Patients with COVID-19 are staying longer than the average three to four days in the intensive care unit (ICU), says Megan Hosey, a rehabilitation psychologist at The Johns Hopkins Hospital’s medical ICU. This puts them at greater risk for developing post-intensive care syndrome (PICS) — physical, cognitive and psychological changes that occur after surviving an illness or injury that requires treatment in the ICU.

Up until 20 years ago, survival was the ICU’s benchmark of success. Today, more people than ever survive, but research over the last two decades finds that survival comes with a price: a cluster of symptoms that can hinder patients’ quality of life for weeks or years to come. While the exact prevalence of PICS is unknown, “It happens in more patients than we probably realize,” says Hosey.

PICS can affect a person’s ability to perform activities of daily living, driving and working; it can also impact family members who must adjust to their loved ones’ “new normal.”

Treating Acute Respiratory Distress Syndrome and Anxiety in Patients with COVID-19

Hosey works closely with Dale Needham, a Johns Hopkins critical care physician and researcher who is internationally renowned for advancing PICS research. Needham says patients with COVID-19 can develop pneumonia that leads to acute respiratory distress syndrome (ARDS) — fluid in the lungs that deprives the organs of oxygen. These patients require a ventilator in the ICU, and, for patients with COVID-19 and ARDS, it’s not unusual to be on a ventilator for more than two weeks. Other patients in the ICU with COVID-19 are typically on oxygen or highly concentrated oxygen.

Hosey also works with Joe Bienvenu, a Johns Hopkins psychiatrist who studies survivors of critical illnesses and intensive care. As of mid-April, 2020, one of the conditions Bienvenu and Hosey find most concerning in patients with COVID-19 in the ICU is anxiety. Reasons include having difficulty breathing, being away from family, fear of getting others sick and fear of reports in the media.

Lately, Hosey has been interacting with these patients remotely — on the phone and in video meetings — due to efforts to decrease transmission of the coronavirus and to conserve personal protective equipment. Patients use the telephones and tablets in their rooms for these visits.

An important aspect of care is to find what makes life most worthwhile for these patients. “Even in the ICU, we try to help patients see the things that are pleasurable and meaningful in their lives because these [reminders] can protect against anxiety and depression. The sooner you can get back into these activities — or even talking about them — the better,” says Hosey.

Hosey also helps patients by reaching out to family members to better understand the patient's history and what helps them cope. In addition, these phone calls assure families that she is taking care of their loved one, even though they are unable to visit.

Recognizing Delirium in Patients with COVID-19

Along with anxiety, Hosey and Bienvenu’s biggest concern regarding the mental health of patients with COVID-19 in the ICU is delirium.

The condition can set in when a patient is in an unfamiliar environment, under sedation and working overtime to fight infection or to recover from an injury, says Bienvenu. He describes delirium as a brain malfunction that makes it hard for patients to interpret what’s going on around them. Their bodies seem to know that something is terribly wrong, but their brains can misinterpret what that is. Patients often describe frightening nightmare-like experiences, sometimes with themes of betrayal by doctors and nurses — at times, even by loved ones.

Hosey says the prevalence of delirium in patients with COVID-19 in the ICU is especially high, likely due to the amount of sedation needed to keep patients on ventilators for an extended period of time.

Unfortunately, the effects of delirium can linger. “Even after it resolves,” Bienvenu says, “the memories can lead to mental health effects’ downstream — increased symptoms of anxiety, depression or post-traumatic stress disorder. Patients may have anxious reactions when they see a hospital. They find themselves wanting to avoid hospitals, and becoming very fearful that they will get sick again.”

Because delirium can also cause cognitive changes in attention, thinking and memory that last beyond hospitalization, Hosey talks to patients about getting in touch with a mental health provider who understands post-intensive care syndrome.

Physical, Speech and Occupational Therapists Report to Johns Hopkins ICU

According to Jennifer Zanni, a Johns Hopkins physical therapist who worked in the ICU for 18 years and now specializes in intensive outpatient post-acute rehabilitation, many therapists from Johns Hopkins rehabilitation facilities have been reassigned to The Johns Hopkins Hospital. These physical, speech and occupational therapists are focused on the early recovery of patients hospitalized with COVID-19, including helping with patient proning in the ICU. (Proning is when patients lie on their stomach to improve their oxygen levels.) Needham says anecdotal evidence shows proning is working for patients with severe pneumonia and COVID-19.

Early Rehabilitation in the ICU Helps Recovery from COVID-19

By helping patients manage their health in the ICU as early as possible, Hosey believes patients will be better equipped to engage in the next phase of their recovery. “Very few ICUs in the country provide patients with the amount and intensity of early rehabilitation that we provide at Hopkins,” she says.

Needham agrees. “We've got an extraordinary program that routinely provides psychological help and physical, occupational and speech therapy, on top of medical care in the ICU. During the pandemic, this program continues.”

Soon, patients recovering from COVID-19 will have a convenient resource to report and monitor their health, including PICS. Ann Marie Parker, a Johns Hopkins physician who specializes in pulmonary and critical care medicine, as well as delirium and rehabilitation in the ICU, is creating a virtual clinic for COVID-19 survivors.