As the world approaches the 6-month mark with the SARS-CoV-2 virus, hospitals have begun to organize after-care for survivors of severe COVID-19 even as long-term sequelae are still emerging.
“We have some insights from experiences around the world where the pandemic got a head start,” noted Matthew Tomey, MD, director of the cardiac ICU at Mount Sinai St. Luke’s Hospital in New York City. “In New York, it’s still early in determining what the intermediate and, certainly, longer-term outcomes will be.”
Data on long-term recovery of patients with a different coronavirus, from the SARS epidemic in 2003, showed at 6 months there were persistent chest radiograph abnormalities in 30%, significant lung function impairment in 16%, and more than expected functional disability. Follow-up at 15 years showed that most lung recovery happened within 2 years but remained mildly impacted thereafter.
With COVID-19, heart injury is also not uncommon, although the most severe manifestations, like fulminant myocarditis, have been rare.
“It could be 20% or so, in some series a little bit higher, of people who had COVID-19 pneumonia that was severe enough that led to the intensive care unit that troponin, our most reliable marker of injury to heart, was elevated,” said Becker. Just what long-term impact on heart function or chronic disease risk that might have is unclear.
Acute kidney injury estimates vary, being seen in about one-third of hospitalized COVID-19 cases and 78% of ICU cases in one New York City series. Some proportion of those patients will face lingering kidney failure; others are at elevated risk for developing it in the future.
Mental health sequelae, including post-traumatic stress disorder, are not uncommon after ICU care, aside from the loneliness and anxiety of quarantine and recovery at all levels of COVID-19 severity.
No guidelines for post-COVID follow-up have emerged yet. Algorithms and even formal clinics to manage this care have instead popped up at individual centers and health systems.
Mount Sinai announced it would centralize follow-up for the thousands of patients it has treated for COVID-19 across its hospitals in a Center for Post-COVID Care at its downtown Manhattan facility, with comprehensive multi-specialty care and systematic evaluation.
An interprofessional collaborative team is key, said Ankita Sagar, MD, director for ambulatory quality at Northwell Health in Manhasset, New York, because “we lean upon services within the health system that previously we probably did not require as aggressively as we need them now.”
For example, she pointed to Northwell’s new acute ventilator recovery units at two of its hospitals to offer individualized care for focused rehabilitation, and weaning of COVID patients who have been on chronic mechanical ventilation for several weeks. That means respiratory therapists, pulmonology-critical care, speech therapy, geriatrics, and so forth.
So far among the 50 some discharged patients treated in the Mount Sinai program in the 3 weeks it has been in operation, its medical director Zijian Chen, MD, told MedPage Today that more than 80% required specialist referral to pulmonology, about 50% to cardiology due to symptoms, 20% to 30% to neurology, many to psychiatry, and some to GI and ear, nose, and throat specialists.
Even for patients whose symptoms never reached the acuity to require admission, there is a broad range of specialties involved in follow-up care, which her health system is also organizing, Sagar noted.
“We are creating a comprehensive program to address all the different needs and symptoms that COVID-19 patients have…even any concerns about anxiety and insomnia, which tends to happen for some of these patients,” she said.
New York City institutions may be on the forefront of setting up such programs, given the number of cases, the severity of cases, and the strengths of the medical community, noted Richard Becker, MD, director of the University of Cincinnati Heart, Lung and Vascular Institute.
“However, large academic centers like ours and others around the country will follow suit. And there will be encouragement from the heart associations and the lung association and others to do so.” he predicted. “Everyone should be thinking in those terms.”
Tomey agreed that even community practices need to be thinking the same way.
“Whether one has a dedicated post-COVID clinic or [is] simply maintaining a high-quality practice of cardiovascular care for a local community, it’s important that we will all have mechanisms for close follow-up, both for those who’ve had COVID but also for our population at-large,” he said.
There’s an advantage to having all the services organized together, though, Chen noted.
“There’s definitely a benefit to having a concentrated group of physicians where you’re caring for a dedicated group of patients,” he said, citing prior experience with the beginning HIV epidemic and World Trade Center-related diseases. “They are a very good repository of clinical experience that you can’t really get from anywhere else if you’re just seeing patients sporadically.”
Keeping COVID-19 patients from falling through the cracks in the healthcare system in a vulnerable time when they have been discharged, but are still decompensated and quarantined, takes concentrated effort.
Chen’s center has ramped up care coordination, sending schedulers and office staff to the hospital; talking constantly with hospital discharge groups like social workers; and trying to capture all of its COVID discharges into a database for further contact after discharge, such as telephone well-checks.
Northwell, too, has been using a “very robust process” to track every COVID-19 discharge with a care navigator to ensure a “warm handoff” to primary care and any needed specialties, not only for scheduling appointments but completing them, Sagar noted.
“After a patient has gone through a very rough course in hospital, the last thing we need to do is require them to be proactive,” she said.
Source: MedicalNewsToday.com
