Lengthier stays in the ICU put patients with COVID-19 at greater risk for developing post-intensive care syndrome.
Patients with COVID-19 are staying longer than the average three to four days in the intensive care unit (ICU), says Megan Hosey, a rehabilitation psychologist at The Johns Hopkins Hospital’s medical ICU. This puts them at greater risk for challenges in recovery, commonly termed post-intensive care syndrome (PICS).
While more patients than ever are surviving after treatment in the ICU, research over the last two decades shows that survival can come with the cluster of physical, psychological and cognitive symptoms associated with PICS — hindering patients’ quality of life for weeks or years to come. Although the exact prevalence of PICS is unknown, “it happens in more patients than we probably realize,” says Hosey, and it is occurring in some patients with COVID-19. To improve outcomes, Johns Hopkins takes a multidisciplinary approach to working with these patients.
Patients recovering from COVID-19 now have a convenient resource to monitor and report on aspects of their health, including symptoms related to PICS. Ann Marie Parker and Emily Brigham, Johns Hopkins physicians who specialize in pulmonary and critical care medicine, as well as delirium and rehabilitation in the ICU, have worked with leaders in physical medicine and rehabilitation to create a virtual clinic for COVID-19 survivors.
“We encourage our case managers and provider teams to refer patients to the clinic, which involves having a virtual or in-person visit with a pulmonologist and a visit with a physiatrist. We talk about pulmonary symptoms and screen for anxiety, depression, PTSD symptoms and cognitive and functional impairment,” says Parker.
The goal of the clinic’s group of providers — deemed the Johns Hopkins Post-Acute COVID-19 Team (JH PACT) — is to create an interdisciplinary standardized approach for COVID-19 survivors. The team includes members from the Division of Pulmonary and Critical Care Medicine, the Department of Physical Medicine and Rehabilitation and the Johns Hopkins Home Care Group.
Patients are eligible for JH PACT if they spent more than 48 hours in the ICU. Those who did not stay in the ICU can still qualify if they meet one of the following conditions: persistent respiratory symptoms, new or increased oxygen requirements at discharge, an inpatient pulmonary consultation that recommended enrollment in JH PACT, or an inpatient rehabilitation consultation with recommendations for post-discharge rehabilitation. Patients who never required hospitalization can also be seen if they have persistent, bothersome symptoms at eight weeks post diagnosis.
Parker, Brigham and Hosey work closely with Dale Needham, a Johns Hopkins critical care physician and researcher who is internationally renowned for advancing PICS research. Needham says patients with COVID-19 can develop pneumonia that leads to acute respiratory distress syndrome (ARDS). These patients require a ventilator in the ICU, and, for patients with COVID-19 and ARDS, it’s not unusual to be on a ventilator for more than two weeks. Other patients in the ICU with COVID-19 are typically on oxygen or highly concentrated oxygen.
By helping patients manage their health in the ICU as early as possible, Hosey believes patients will be better equipped to engage in the next phase of their recovery. “Very few ICUs in the country provide patients with the amount and intensity of early rehabilitation that we provide at Hopkins,” she says.
Needham agrees. “We've got an extraordinary program that routinely provides psychological help and physical, occupational and speech therapy, on top of medical care in the ICU. During the pandemic, this program continues.”
Hosey has been working with Joe Bienvenu, a Johns Hopkins psychiatrist who studies survivors of critical illnesses and intensive care. Since April of 2020, one of the conditions Bienvenu and Hosey find most concerning in patients with COVID-19 in the ICU is anxiety. Reasons patients may have anxiety include having difficulty breathing, being away from family, fear of getting others sick and fear of reports in the media.
Along with anxiety, Hosey and Bienvenu’s biggest concern regarding the mental health of patients with COVID-19 in the ICU is delirium. The prevalence of delirium is especially high, likely due to the amount of sedation needed to keep patients on ventilators for an extended period of time, Hosey says.
Unfortunately, the effects of delirium can linger. “Even after it resolves,” Bienvenu says, “the memories can lead to mental health effects downstream — increased symptoms of anxiety, depression or post-traumatic stress disorder. Patients may have anxious reactions when they see a hospital. They find themselves wanting to avoid hospitals, and becoming very fearful that they will get sick again.”
Because delirium can also cause cognitive changes in attention, thinking and memory that last beyond hospitalization, Hosey talks to patients about seeking the care of a mental health provider who understands post-intensive care syndrome.