Damian Sendler: After a life-threatening illness, many people suffer from long-term physical, cognitive, and mental health consequences. The pandemic of COVID-19 is expected to significantly increase the number of patients infected. Many people who have survived an intensive care unit stay in the care of their primary care physician for an extended period of time. This is why proper awareness and management of these side effects is essential. As part of a narrative literature review, an interdisciplinary group of authors worked together to identify the most pressing issues in the care of COVID-19 ICU survivors in primary care. We hope to synthesize relevant research in order to better understand and treat the long-term effects of COVID-19 critical illness in the primary care setting.
Damian Jacob Sendler: Many aspects of primary care are being impacted by the COVID-19 pandemic, including a lack of personal protective equipment, limited resources for triage, a lack of therapeutic options, and economic constraints. In addition, the pandemic’s recovery after intensive care unit treatment is becoming clearer (ICU). More patients survive the COVID-19 than die, even after a lengthy stay in the intensive care unit. We have strong evidence that many ICU survivors do not return to their pre-ICU health status after more than two decades of research: The Post-Intensive Care Syndrome (PICS) [1] is a collection of symptoms that affects the ability of patients who have undergone intensive care to return to work or meaningful activities for months or years.
Dr. Sendler: Patients who have survived an intensive care unit stay in contact with their primary care physicians for the foreseeable future, as does the majority of the chronically ill population. PICS may have been under-recognized in primary care because ICU survivors make up only a small percentage of patients. Patients with PICS may also experience similar clinical symptoms as other chronic diseases. Because these two medical specialties are at opposite ends of a continuum of care, the flow of information between them is hindered. As more and more COVID-19 survivors are sent home and require follow-up care, the current situation may shift. Rehabilitation needs are predicted to be “tsunami-sized” by the Chartered Society of Physiotherapy [2] and primary care physicians are expected to see a significant increase in COVID-19 patients. According to FICM, this is a “opportunity to fully implement existing hospital and community based rehabilitation services for people recovering from critical illness.” [3].
There is currently no conclusive evidence to support the use of structured ICU after-care: There has been no evidence that outpatient post-ICU clinics improve patient outcomes in randomized trials [8]. However, the UK’s NICE guideline recommends a primary care clinical assessment, within 90 days after hospitalization, including the reconciliation or elimination of inappropriate medications [9].. Effective information exchange and networks are necessary to ensure that primary care assessments are accurate. For example, complete hospital discharge notes are required, which should include information on the patient’s respiration, mobility, swallowing, daily activities, and cognitive and mental health. Patient-directed discharge letters [10] may help smooth the transition from hospital-based to primary care.
Critical illness polyneuropathy (CIP) and critical illness myopathy (CIM) are three conditions that can lead to ICU-Acquired Weakness (ICUAW) and have a significant impact on mobility and other activities of daily living [34]. Physical, occupational, and nutritional therapy should be started as soon as possible in primary care to help patients recover.
The risk of aspiration and pneumonia is increased in patients who have long-term mechanical ventilation with dysphagia symptoms [17]. Prior to discharge from the hospital, the patient may have been evaluated by a speech and language therapist/pathologist (SLP), including an instrumental assessment of swallowing. Speech and language therapy needs should be evaluated in the primary care setting.
Only about one in a hundred patients with severe COVID-19 infections have persistent, clinically significant impairments in lung function due to Acute Respiratory Distress Syndrome (ARDS). Exercise capacity (as measured by the 6-Minute Walk Test, compared to a matched control group) is reduced over the long term when physical and cardiopulmonary impairments are present in combination. Alternatively, the 4-Meter Gait Speed Test may be used if a minimum 12-meter walkway is not available in the primary care practice. [15] Among survivors of COVID-19, early pulmonary rehabilitation, including breathing and movement training, appears to improve respiratory and physical function [36].
Cardiorespiratory function can be assessed by a primary care physician, who can then refer you to a physiatrist, physiotherapist, occupational therapist, or primary care physician assistant for guidance on breathing exercises and physical rehabilitation.
After intensive care, almost every organ system can be affected, according to a Position Statement from the FICM for COVID-19 survivors [3]. In order to cover every possible complication, this article would be too long. Erectile dysfunction, for example, is a topic that is often overlooked, and it is imperative that it be addressed.
Damian Sendler
Critical illness and hospitalization in the intensive care unit (ICU) are feared by many patients. Symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD) can worsen over time. Many factors are involved in the etiology, including delirium, intrusive memories, use of sedative medications (e.g. benzodiazepines), and prior psychiatric history. Overcrowding in intensive care units (ICUs) and other pandemic-related environmental factors can increase this risk [3, 38]. A Wuhan observational study found that nearly all COVID-19 survivors had signs of post-traumatic stress disorder (PTSD) [39]. Pandemic-related PTSD rates are expected to be similar to those of large-scale disasters [40].
Damian Jacob Markiewicz Sendler: A proactive examination of these symptoms by the primary care physician, supported by the use of screening questionnaires, may be necessary [41, 42], as many affected patients may avoid talking about these experiences. It is recommended that patients use an ICU diary if one is available to document their experiences in the ICU [41]. Referral to a psychologist, psychiatrist, or other mental health professional may be beneficial for patients with severe or persistent symptoms. Recent studies have highlighted the use of cognitive therapy for the treatment of post-traumatic stress disorder (PTSD) following critical illness [43].
A history of delirium, hypoxia and/or hypotension in the ICU is associated with neurocognitive impairment among ICU survivors [44]. This can have a significant impact on daily life. Attention, memory, and executive function are among the most common symptoms of this condition. You should rule out anything reversible, like hypothyroidism, as a possible cause of your cognitive decline. By helping the patient and their loved ones organize their daily routines, primary care physicians can help improve the quality of life for those who suffer from Alzheimer’s disease or other forms of dementia.
Family members are frequently present in the intensive care unit when a loved one is receiving treatment there. They may experience symptoms such as anxiety, PTSD, or depression during or following a loved one’s illness [45]. As a result, a new term was coined to call attention to these issues: There is a family of PICS. In the event of a pandemic, limiting access to inpatients may increase this risk. As a result, family members should be included in the evaluation of a patient’s psychological symptoms [46]. Primary care settings may require this, even if time constraints make it difficult.
Another important issue to consider is reintegration into the workplace: As many as 40 percent of critical illness survivors are out of work at 12 months after discharge, while those who return to work may experience negative changes in their occupation or employment status. There is a link between unemployment and poor mental health outcomes, which can worsen a patient’s situation. Uncertainty about the impact of the unprecedented economic shutdown on ICU survivors’ unemployment during the COVID-10 pandemic is a major concern.
Damian Jacob Sendler
Before now, there was no conclusive research on how best to get people back to their jobs after a serious illness. A multidisciplinary approach to rehabilitation, including close coordination between the primary care physician, employer, and occupational medicine specialists [47], may be beneficial to those who have been harmed.
Damien Sendler: Additional support for patients and primary care providers is needed for ICU follow-up in primary care. In the future, more and more care will be provided via the virtual world in situations where physical contact is restricted. Activation of behavior, breathing exercises, and mindfulness can all be supported by mobile apps for patients [48]. Following ICU discharge, even a telephone-based intervention has been shown to improve coping skills [49]. Diagnosis and treatment planning are being aided by a growing number of online resources. To give just one example, a recent BMJ “Practice Pointer” [50] offers general advice on how to manage post-acute COVID-19 patients in primary care. A ‘functional reconciliation checklist’ can be used to monitor the progress of a patient’s condition, but its effectiveness has not been evaluated.
PICS-related impairments may be easier to diagnose with the use of standardized screening instruments, as has been agreed upon internationally for acute respiratory failure survivors [6]. Patients who are older, have chronic conditions, are in intensive care, or are members of ethnic minorities [29] are at greater risk for impairments and should be targeted for screening. In addition, if one is available, patients and their loved ones can be referred to a support group or clinic for those in intensive care. COVID-19 survivors can also benefit from a detailed exercise instruction guide that was published [13].
Those who survive a critical illness face long-term consequences for their physical, cognitive, and emotional well-being. The pandemic of COVID-19 will make these issues even more important. The COVID-19 pandemic may be a catalyst for multidisciplinary collaboration in ICU follow-up because of the complexity and heterogeneity of the clinical course of ICU survivors. Patient self-care and long-term knowledge of a patient’s and his or her family’s medical history make primary care physicians an important resource for post-ICU sequelae management. The COVID-19 pandemic highlights the need for additional research into post-ICU follow-up care and the challenges it presents in primary health care.
