Post-COVID Recovery: Characteristics of Chronically Critically Ill Patients Admitted to a Long-Term Acute Care Hospital Meg Stearn Hassenpflug, MS, RD, FCCM; Dale Jun, MD; David R. Nelson, MD; Tamas Dolinay, MD, PhD Barlow Respiratory Hospital, Los Angeles, CA UCLA David Geffen School of Medicine, Los Angeles, CA
Introduction Advances in technology, research, and adoption of evidence-based practices have significantly improved ICU survivorship, creating the population of patients recognized as chronically critically ill (CCI)1. This improved survival, however, is often accompanied by a prolonged and challenging course of recovery. This population now includes ICU survivors of Coronavirus disease 2019 (COVID-19) in need of post-acute care for continued recovery from their infection. Long-term acute care (LTAC) hospitals are vital in the care of CCI patients2, but their role in patients post COVID-19 infection is not known. Barlow Respiratory Hospital (BRH) is a 105-bed, not for profit, LTAC hospital network serving ventilator-dependent and medically complex patients transferred from the ICUs of hospitals in southern California. Herein, we report patient characteristics of our first series of COVID-19 survivors admitted to the postacute venue of an LTAC, as an essential step in the continuum of care for treatment, rehabilitation, and recovery. Methods This is a single-center descriptive report of patients recovering from acute infectious complications of COVID-19 pneumonia requiring long-term respiratory support. The majority are admitted on invasive mechanical ventilation having experienced respiratory failure at the transferring hospital, as well as for continued care and treatment of infections, complications, and co-morbid conditions. Data were collected in a de-identified fashion from a performance improvement database approved by hospital leadership. The database is constructed from routinely collected transfer document and BRH medical record information. Results From 4/28/2020-7/7/2020, 30 patients were admitted to BRH for continued recovery from COVID-19 pneumonia. All tested negative for COVID-19 prior to transfer. Selected demographic and patient characteristics are shown in Table 1. The length of stay at the transferring hospital was twice that of non-COVID patients admitted during the same time period. All mechanical ventilation and hemodialysis interventions were initiated at the transferring hospital. Table 2 presents treatment interventions already in effect on admission to BRH, and some descriptive characteristics.
Table 1. Selected Demographics and Characteristics of Patients Admitted for Post-COVID Recovery Variable Age, years
n=30 74.5 [44-94]
Gender, male
60%
Premorbid location, home
63.3%
Race/Ethnicity:
n (%)
African American
2 (6.7)
Asian/Pacific Islander
3 (10)
Caucasian
14 (46.7)
Hispanic
11 (36.7)
COVID-19 Risk Factors: Type 2 Diabetes Mellitus
n (%) 18 (60)
Hypertension
22 (73.3)
Coronary Artery Disease
10 (33.3)
Hyperlipidemia
10 (33.3)
Obesity (BMI ≥ 30)
14 (46.7)
At Transferring Hospital:
n (%)
ARDS
13 (43.3)
Sepsis/Septic Shock
13 (43.3)
Invasive Mechanical Ventilation
27 (90)
Tracheotomy
24 (80)
Acute Kidney Injury/Acute Renal Insufficiency
19 (63.3)
Heart Failure
11 (36.7)
Transferring hospital length of stay, days
40 [8-77]
Table 2. Status of Post-COVID Recovery Patients on Admission Variable Invasive Mechanical Ventilation Admitted for weaning
n=30 16 (53.3) 11 (36.7)
Tracheostomy tube
24 (80)
Hemodialysis
9 (30)
Enteral feeding tube
24 (80)
Central line
14 (46.7)
Indwelling urinary catheter
10 (33.3)
Pressure Injury ≥ Stage 2
22 (73.3)
Multiple Pressure Injuries
14 (46.7)
Laboratory Values: Mean (SD) Serum albumin (g/dl)
2.9 ± (.59)
Hematocrit (%)
30.2 (5.9)
BUN (mg/dl)
41.8 (27.4)
Creatinine (mg/dl) Glucose
1.7 (2.1) 143 (50.6)
Discussion and Conclusions LTAC hospitals provide specialized care for patients suffering from CCI 3. With increased survival in the ICU, the number of patients transferred to these hospitals has increased in the past decades2. Early reports of the COVID-19 pandemic indicate that 5 to 12% of patients with COVID-19 infection require ICU hospitalization4-6. These numbers suggest that the role of LTAC hospitals will expand during the COVID-19 pandemic, due in part to their ability to treat patients with illnesses and conditions that do not follow a linear trajectory of improvement. To our knowledge, this is the first report to characterize CCI and medically complex COVID-19 patients transferred to the post-acute venue of an LTAC. Patients on average spent over six weeks in the transferring hospital, are largely elderly, carry the known risk factors for COVID19 infection, and experienced respiratory failure necessitating prolonged mechanical ventilation via tracheostomy. Patients present with physiological imbalances, numerous penetrating and indwelling catheters and disruptions of skin integrity breaching host defenses, and manifestations of allostatic load burden. Overall, our findings suggest that these patients will continue to require considerable medical interventions and treatments, including weaning from mechanical ventilation, owing to the numerous sequelae of the infection and the burden of acute-on-chronic diseases. As ICU survival rates improve, this survey further emphasizes the important role of the LTAC in responding to the COVID-19 crisis. LTAC hospitals will play an increasingly critical function to fill gaps in our preparedness and response to COVID-19 infection by resuming and relieving care initiated in the acute hospital setting. Our analysis is limited by several factors: it is a single center descriptive report, with a small cohort of patients, and a still emerging evidence base for COVID and post-COVID infection. Efforts to quantify disease burden and report the number and variety of interventions may be warranted to objectify the intensity of treatment at the LTAC hospital. In addition to reporting broad outcomes (wean rate, length of stay, discharge disposition) a goal is to identify subgroups of patients and craft specific clinical outcomes. 1. Nelson JE, Cox CE, Hope AA, Carson SS. Chronic critical illness. Am J Respir Crit Care Med 2010; 182: 446454. 2. Kahn JM, Benson NM, Appleby D, Carson SS, Iwashyna TJ. Long-term acute care hospital utilization after critical illness. JAMA 2010; 303: 2253-2259. 3. Kahn JM, Werner RM, David G, Ten Have TR, Benson NM, Asch DA. Effectiveness of long-term acute care hospitalization in elderly patients with chronic critical illness. Med Care 2013; 51: 4-10. 4. Grasselli G, Pesenti A, Cecconi M. Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency Response. JAMA 2020. 5. Young BE, Ong SWX, Kalimuddin S, Low JG, Tan SY, Loh J, Ng OT, Marimuthu K, Ang LW, Mak TM, Lau SK, Anderson DE, Chan KS, Tan TY, Ng TY, Cui L, Said Z, Kurupatham L, Chen MI, Chan M, Vasoo S, Wang LF, Tan BH, Lin RTP, Lee VJM, Leo YS, Lye DC, Singapore Novel Coronavirus Outbreak Research T. Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore. JAMA 2020. 6. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DSC, Du B, Li LJ, Zeng G, Yuen KY, Chen RC, Tang CL, Wang T, Chen PY, Xiang J, Li SY, Wang JL, Liang ZJ, Peng YX, Wei L, Liu Y, Hu YH, Peng P, Wang JM, Liu JY, Chen Z, Li G, Zheng ZJ, Qiu SQ, Luo J, Ye CJ, Zhu SY, Zhong NS, China Medical Treatment Expert Group for C. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med 2020; 382: 1708-1720.
(Submitted to the Society of Critical Care Medicine 2021 Critical Care Congress) Š2020 Barlow Respiratory Hospital