Restore
January 1, 2013

Although stabilized, the critically ill MICU patient panicked when caregivers attempted to reduce support from the mechanical ventilator. It was clear to the middle-aged patient’s providers that his fear of breathing on his own was hindering his recovery from pneumonia. But the providers, while trained to give life support, were not equipped to diagnose and treat psychological disorders that might complicate patients’ recovery.

Fortunately, Johns Hopkins rehabilitation psychologist and MICU team member Jennifer Stevenson was available for consultation. Based on her assessment, Stevenson determined that the man was suffering from severe anxiety. Using cognitive behavioral therapy techniques she has adapted for use in the ICU, she helped the patient manage his distress by adopting healthier patterns of thought. Soon, his anxiety abated, the man was breathing without a ventilator, receiving physical therapy and planning to go home.

In a prior era, the patient may have remained sedated for a much longer period during his MICU stay. And, once alert, his anxiety would have been managed less effectively. In recent years, however, the reduced use of sedatives, such as benzodiazepines, has helped to accelerate recovery for MICU patients. No longer comatose, even patients on ventilators are working with physical and occupational therapists to get up and move as soon as possible, rather than waiting until they’re discharged from the MICU. What’s more, such patients are less at risk for delirium, commonly caused by benzodiazepines.

But there’s a catch. Symptoms of anxiety may be more overt in alert ICU patients and impede some patients’ recovery, says Dale Needham, director of the critical care physical medicine and rehabilitation program at Hopkins. Such patients “may also require psychological therapy to manage this anxiety and to help the recovery process,” Needham says. As reliance on sedation in critical care settings decreases, he sees an expanding role for rehabilitation psychologists who work side by side with ICU doctors, nurses and respiratory therapists.

Since joining the MICU team last year, Stevenson has received dozens of consults for patients on the unit. “Critically ill patients tend to experience anxiety at a higher rate than the general population, and it tends to lead to poor consequences afterward,” she says.

Stevenson relies on several evidence-based approaches, including behavior modification, to reinforce a patient’s good behavior. When, for example, the pneumonia patient engaged in his rehabilitation therapy and ventilator weaning, hospital staff indulged his love of holiday decorations by gradually transforming his room into a Christmas wonderland.

In regular meetings, Stevenson shares intervention strategies with MICU team members, with recommendations ranging from communicating effectively with patients to “environmental modifications,” such as placing monitors out of a patient’s view if “that information is anxiety-provoking.” Stevenson also works closely with the Department of Psychiatry when a patient’s condition indicates the need for medication.

Stevenson has high expectations for the rehabilitation approach she has customized for the ICU in concert with Needham and other colleagues. “We hope this approach will continue to help patients, family members and staff,” she says, “so that we can refine it and perhaps help other ICUs start using it in the future.”