Summary Many survivors of serious illnesses suffer lasting physical, cognitive, and mental health consequences. The number of affected patients is expected to increase markedly due to the COVID-19 pandemic. Many ICU survivors receive long-term care from a primary care physician. Therefore, awareness and proper management of these sequelae are crucial. An interdisciplinary team of authors engaged in a narrative literature review to identify key issues in the management of COVID-19 ICU survivors in primary care. The objective of this perspective paper is to synthesize literature important to understanding and managing the sequelae of critical illness from COVID-19 in the primary care setting. |
Background
The COVID-19 pandemic is impacting primary care in many ways, including shortages of personal protective equipment, resource-limited triage, lack of therapeutic strategies, use of telemedicine, and financial constraints. However, another aspect of the pandemic is coming into view: recovery after treatment in an intensive care unit (ICU).
Significantly more patients survive than die from COVID-19, some after a long stay in an ICU. From more than two decades of research, we have substantial evidence that many ICU survivors do not return to their previous health status: Multiple physical, cognitive, and mental health sequelae, known as post-intensive care syndrome (PICS) , impact survivors’ return to work or meaningful activities for months or even years.
Like most patients with chronic illnesses, ICU survivors continue to receive long-term aftercare from their primary care physicians. Within primary care, awareness of PICS may have been low until now, with ICU survivors representing only a very small percentage of primary care patients. Furthermore, the clinical signs associated with PICS are often similar to those caused by other chronic diseases.
Additionally, the flow of information between intensive care and primary care is hampered, as these specialties represent opposite ends of a spectrum within healthcare.
This current situation may change with an increasing number of COVID-19 survivors being discharged home and needing ongoing care. The Chartered Society of Physiotherapy even predicts "a tsunami of rehabilitation needs" and primary care doctors are also likely to encounter substantially higher numbers of Covid-19 patients post-ICU.
Consequently, the British Faculty of Intensive Care Medicine (FICM) warns of "a real opportunity to ensure the full implementation of existing hospital and community-based rehabilitation services for people recovering from critical illness."
The goal of this perspective work is to synthesize important literature to support primary care providers in understanding and managing the sequelae of critical illness due to COVID-19.
Methods
We convened an interdisciplinary authorship team that has collaborated over a period of up to 10 years on post-ICU research. In addition, several authors have participated in guideline and review articles on post-ICU and post-COVID-19 care.
Results
Post-ICU Care
So far, the evidence supporting structured ICU aftercare is inconsistent: in randomized trials, outpatient post-ICU clinics have failed to demonstrate improved patient outcomes. However, a primary care clinical assessment, within 90 days of hospitalization, is recommended by UK NICE guidance, including reconciliation or elimination of inappropriate medications.
To ensure optimal evaluation of primary care, effective networks and information transfer are needed. For example, detailed hospital discharge notes are essential, including data on breathing, mobility, swallowing, activities of daily living, as well as cognition and mental health status. Discharge letters delivered directly to the patient provide a possible way to improve this transition between hospital care and primary care.
Since recovery pathways and underlying illnesses differ widely among ICU survivors, the reassessment process must be tailored individually. In summary, three key dimensions are recommended for primary care providers caring for post-ICU patients.
- Motor function, swallowing and physical condition.
- Mental health and cognitive function.
- Family and social health.
Motor function, swallowing and physical status
ICU-acquired weakness (ICUAW), commonly caused alone or in combination by muscle atrophy, critical illness polyneuropathy (CIP), or critical illness myopathy (CIM), has a major impact on mobility and other activities of daily living. Within primary care, early initiation of frequent physiotherapy, occupational therapy and nutritional counseling can facilitate recovery from these conditions.
About a third of patients on long-term mechanical ventilation have persistent symptoms of dysphagia, increasing the risk of aspiration and pneumonia.
Evaluation by a speech-language pathologist/therapist (SLP) may have occurred in the hospital setting prior to discharge. The need for ongoing speech and language therapy should be assessed in the primary care setting.
In patients with acute respiratory distress syndrome (ARDS), which is common in severe cases of COVID-19 infections, long-lasting and clinically important impairments in lung function are surprisingly rare . However, combined deterioration in physical and cardiopulmonary fitness contributes to long-lasting reduction in exercise capacity (compared to a matched control group), as measured by the 6-minute walk test.
Early experiences among COVID-19 survivors suggest that early pulmonary rehabilitation , including breathing and movement training, may improve recovery of respiratory and physical function.
Following assessment of cardiorespiratory function by the primary care physician, breathing exercises and physical rehabilitation may be guided by physical therapists, occupational therapists, and/or primary care physician assistants, with expert involvement from physiatrists, as needed. .
Beyond that, almost all organ systems can be affected after intensive care. Presenting all the possible complications would be beyond the scope of this article. However, it is especially important to actively address potentially neglected topics, such as erectile dysfunction in male patients.
Mental health and cognitive function
Many patients experience critical illness and ICU treatment as life-threatening events. New or worsening symptoms of depression, anxiety, and/or post-traumatic stress disorder (PTSD) are common in the long term. The etiology is complex: delirium, intrusive memories, use of sedative medications (e.g., benzodiazepines), and prior psychiatric history are commonly reported risk factors.
Environmental factors related to the pandemic, such as contact isolation, crisis mentality, or overcrowded ICUs, may increase this risk. According to an observational study from Wuhan, almost all COVID-19 survivors showed symptoms of post-traumatic stress. Psychiatrists expect upcoming pandemic-related PTSD rates similar to large-scale disasters.
As many affected patients may avoid talking about these experiences, a proactive exploration of such symptoms by the primary care physician may be necessary, ideally supported by the use of screening questionnaires. Talking about the ICU experience, and being listened to, is considered helpful - ideally using an ICU diary , if available.
Patients with severe or persistent symptoms may benefit from referral to a psychologist, psychiatrist, or other mental health clinician. Among others, cognitive therapy has recently been highlighted to be applied in PTSD after critical illness.
Neurocognitive impairment among ICU survivors, associated with a history of delirium, hypoxia, and/or hypotension in the ICU, can lead to significant impairment in daily life.
Common aspects of this condition include reduced attention, memory, and executive function. Reversible causes for cognitive impairment (eg hypothyroidism) should be excluded. Once this is done, the primary care physician can contribute to quality of life by assisting the patient and family to practically organize daily life, along with specialized help from neuropsychologists and/or cognitive rehabilitation therapy.
Family and social health
Family members often experience their loved one’s ICU course up close. Therefore, around 30% of them may suffer relevant symptoms of anxiety, PTSD or depression during or after a critical illness of a family member. Therefore, a separate term was introduced to raise awareness of these issues: PICS-Familiar .
Restricted access to hospitalized patients in times of pandemic may increase this particular risk. Consequently, evaluation of psychological symptoms should also extend to a patient’s close family members. Even if challenging due to time constraints, this may be especially necessary in the primary care setting.
Reintegration into the workplace is another important issue to consider: approximately 40% of critical illness survivors are unemployed within 12 months of discharge, while those who return to work may experience changes adverse effects on the occupation or work situation. Unemployment, in general, is associated with adverse mental health outcomes and could further aggravate the condition of patients. During the COVID-10 pandemic, it is unclear how the unprecedented economic shutdown may further exacerbate unemployment in ICU survivors.
Until now, there has been little evidence regarding specific interventions that promote return to work after critical illness. However, affected patients could benefit from multidisciplinary rehabilitation, including close coordination between their primary care physician, employer, and occupational medicine specialists.
Support Options
ICU monitoring within primary care is challenging; Additional support is needed for patients and primary care providers. Continuity of care in times of contact restrictions will increasingly extend to the virtual space. Patients can receive support through mobile apps that promote behavioral activation, breathing exercises, or mindfulness.
A telephone intervention has even been shown to increase coping skills after ICU discharge. A growing selection of web resources supports diagnosis and treatment planning. Progress in a patient’s condition can be tracked using a "functional reconciliation checklist", which is considered useful, although its impact has not been evaluated.
Standardized screening instruments are likely to facilitate diagnostic evaluation of PICS-associated impairments, as internationally agreed upon for survivors of acute respiratory failure. Patients with advanced age, pre-existing chronic conditions, high intensive care intensity, and also ethnic minority backgrounds have the highest risk of impairments; the use of screening instruments should focus on these groups.
Additionally, patients and their families may be referred to an acute care support group or follow-up clinic, if available. Additionally, a detailed exercise instruction guide has been published to assist COVID-19 survivors in physical rehabilitation at home.
Primary care physicians need training in the management of ICU survivors.
The authors advocate for the integration of post-ICU care into primary care training and continuing medical education. Among other ideas, longitudinal internships to follow patient courses from ICU to primary care may provide one possible approach.
Limitations
The information presented in this narrative review does not represent a clinical practice guideline, as it is limited by the non-systematic identification of studies, as well as the lack of a formal assessment of the risk of bias of the selected literature. Given the rapid development of research during the pandemic, new data may emerge and change any information presented in this document. However, we believe that the principle of multidisciplinary collaboration will continue to be an important guiding principle in the field, with primary care physicians playing a key role in post-ICU management.
Conclusion Survivors of critical illness are at risk for long-lasting physical, cognitive, and mental health sequelae. With the COVID-19 pandemic, these issues will grow in importance. Given the complexity and heterogeneity of the clinical course of ICU survivors, ICU follow-up requires multidisciplinary collaboration, which may be catalyzed by the COVID-19 pandemic. Primary care physicians play a key role in managing post-ICU sequelae due to their expertise in integrative medicine, coordination of care, acceptance of patient self-care, and long-term knowledge of patients’ medical history. patients and their families. The COVID-19 pandemic emphasizes the need for further research on post-ICU follow-up care, and its challenges in primary care. |
