Pics may be the next health crisis that we face when this acute form of Covid-19 crisis settles down a bit.
One thing that didn't make to the spotlight in this Covid-19 pandemic is a question that what happens to the Covid-19 patients after they are discharged from the critical care? A common assumption around the world is that once a patient is discharged from the hospital and is tested negative the problem is resolved. This may be based on a relative lack of information and knowledge, even among the health care professionals, regarding a condition described as Post-Intensive Care Syndrome (Pics).
Pics may be a next public health crisis that we may face when this acute form of Covid-19 crisis settles down a bit. And it wouldn't be prudent to ignore this serious problem until it becomes another challenge for societies around the world.
Pics is characterised by conglomeration of symptoms involving physical strength deficits, cognitive decline, and mental health disturbances observed after discharge from critical care that persist for a protracted amount of time.
In the United States alone, approximately 0.8 million people every year suffer from critical illness requiring mechanical ventilation during their stay in critical care and this goes across all age groups. Although, data on this topic hasn't been collected yet in relation to Covid-19 patients, it will be reasonable to assume that this number is going to drastically increase because of the pandemic as at least 20 per cent of Covid-19 patients are reported to require supportive care in critical care units.
Patients infected with Covid-19 that are admitted to critical care often need 10 days of supportive care utilising mechanical ventilation. This will result in additional admissions in the intensive care units (ICU) of the hospital for patients who need supportive care.
Approximately 50pc of all patients, across all ages, admitted to the ICU requiring mechanical ventilation go on to developing Pics.It is important to note here that the patients who are at risk of developing Pics have a history of associated morbidities, such as diabetes, hypertension, asthma, chronic obstructive pulmonary disease and prolonged period of mechanical ventilation (because of direct injury to the lungs) that is exactly similar to the clinical profile of Covid-19 patients who are admitted in hospital ICUs.
People who survive up to two years after discharge from critical care have had to be admitted to a rehabilitation facility or to an ICU again up to the frightening rate of 80pc. This readmission rate is higher in people who have again a similar clinical profile of Covid-19 ICU survivors, such as associated morbidities and acute respiratory distress injuries. Another alarming facet of this problem is long-term cognitive decline. Neurocognitive deficits, including anxiety and depression, were reported in 46 % of patients at one year and 47% of ICU survivors at the two year follow-up.
Patients also reported consistent deficits in quality of life at one and two years after discharge with no improvement in emotional, pain and general health over the period of time, rather further deterioration was observed in mental health at two years.
Chronic pain after critical care persisting over years may be another reason adding to the mental health disturbances of these patients over a period of time.
Notably, physical impairment such as balance problems and muscular weakness have also been found in these patients that can potentially increase the risk of falls.
Each additional day of bed-rest in critical care is associated with 11pc decrease in muscle strength even at 24 months of follow-up. Muscle weakness is directly associated with deterioration in health related quality of life and physical function throughout and beyond the two years of follow-up in ICU survivors of respiratory illness.
On top of that, there is an alarming impact of Pics on an individual's financial stability. A majority of ICU survivors face some problems returning to work with 31pc of them experiencing major occupational changes, and a quarter of them becoming completely jobless. It doesn't stop here; these patients also develop extreme difficulties in performing their activities of daily living, such as driving a vehicle.
It has been reported that 33pc of individuals even up to a year after discharge from critical care are unable to drive, limiting their mobility and ability to fulfill social responsibilities. These are startling statistics and may be an impending disaster in Covid-19 recovered patients that we are unable to recognise as of now.
Now, another question is what can we do about it?
The solution to this problem is developing an integrated rehabilitation response by mobilising our rehabilitation troops and bringing them on the frontline to cater to these complications of stay in critical care.
Professionals such as physical therapists, occupational therapists, psychologists, nutritionists and physical medicine and rehabilitation physicians (physiatrists) can work together to develop strategies to treat the complications arising from ICU stay. Exercise programmes tailored towards increasing strength and balance along with good nutrition that may increase functional capacity should start soon after discharge.
It has been previously reported that patients recovering from critical care at hospital had improved physical and psychological outcomes when strengthening exercises were supplemented with amino acids.
Many of the patients recovering from ICU may need to be transferred to in-patient rehabilitation settings. However, it poses several challenges such as dire paucity of personal protective equipment which may put rehabilitation professionals at risk. This may result in further spread of disease; healthcare provider carrying Covid-19 asymptotically can become a 'super spreader'.
At the same time, ensuring healthcare providers and staff safety, and greater outreach of rehabilitation services, telerehabilitation and virtual rehabilitation may become the mainstay of providing these services.
Also, conducting multi-national telerehabilitation conferences may help rehabilitation professionals to develop skills to manage these patients in different parts of the world, and give them an opportunity to devise a common framework to address impairments in ICU survivors of Covid-19 patients.
We also see that in many developing countries, the emphasis on rehabilitation is minimal and there are no facilities available there for in-patient rehabilitation. In such situations, there is an increased need to raise awareness that rehabilitation is necessary for Covid-19 patients post-discharge, and that a post-discharge crisis may hit these countries harder due to lack of availability of basic services, such as health and social safety.
With all of this, it is time for global policy leaders such as the United Nations and the World Bank to take Pics and its implications in Covid-19 ICU survivors into account when allocating healthcare relief funds when it comes to developing countries.
Furthermore, emphasis on rehabilitation should be integrated as an essential part of support programmes, such as "Securing Human Investments to Foster Transformation (Shift)", that are aimed at capacity building of developing countries such as Pakistan to fight this pandemic.
Lastly, one critical aspect in management of these patients is educating the family members. Pics can have a significant influence on the patients' family members. This phenomenon is also known as Pics-family.
After getting discharged from the hospital, the patient will in most cases be completely dependent on the family, which can play an important role in offering the recovering individual requisite emotional and physical support.
The family should recognise mental health disturbances in patients that may develop on account of anxiety and depression, provide continual emotional support, and help the patient understand the need for physical rehabilitation by engaging them in regular physical activity.
Pics is a relatively newer term that was introduced almost 10 years ago to healthcare professionals involved in the treatment of patients discharged after critical care to identify the impairments that are usually missed by clinicians, and administer tailored care to address these impairments. This article is an effort to bring this looming yet unrecognised problem to public attention because hospitalisations due to Covid-19 may demand recognition of Pics more than ever, and sooner rather than later.
This article was originally published in Heart & Lung: The Journal of Cardiopulmonary and Acute Care and has been reproduced with permission.
Dr Abbis Jaffri is currently Assistant Professor at the School of Pharmacy and Health Professions at Creighton University. His research expertise is in rehabilitation medicine and in primarily designing and investigating novel diagnostic tools and treatment protocols to optimise patient care and health-related quality of life post-injury. He reviews many high impact scientific journals and has presented his scientific work at international fora. He tweets @Abbis_Jaffri
Ume Abbiyha Jaffri is a student of medicine in her 4th year of MBBS at the Ameer-ud-Din Medical College which is affiliated with the Lahore General Hospital.
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