Abstract: Patients critically ill with coronavirus disease 2019 (COVID-19) spend significant time on mechanical ventilation and have prolonged hospitalization duration.1Chiumello D. Coppola S. Froio S. Gotti M. What's next after ARDS: long-term outcomes.Respir Care. 2016; 61: 689-699Crossref PubMed Scopus (71) Google Scholar Whether these patients have immediate pulmonary and neurocognitive recovery following discharge is unknown. Patients were admitted to the University of Virginia (UVA) Medical Center ICU with COVID-19 and underwent follow-up at the UVA Post-COVID-19 ICU clinic approximately 6 weeks following discharge. Lung function and exercise capacity were assessed by using spirometry, lung volumes, diffusion capacity, and the 6-min walk test. Depression, cognitive function, and insomnia were assessed by using the Patient-Reported Outcomes Measurement Information System Depression 8a-Short Score, the Quality of Life in Neurological Disorders adult cognitive function version 2.0 score, the Montreal Cognitive Assessment (MOCA) score, and the insomnia severity index. The study was approved by the UVA Institutional Review Board. As of July 30, 2020, a total of 102 patients with COVID-19 were admitted to the UVA ICU. Fifty-nine patients (57.84%) were discharged alive, 22 (21.57%) died, and 21 (20.59%) remained hospitalized. Every discharged patient is contacted to follow up in the UVA Post-ICU COVID-19 clinic. The first patient was seen on June 2, 2020. Twenty-eight of the 29 scheduled patients attended the clinic as of July 30, 2020 (Table 1), resulting in a 96% show-rate. The remaining discharged patients are scheduled but have not yet been seen. Seven (25%) and 10 (57.14%) patients self-identified as African American and non-white Hispanic, respectively. The median age was 56 years (interquartile range [IQR], 47.5-65.75 years); 24 patients (85.71%) required mechanical ventilation, and the median number of days on mechanical ventilation was 11 (IQR, 3.25-15 days). The mean Sequential Organ Failure Score, the Acute Physiology and Chronic Health Evaluation II score, and the Simplified Acute Physiology Score II were 6 ± 2.5, 14 ± 6.2, and 32 ± 12.4, respectively. Seventy-five percent were diagnosed with delirium in the ICU. Median ICU and hospital length of stay were 14 (IQR, 6-21.5) days and 22 (IQR, 11.5-31) days, respectively. Two patients were discharged on antipsychotic agents or opiates.Table 1Epidemiologic and Clinical Characteristics of PatientsPatient No.Age, ySexSelf-Reported EthnicityLowest Po2/ Fio2Days on MVReceived Paralysis and ProningEvidence of DeliriumaDelirium is assessed by the nursing staff every shift using the Confusion Assessment Method for the ICU.ICU LOSHospital LOSDays From Discharge to VisitSpirometryDiffusion Capacity (% Predicted)6MWD (m)/ % PredictedPROMIS Depression 8a T ScorebT score > 45 represents no depression, 40 to 45 represents mild depression, 30 to 40 represents moderate depression, and < 30 represents severe depression.Neuro-QoL Adult Cognitive Function T ScorecNeuro-QoL adult cognitive function version 2.0: T score > 45 represents normal cognition, 40 to 45 represents mild cognitive impairment, 30 to 40 represents moderate cognitive impairment, and < 30 represents severe cognitive impairment.MOCA ScoredMOCA scores > 25 represent normal cognition; 18 to 25 represent mild cognitive impairment; 10 to 17 represent moderate cognitive impairment; and scores < 10 represent severe cognitive impairment.Insomnia Severity IndexeInsomnia: scores 0 to 7 represent no clinically significant insomnia; 8 to 14 represent subthreshold insomnia; 15 to 21 represent moderate severity clinical insomnia; and 22 to 28 represent severe clinical insomnia.SOFAfScores on the SAPS II range from 0 to 163; higher scores indicate more severe disease and higher risk of death./APACHE IIgScores on the APACHE II range from 0 to 71; higher scores indicate more severe disease and higher risk of death./SAPS IIhScores on the SOFA range from 0 to 24; higher scores indicate more severe disease and higher risk of death.159FAfrican American11814YesYes173236Mixed obstruction and restrictionReduced (59%)362/76%38.240.926NA10/15/11254MHispanic1287NoYes91336NormalNormal (97%)168/38%44.764.222153/8/34367MAfrican American2125NoNo61440NormalNormal (83%)390/67%44.750.927NA7/22/46474FWhite6615NoYes223441NormalNormal (70%)350/78%38.248.320163/11/21571MHispanic1383NoNo51530NormalNormal (99%)378/85%38.242.91874/13/42675MWhite11127YesYes383936Unable to performUnable to performNA47.548.322225/25/56769MAfrican American15018YesYes223140RestrictionReduced (58%)327/57%38.250.91879/21/52865FAsian Indian4715YesYes172641ObstructionUnable to perform201/46%55.143.92728/19/44966FAfrican AmericanRA0NoneNo2243NormalNormal (80%)311/87%59.448.328NANA1059MAfrican American1707NoYes91340ObstructionNormal (83%)352/72%38.248.329118/13/331143MHispanic1436NoNo132035ObstructionReduced (62%)50/1%64.94619194/4/271230FHispanic4216YesYes233138ObstructionNormal (107%)345/83%56.856.318127/10/151360FHispanicNA0NoNo3631RestrictionReduced (67%)NA38.2n.a2325 (known OSA)4/21/351441MHispanic8814YesYes162341NormalNormal (115%)325/52%38.248.324NA8/12/361570MHispanic14615NoYes253840NormalNormal (90%)250/59%63.93511NA8/20/481658FWhite18022NoYes234639NormalReduced (69%)287/54%58.538.929137/16/341751MHispanic8012YesYes182839RestrictionNormal (106%)268/50%38.264.227NA8/9/231864FAfrican American11526Yesyes273340NormalNormal (79%)203/52%38.250.924147/15/451951MHispanic7010Yesyes111935NormalNormal (85%)386/63%38.2592139/12/272050MWhite9216YesYes202842RestrictionReduced (69%)325/50%55.344.926169/20/382159MHispanic1009NoNo122544RestrictionReduced (62%)326/69%37.164.22308/28/382252MHispanic10014YesYes152143NormalNormal (114%)400/87%43.364.22314/12/342351FHispanic2003NoYes4640NormalNormal (103%)340/64%37.139.917103/12/212439MHispanicNA0NoNo61135NormalNormal (86%)350/59%37.152.42302/6/112547FAfrican American1383NoNo41132NormalNormal (90%)304/95%49.847.12923/6/332649MHispanic10415YesYes202742Unable to performNormal (110%)444/75%53.456.32229/13/242736FHispanicNA0NoNo6938NormalNormal (114%)339/69%37.164.22433/11/112844MHispanic954NoNo7938NormalNormal (101%)418/72%43.452.41915/12/29Mean ± SD55.5 ± 11.9118 ± 4510.6 ± 7.714.3 ± 8.621.8 ± 11.538.4 ± 3.6315 ± 85)/63%45.4 ± 9.2450.8 ± 8.423 ± 49 ± 86 ± 2.5/14 ± 6.2 /32 ± 12.46MWD = 6-min walk distance; APACHE = Acute Physiology and Chronic Health Evaluation; F = female; LOS = length of stay; M = male; MOCA = Montreal Cognitive Assessment; MV = mechanical ventilation; NA = not available; Neuro-QoL = Quality of Life in Neurological Disorders; PROMIS = Patient-Reported Outcomes Measurement Information System; RA = room air; SAPS = Simplified Acute Physiology Score; SOFA = Sequential Organ Failure Assessment.a Delirium is assessed by the nursing staff every shift using the Confusion Assessment Method for the ICU.b T score > 45 represents no depression, 40 to 45 represents mild depression, 30 to 40 represents moderate depression, and < 30 represents severe depression.c Neuro-QoL adult cognitive function version 2.0: T score > 45 represents normal cognition, 40 to 45 represents mild cognitive impairment, 30 to 40 represents moderate cognitive impairment, and < 30 represents severe cognitive impairment.d MOCA scores > 25 represent normal cognition; 18 to 25 represent mild cognitive impairment; 10 to 17 represent moderate cognitive impairment; and scores < 10 represent severe cognitive impairment.e Insomnia: scores 0 to 7 represent no clinically significant insomnia; 8 to 14 represent subthreshold insomnia; 15 to 21 represent moderate severity clinical insomnia; and 22 to 28 represent severe clinical insomnia.f Scores on the SAPS II range from 0 to 163; higher scores indicate more severe disease and higher risk of death.g Scores on the APACHE II range from 0 to 71; higher scores indicate more severe disease and higher risk of death.h Scores on the SOFA range from 0 to 24; higher scores indicate more severe disease and higher risk of death. Open table in a new tab 6MWD = 6-min walk distance; APACHE = Acute Physiology and Chronic Health Evaluation; F = female; LOS = length of stay; M = male; MOCA = Montreal Cognitive Assessment; MV = mechanical ventilation; NA = not available; Neuro-QoL = Quality of Life in Neurological Disorders; PROMIS = Patient-Reported Outcomes Measurement Information System; RA = room air; SAPS = Simplified Acute Physiology Score; SOFA = Sequential Organ Failure Assessment. The median number of days to follow-up in the clinic posthospital discharge was 39.5 (IQR, 36-41 days). Results of prior lung function tests were not available for comparison. At follow-up, 16 patients (61.54%) had normal lung function, four (15.38%) had obstruction, five (19.23%) had restriction, one (3.85%) had mixed obstruction and restriction, and seven (26.92%) had reduced diffusion capacity. The mean 6-min walk distance was 315 ± 85.4 m, and mean percent predicted was 65.5 (IQR, 51.5-76.5). None of the patients required supplemental oxygen. None of the patients had clinically diagnosed depression, cognitive impairment, or insomnia prior to admission. At follow-up, seven patients had mild to moderate depression. Assessment of mild cognitive impairment was more frequent according to MOCA (n = 16 [57.14%]) but not according to the Quality of Life in Neurological Disorders (n = 6 [22%]) score. All but one patient (96%) performed activities of daily life without difficulty. Five of 23 patients who completed the insomnia severity index had moderate to severe insomnia. Detailed patient information is given in Table 1, and Figure 1 shows representative examples of the visuospatial/executive MOCA test. To the best of our knowledge, this analysis is the first case series of outpatient follow-up visits for patients who were hospitalized in the ICU with COVID-19. We found a low prevalence of obstruction and restriction, similar to previously published data in ARDS.1Chiumello D. Coppola S. Froio S. Gotti M. What's next after ARDS: long-term outcomes.Respir Care. 2016; 61: 689-699Crossref PubMed Scopus (71) Google Scholar,2Cummings M.J. Baldwin M.R. Abrams D. et al.Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study.Lancet. 2020; 395: 1763-1770Abstract Full Text Full Text PDF PubMed Scopus (1477) Google Scholar The prevalence of diffusion impairment in this cohort was lower compared with post-ARDS follow-up.3Herridge M.S. Moss M. Hough C.L. et al.Recovery and outcomes after the acute respiratory distress syndrome (ARDS) in patients and their family caregivers.Intensive Care Med. 2016; 42: 725-738Crossref PubMed Scopus (278) Google Scholar The mean 6-min walk distance in the current cohort was higher compared with what has been reported in prior ARDS studies.3Herridge M.S. Moss M. Hough C.L. et al.Recovery and outcomes after the acute respiratory distress syndrome (ARDS) in patients and their family caregivers.Intensive Care Med. 2016; 42: 725-738Crossref PubMed Scopus (278) Google Scholar Despite significant dosages for sedation and a high prevalence of delirium in the ICU, the majority of the current patients had no or only mild cognitive impairment at 6 weeks following hospital discharge. This observation, and the fact that only one patient still had difficulties with activities of daily life, differs from previous reports of survivors of critical illness.4Sevin C.M. Bloom S.L. Jackson J.C. Wang L. Ely E.W. Stollings J.L. Comprehensive care of ICU survivors: development and implementation of an ICU recovery center.J Crit Care. 2018; 46: 141-148Crossref PubMed Scopus (122) Google Scholar The prevalence of depression and insomnia were comparable with previous post-ICU outcome studies.5Altman M.T. Knauert M.P. Pisani M.A. Sleep disturbance after hospitalization and critical illness: a systematic review.Ann Am Thorac Soc. 2017; 14: 1457-1468Crossref PubMed Scopus (133) Google Scholar,6Jackson J.C. Pandharipande P.P. Girard T.D. et al.Depression, post-traumatic stress disorder, and functional disability in survivors of critical illness in the BRAIN-ICU study: a longitudinal cohort study.Lancet Respir Med. 2014; 2: 369-379Abstract Full Text Full Text PDF PubMed Scopus (454) Google Scholar The majority of the post-ICU clinic patients were African American or Hispanic, which is supportive of recent studies that suggest non-white racial/ethnic groups are severely affected by COVID-19.7Martinez D.A. Hinson J.S. Klein E.Y. et al.SARS-CoV-2 positivity rate for Latinos in the Baltimore-Washington, DC region.JAMA. 2020; 324: 392-395Crossref PubMed Scopus (109) Google Scholar This was a single-center case series, and we do not have sufficient long-term data to assess how these outcomes change over time. The long-term impact of this disease remains unclear but our study suggests the feasibility of an in-person outpatient clinic for post-ICU COVID-19 patients and a low burden of pulmonary and neurocognitive morbidity at immediate follow-up. Other contributions: The authors acknowledge the efforts of Norma Nelson, RN, and Amanda Campbell, RRT, for the help with scheduling follow-up visits and pulmonary function tests.