Best Practices to Promote COVID-19 Recovery

Hallie C. Prescott, MD, MSc; Timothy D. Girard, MD, MSCI – JAMA. Published online August 5, 2020. doi:10.1001/jama.2020.14103

  • There are limited data specific to recovery from COVID-19.
  • Below are the practices that are recommended to enhance recovery from sepsis that are applicable to patients recovering from severe COVID-19.
  • Patients with viral sepsis from COVID-19 should receive these recommended practices.
  • Recovery practices include anticipatory guidance regarding potential new problems, screening for new impairments at hospital discharge and early outpatient follow-up, anticipation and mitigation of risk for common and preventable health deterioration, medication optimization, and referral or instructions for a structured exercise program.
  • Patients have an increased risk of death for at least 2 years after sepsis, and it is important to consider transitioning to a palliative focus of care.
  • These recommended practices are associated with better clinical outcomes.
  • Receipt of these practices was associated with lower odds of rehospitalization or death.
  • Only 20% of patients received all 4 recommended practices within 90 days of sepsis hospitalization.
  • There is a need to develop better implementation strategies for these recommended practices

Anticipatory Guidance

Patients, families, and non-ICU health care professionals are often unfamiliar with the consequences of sepsis.

Anticipatory guidance about common challenges after sepsis is helpful but does not occur regularly.

Screening/Referral for New Limitations

Sepsis is associated with a 10 percent absolute increase in cognitive impairment and the development of new functional limitations.

Patients and family should be questioned regarding new symptoms of cognitive impairment, physical limitations, and swallowing difficulties, and then referred to supportive services, such as physical therapy, occupational therapy, and sleep-language pathology.

Medication Optimization

Long-term medications are often held during critical illness due to short-term contraindications (eg, β-blocker held due to hypotension), while new medications are started for symptom control (eg, antipsychotics for agitated delirium).

However, while intended to be temporary, such changes often persist after hospitalization and may contribute to future health deterioration.

Various interventions focused on medication optimization reduce rehospitalization and emergency department visits after acute illness, underscoring the benefit of medication optimization.

Anticipate and Mitigate Risk for Health Deterioration

Rehospitalization is common among who survived sepsis, most often for recurrent infection, acute kidney failure, and exacerbation of chronic health conditions.

Patients should be given advice regarding risk and symptoms of recurrent infection and other common causes of rehospitalization.

At hospital discharge and early outpatient follow-up, patients should have volume status assessed and clinical management should focus on reducing risk for common and preventable causes of rehospitalization.

Peer Support

Peer support programs, both in-person and virtual, have emerged as a valuable resource for patients and families after critical illness.

These programs allow survivors to share their story, receive empathy, and learn managing and adaptation strategies from other patients.

Patients and families should be directed toward available peer support programs.

Structured Exercise Program

Weakness and decreased exercise capacity are nearly common after critical illness.

All patients will need to increase exercise gradually over time to regain their exercise capacity they had before sepsis.

Depending on the severity of physical impairments, patients may benefit from referral to physical therapy, cardiac or pulmonary rehabilitation, or a structured self-exercise program.

Palliation, Goals of Care Discussion

Patients have an increased risk of death for at least 2 years after sepsis.

For patients who are weak and/or declining health leading into sepsis, it
is important to reassess goals of case and consider a palliative focus.

Source:

JAMA. Published online August 5, 2020. doi:10.1001/jama.2020.14103. https://jamanetwork.com/journals/jama/fullarticle/2769290


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