Clinicians work through many unknowns, ever-changing information to care for COVID-19 survivors
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As of April 15, nearly 2 million confirmed cases and more than 126,000 deaths in 213 countries and territories worldwide had been reported in the COVID-19 pandemic, according to WHO. However, in spite of these increases that are widely reported, many people are being discharged from hospitals and making a full recovery.
Many aspects about the future for survivors of COVID-19 are unknown. Infectious Disease News Editorial Board Member Peter Chin-Hong, MD, professor of medicine and director of the transplant infectious disease program at the University of California, San Francisco (UCSF), who has treated patients with COVID-19, offered insight into what they could expect.
When to discharge patients from the hospital
According to Chin-Hong, before a patient with COVID-19 can be discharged, doctors need to determine when the use of personal protective equipment (PPE) can stop. Currently, there are two strategies being used: a test-based strategy and a clinical strategy.
The CDC guidelines suggest that if a patient has no fever and there has been clinical improvement, and two tests for COVID-19 that are conducted 24 hours apart with different specimens are both negative, they can be discharged at any time, Chin-Hong told Healio.
“The problem with that is many people didn't have swabs for a long time, so most people just use clinical criteria. Per the CDC, this is defined as no fever and a general feeling of improvement 3 days after recovery and at least 7 days since the symptoms first appeared — whatever is sooner,” Chin-Hong said. “Essentially, that’s 3 days after the last sign of illness, but at least 7 days since the illness began.”
At UCSF, doctors are following a stricter timeline of 14 days to protect a large population of immunocompromised patients. Chin-Hong added that if a patient had not “completed” the 14 days in the hospital, proper precautions should be taken for home care.
Caring for patients with COVID-19 at home
Chin-Hong suggests following the “Five Ps” for home care.
“The first P is PPE,” he said. “If the patient is potentially infectious, even though they've been discharged from the hospital, the caregiver wears a mask. The patient wears a mask.”
The second P is for “phone or iPad” because communication is necessary for patients, to prevent loneliness. The third is “personal belongings,” which should be kept to a minimum in the room with the patient if possible, so there are fewer surfaces to clean and disinfect.
The fourth P is “posting signs.”
“That’s kind of less important in the home, but certainly if you're being discharged to a group setting like a skilled nursing facility or a nursing home you’ll want signs posted outside the patient’s room,” Chin-Hong told Healio.
The final P is for “prescreening visitors,” even at home. Chin-Hong says before people go in the room to visit the patient, they should be informed of the patient’s condition and given the appropriate PPE, which should include hand sanitizer and the ability to wash hands as well.
According to Chin-Hong, the “Five Ps” should be followed until the end of the 14-day period from the start of symptom onset. After 14 days, normalcy can return.
“There’s a debate in the literature as to whether or not people can experience reactivation of COVID-19. I actually don't believe so,” he said. “I’m not certain about what happened with the instances of ‘reactivation,’ but we haven't really seen much of that so far in our clinical experience at UCSF.”
Other people in the home, however, should continue to monitor themselves for symptoms. Chin-Hong recommends following advice given by Carlos del Rio, MD, executive associate dean at Emory University School of Medicine: Wake up, feel for a fever and smell your coffee.
“If you don’t have a fever and you can smell the coffee, you’re good to go,” Chin-Hong said. “It’s the best rule ever. I think about it every morning,”
Possible long-term effects and complications
From what Chin-Hong has observed in patients at his facility, he believes most patients will recover with little trouble, although some patients have reported a lingering influenza-like illness, fatigue and body aches that outlast the fever.
However, Chin-Hong says patients who do go to the ICU to receive treatment and recover are at an increased risk for acute respiratory distress syndrome (ARDS).
One study that examined a cohort of 201 patients with COVID-19 admitted to Wuhan Jinyintan Hospital in China from Dec. 25, 2019 to Jan. 26, 2020 found that 41.8% of the patients developed ARDS; slightly more than half of these patients died. Researchers determined that risk factors associated with developing ARDS, and progressing from ARDS to death, were older age, neutrophilia, organ and coagulation dysfunction such as higher lactate dehydrogenase and D-dimer levels.
Chin-Hong added there could also be unknown consequences for patients with a lung injury from an ICU stay, especially for younger patients who may have been intubated during treatment.
“You wonder if they’ll experience consequences from that, such as requiring oxygen or developing some sort of chronic pulmonary disease later on,” he said. “Will there be a whole generation of young people roaming around the earth with lungs that are not quite right after this horrific episode of lung injury from COVID-19?”
One more immediate concern that doctors and COVID-19 survivors should prepare themselves for is the impact of the disease on mental health.
“We're bad about dealing with mental illness as a society and are paying for it,” Ching-Hong said. “I hope that somebody will think about how to deal with the ripple effects of COVID-19 later on — not just the traditional medical concerns that we focus on, but also the psychiatric complications.”
Mental health issues stemming from COVID-19 go beyond patients. Mental health professionals have expressed concerns about the effect that lack of structure will have on kids; college students facing depression and increased anxiety, which is also a concern for clinicians, working adults and patients; and older adults who need connection and socialization to combat loneliness.
One study from JAMA Network Open examined the psychological burden suffered by health care workers in Wuhan and other regions of China. The results showed high rates of depression, anxiety, insomnia and distress.
Although there are limited clinical data on the mental health burden in patients with COVID-19, Chin-Hong says they are at greater risk for anxiety, depression and PTSD in the future. As for now, however, Chin-Hong says everyone needs to keep an open mind.
“In the last 2 weeks alone, it seemed like every hour of life during COVID-19 was like several months in regular time. Every hour, we are getting new information,” he said. “Each time we get new information, we anticipate the long-term effects of it. We are only now seeing the start of people who have recovered from this illness, but what will happen in 1 year or 2 years? Nobody knows. We have to serve as witnesses to a patient's experiences and keep an open mind, listen to patients’ stories and read the studies, to try to understand this.” – by Caitlyn Stulpin
Disclosure: Chin-Hong reports no relevant financial disclosures.
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