innovation, implementation, and knowledge-sharing specific to RCs for PICS and PASC. In alignment with this intentional diversity, we identified heterogeneity in ICU-RC and COVID-RC operation, team composition, referral criteria, and recovery assessment tools and measures. Clinic differences in structure and operational processes could reflect alignment with individual institutional needs and resource availability, including federal COVID-19 relief funds contributing to resource availability for COVID-RCs (17). The marked heterogeneity in application of recovery assessment tools could be related to our limited understanding and variability of PICS and PASC and an absence of evidence-based diagnostic and treatment guidelines (18,19). For example, the phenotype of patients best suited to benefit from focused RC care is largely unclear, with varied criteria qualifying patients for referral. Persistent heterogeneity of measures can inhibit comparison and generalizability of results across diverse populations experiencing PICS and PASC (14). For example, depression is measured used four relevant, but different, psychometrically validated scales: HADS, PHQ-9, General Anxiety Disorder-7, and the Becks Depression Inventory. The use of common data elements for critical care research, including ICU-RC and COVID-RC services, could contribute to aggregating insights into postacute sequelae over time, accelerating intervention development, and testing in both populations. The optimal ICU-RC and COVID-RC structures and processes to achieve best PICS and PASC outcomes are still unknown. Reports have highlighted the role of specific providers (e.g., pharmacist [20]), staffing rationales [21], and services (e.g., medication reconciliation [22]) within ICU-RCs. At present, ICU-RCs and COVID-RCs have been developed iteratively with local clinicians and patients tailoring RC structure and processes to regional context and constraint (23,24), leading to heterogeneous clinic models and measures (14). Systematic and scoping reviews of the literature affirm diverse structures and interventions in ICU-RCs with mixed efficacy findings (7,25,26). At present, the deliverables of RCs in the US are largely undefined. Deliverables, such as the percentage of patients returning to the workforce, are not traditionally defined as metrics of success, nor listed as operational targets. Application of implementation frameworks and use of hybrid effectiveness-implementation trials (27) are needed to drive standardized ICU-RC and COVID-RC development, operation, and outcome measures. For example, pragmatic stepped-wedged cluster trials designed to evaluate long-term outcomes in the context of clinic delivery modes (e.g., telehealth) or clinical team composition could yield insights into intervention effectiveness via routine implementation. Finally, RC development and implementation should consider key factors identified to influence patient access and engagement (e.g., patient rurality and severity of illness) (28,29) and, thus, clinic sustainability.
Demand for ICU-RC and COVID-RC services surged in 2020 to manage sequelae of both COVID-related and non-COVID-related acute and critical illness (15,30). Recovery services to address the sequelae of critical illness need to be met with organized, funded care systems. In ICU-RC care, volunteer effort and in-kind institutional support are funding sources in more than 30% of the clinics. As RCs become more necessary for both post-ICU and COVID recovery cares, the prepandemic reliance of ICU-RCs on clinician and staff volunteerism and institutional support will adversely affect sustainability. Additionally, access to COVID-RC care is largely tied to clinical billing (92%, n = 12), highlighting access disparities for patients seeking care via self-pay. As the demand for both COVID-19 and non-COVID critical illness (31) recovery services increases, reliance on volunteerism and discretionary institutional support will not be sufficient. This patchwork approach contrasts with other developed healthcare systems, most notably in the United Kingdom, where structured follow-up after critical illness is embedded in national care guidelines (32).
The generalizability of our results is limited by the convenience sampling and selection bias specific to CAIRO Collaborative members in the United States. It is also possible that the information provided by some respondents could contain minor inaccuracies not fully reflective of the evolving structure and process of ICU-RC and COVID-RC. Despite the limitations, survey responses that were contributed are representative of 29 prominent health systems in the United States. Responses were granular and contribute to characterizing the current landscape. Insights into acute and critical care resources (16) are needed for this segment of vulnerable patients and families.

CONCLUSIONS
This description of the attributes of 39 RCs in 29 health systems contributes to characterizing the structure and process of both established and newly implemented RCs supporting post-ICU and post-COVID cares in the United States. Our sample sites employed various referral criteria and endorsed different assessment measures to guide care coordination and subsequent referrals. The operating structures also varied, though almost all describe modest capacity and reliance on volunteerism and discretionary institutional support. These data highlight the evolving postacute recovery care landscape in the COVID-19 era.