COVID-19 Follow-up care paths and Long-term Outcomes Within the Dutch health care system: a combined rehabilitation, pulmonary, and intensive care perspective
Acronym: CO-FLOW study
From the beginning of 2020 the world has been overwhelmed by COVID-19, a new respiratory infectious disease that was first discovered in China at the end of 2019. Hospitalization, including Intensive Care Unit (ICU) treatment, is frequently needed. Hospitalized patients have to deal with a broad range of mild to severe symptoms, and this without the support of family and loved ones. This new disease and surreal situation are expected to cause severe and long-lasting physical, cognitive and psychological consequences, affecting participation and health-related quality of life.
Little is known yet about the long-term consequences of COVID-19, and therefore, the European Academy of Rehabilitation Medicine recently warned for the unknown aftershocks of the pandemic and called for action. Since recent years it has come to the attention that patients after ICU treatment can experience a combination of long-term physical, cognitive, and psychological symptoms, also known as post-intensive care syndrome (PICS). COVID-19 has unique features in that ICU length of stay is relatively long and that patients are frequently immobilized in prone position with (high pressure) mechanical ventilation. Specific problems described after ICU for COVID-19 include reduced joint mobility, neck and shoulder pain, dysphagia, difficulty in verticalization, impaired balance and gait, and difficult awakening with long-lasting confusional state and psychological problems. Furthermore, the viral pneumonia may cause permanent lung fibrosis, and secondary ventilator induced damage will occur in a large proportion of patients, leading to permanent pulmonary function decline, necessitating respiratory rehabilitation or even long-term non-invasive ventilation.
Although long-term consequences of COVID-19 are expected to be most prominent in patients after ICU treatment, also hospitalized patients without ICU treatment may experience long-term symptoms in several areas. Likewise, many of these patients are severely ill, are immobilized for a relatively long period, are not allowed to have visitors, are confronted with isolation measures, and may develop permanent pulmonary damage. Such a unique situation could, besides affecting physical function, potentially result in cognitive and psychological impairments such as anxiety, concentration problems, and post-traumatic stress. Rehabilitation, with its multidisciplinary approach, is the cornerstone of management of the consequences of COVID-19, aiming at minimizing the effects of potential long-term consequences on participation (including return to work, leisure activities, and social relationships) and HRQoL.
Aims of the CO-FLOW study
The sudden COVID-19 pandemic forced a quick development of aftercare paths for this new patient group. These aftercare paths comprise community based rehabilitation, in- and outpatient medical rehabilitation (MSR), rehabilitation in skilled nursing facilities (GRZ), and sheltered care..However, whether these newly developed care paths provide patients with the right care in the right place is unknown yet. This project aims to further develop the aftercare paths for current and future patients with COVID-19 and other comparable infectious diseases. Therefore, the aim of the CO-FLOW study is, by following the healthcare paths of all COVID-19 patients who survived hospitalization in the Rotterdam-Rijnmond region, to systematically study over a 2 years-period:
- trajectories of physical, cognitive, and psychological recovery;
- patient flows, healthcare utilization, patient satisfaction with aftercare, and barriers/facilitators regarding aftercare as experienced by healthcare professionals;
- effects of physical, cognitive, and psychological outcomes on participation and HRQoL;
- predictors for long-term recovery, health care utilization, and patient satisfaction with aftercare.
CO-FLOW is a multicenter prospective cohort study with a 2-year follow-up period. Measurements comprise non-invasive clinical tests and patient reported outcome measures from a combined rehabilitation, pulmonary, and intensive care perspective. Measurements are performed at 3, 6, 12, and 24 months after hospital discharge and, if applicable, at rehabilitation discharge. CO-FLOW aims to include at least 500 patients who survived hospitalization for COVID-19, aged ≥ 18 years.