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Planning beyond COVID-19 survival to longer-term health and healthcare risks

Introduction by Croakey: There is growing recognition and concern that many people who have contracted COVID-19 are experiencing lasting effects from the infection and treatment – prompting the term ‘long covid’, according to this recent article in the BMJ.

This raises critical issues not just for patients, but for healthcare settings and systems, write Associate Professor Steven G Faux and Professors Kathy Eagar, Ian D Cameron and Christopher J Poulos in today’s edition of The Medical Journal of Australia.

In the article below, Faux – the clinical lead of the NSW Ministry of Health’s Community of Practice in Rehabilitation, which is providing advice on COVID-19 rehabilitation – writes that we need to plan as urgently for COVID-19 rehabilitation, particularly when it comes to contagion, as we have for its acute phase.

He warns:

In order for Australia to mount an effective rehabilitation response we need increased resources for our mobile rehabilitation teams and telerehabilitation services, and to prepare our public rehabilitation wards for incoming COVID patients.”


Steven Faux writes:

And if you survive COVID…. what then?

Our ability to plan and take early action during the COVID-19 pandemic has been our strength, and our acute medical system has been managing well.

However, once our ICUs have managed the acute phase of the illness, what happens then? What are we going to do with the survivors?

In Australia we don’t, as yet, have a plan to rehabilitate survivors of COVID-19. Lessons from the Ruby Princess inquiry continue to inform us of the risks inherent in not having a plan.

For many COVID survivors it’s just not as simple as going straight home from ICU. Many survivors can’t walk for days or weeks, the fatigue and weakness makes it difficult even getting to the toilet; the rehabilitation and recovery is just beginning.

UK Prime Minister Boris Johnson  didn’t get back to work for a month and, several months later, Paul Garner, Professor of Infectious Diseases at Liverpool School of Tropical Medicine, is still suffering the long tail of the disease.

Complication and debilitation

Currently in Australia the numbers needing rehabilitation are at a trickle. However, in Italy, rehabilitation doctors are treating post-ventilation swallowing difficulties, prolonged weakness and COVID-related strokes. In England the British Rehabilitation Society has encouraged partnerships with ICU specialists to help efficiently move patients out of ICU to rehab to improve access to ventilators. In the US, entire post-COVID rehabilitation hospitals have had to be established.

Researchers in April’s Lancet wrote that in Wuhan, 36 percent of those hospitalised with COVID-19 developed neurological complications, weakness and loss of feeling in hands and feet (critical care neuropathy and myopathy) and other ICU complications like clots in the legs, delirium and infections.

The 2016 RECOVER study showed that for Americans coming off a week of ventilation, 60 percent were unable to walk and 17 percent had died within a year. Those with ICU complications will generally stay at least three weeks in rehabilitation units and those with stroke or heart attack stay longer. Some may need homecare for years.

COVID-19 preparation has necessarily been focused on planning, prevention and survival.

But now we need the same approach for our post-acute and rehabilitation response.

Any sudden outbreaks or hotspots will try our local readiness. This pandemic will continue to threaten, and complacency is its ally.

The Australian Government’s emergency response plans have devolved the recovery phase to the states. In late April the NSW Ministry of Health set up a post-acute or rehabilitation community of practice to advise on how to prepare our rehab units.

As part of that community of practice, we are working on a staged escalation plan for rehabilitation services. But our plans turn on one integral point — contagion.

Managing contagion

When COVID-19 survivors come to our rehabilitation wards, will they no longer be infected?

Can we consider them de-isolated? Our current research shows that many severe COVID-19 patients may remain infectious for days after the onset of their symptoms. Some exude virus particles for up to 37 days. This timetable will be at odds with the acute hospital’s need to make ICU beds readily available by shifting patients home or to rehab.

In New Orleans, a 1,000 bed COVID-19 post-acute care hospital has been established where many patients continue to require rehabilitation to be weaned off 24 hours a day oxygen and to walk by themselves. In these hospitals, patients are presumed infective for their entire stay.

A protocol for de-isolation has been published by the Australian Health Protection Principle Committee and in NSW we are working hard to finalise a protocol to protect health care workers and to escalate rehabilitation services in order to cope with any surges.

In order for Australia to mount an effective rehabilitation response we need increased resources for our mobile rehabilitation teams and tele-rehabilitation services, and to prepare our public rehabilitation wards for incoming COVID patients.

Without attention to this process, newly infected patients may not receive unfettered access to acute hospital or ICU beds.

Planning for the survivors of COVID-19 will require the same courage and leadership that made our acute COVID-19 response world leading, collaborative and publicly supported.

In the UK and the USA, we see the brutality of this pandemic with mass burials and the tragic toll on healthcare workers.

We need to plan for our recovery phase because not having a plan is unforgivable and surviving is not the same as living.

Steven Faux is the clinical lead of the NSW Ministry of Health’s Community of Practice in Rehabilitation charged with advising the Ministry on the rehabilitation response. He is also an Associate Professor of Rehabilitation Medicine and Pain Medicine at the University of NSW and Director at the Rehabilitation Unit at St Vincent’s Hospital Sydney.

 

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