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Even healthcare professionals may not be aware and prepared for a condition called Post-ICU Syndrome (PICS) that can occur in the aftermath of COVID-19. What about those who were hospitalized for COVID-19, treated in ICU, and are unaware of the possible long-term impact and rehabilitation phase? There is a tendency to think that once the patient is discharged from the hospital, has tested negative, and looks well, the problem is resolved. However, the struggle of COVID-19 survivors and family members or caregivers may not end there.

PICS is an ongoing challenge that may potentially present as a public health crisis. PICS is a term used to describe the group of impairments faced by ICU survivors. It can persist for months or years. PICS encompasses a combination of physical, neurological, social, and psychological decline (Jaffri & Jaffri, 2020). The physical impairments include intensive care acquired weakness, classified as critical illness myopathy, neuropathy, and neuromyopathy. Cognitive and psychological impairments involve impaired memory, language, delirium, depression, anxiety, and post-traumatic stress disorder (Inoue et al., 2019). Especially in COVID-19 ICU patients, some of these impairments are not just because of critical illness, but the invasion of virus in multiple tissues (Papathanassoglou, Manhas, & Kusi-Appiah, 2020).

During the COVID-19 pandemic, critically ill clients are considered the most vulnerable to PICS. Among these, 30% suffer from depression and 70% experience anxiety and post-traumatic stress disorder after ICU discharge (Inoue, et al., 2019).  Moreover, survivors can experience additional stress as a result of isolation and limited contact with loved ones/family and reduced contact with staff due to precautionary measures such as personal protective equipment (O’Hanlon & Inouye, 2020). Therefore, every patient suspected of PICS needs early rehabilitation and a formal mental assessment at acute and post-acute phase.

The risk of PICS is not confined to patients. The aftermath of critical illness affects not only ICU survivors but also has a great impact on their families, who may suffer from anxiety, somatic symptoms, stress and complicated grief.  Such adverse effects are classified as post ICU syndrome-family (PICS-F) (Inoue et al., 2019).  Another challenge PICS clients face is potential financial instability. The majority face difficulty in returning to their usual work, some become jobless and some experience occupational challenges, and the list does not end here. They may encounter extreme difficulties in performing daily living activities and limited mobility, social responsibilities, and interactions (Jaffri & Jaffri, 2020).

So, what can be done to meet the challenge of PICS? Mobilizing an early rehabilitation response is vital. Multidisciplinary teams including nurses, doctors, physiotherapists, occupational therapists, psychologists, nutritionists, and so forth can develop early rehabilitation protocols to curb PICS complications in survivors and increase their functional capacity. COVID-19 survivors may require extensive and prolonged rehabilitation. Some require tertiary rehabilitation centers and others may need community-based care (Papathanassoglou, Manhas, & Kusi-Appiah, 2020). Therefore, an appropriate post-acute care setting is required to address physical, psychological, and cognitive impairments resulting from infection, mechanical ventilation, and prolonged ICU stay. Additionally, to ensure rehabilitation and healthcare professional safety to prevent viral transmission to clients and providers, tele- or virtual rehabilitation facilities need to be initiated early to address impairments encountered by PICS survivors of COVID-19 (Phillips et al. 2020). A comprehensive discharge plan inclusive of immediate needs, goals, interventions, follow-ups, and a comprehensive rehabilitation assessment are strongly recommended to facilitate the diversity of rehabilitation issues and planning of treatment post-hospitalization (Alberta Health Services, 2020). A crucial time has arrived. There is an immediate need to implement tailored care to address PICS related impairments in COVID-19 survivors.

References

Alberta Health Services (July 17, 2020). COVID-19 Scientific Advisory Group Rapid Evidence Report.
Retrieved from https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-covid-19-sag-rehabilitation-needs-rapid-review.pdf

Inoue, S., Hatakeyama, J., Kondo, Y., Hifumi, T., Sakuramoto, H., Kawasaki, T., … & Kenmotsu, Y. (2019). Post‐intensive care syndrome: its pathophysiology, prevention, and future directions. 
Acute Medicine & Surgery6(3), 233-246. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6603316/

Jaffri, A., & Jaffri, A. (2020). Post-Intensive Care Syndrome and COVID-19: crisis after a crisis? 
Heart & Lung: The Journal of Cardiopulmonary and Acute Care. https://doi.org/10.1016/j.hrtlng.2020.06.006

O’Hanlon, S., & Inouye, S. K. (2020). Delirium: A missing piece in the COVID-19 pandemic puzzle.
Age and Ageing 1-2. doi:10.1093/ageing/afaa094. https://academic.oup.com/ageing/article/49/4/497/5831131

Papathanassoglou, E, Manhas, K. P., & Kusi-Appiah, E. (2020). Beyond acute respiratory distress: Multiple organ effects and early rehabilitation in COVID-19.
Connect: The World of Critical Care Nursing, Vol 13 (4), 1–7. DOI: 10.1891/WFCCN-D-20-00008. https://connect.springerpub.com/content/sgrwfccn/13/4/155

Phillips, M., Turner-Stokes, L., Wade, D., & Walton, K. (2020). Rehabilitation in the wake of COVID-19: A phoenix from the ashes.Accessed on May 12, 2020. Retrieved from https://www.bsrm.org.uk/downloads/covid-19bsrmissue1-published-27-4-2020.pdf

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Shaista Meghani, MScN, BScN, RN, RM, PhD Student
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