Postdischarge symptoms and rehabilitation needs in survivors of COVID‐19 infection: A cross‐sectional evaluation

There is currently very limited information on the nature and prevalence of post‐COVID‐19 symptoms after hospital discharge.

Kingdom has been one of the worst affected countries with over 286 000 confirmed cases and more than 44 000 confirmed deaths at the time of writing. 1 COVID-19 is caused by the coronavirus SARS-CoV-2 and presents with a wide spectrum of clinical symptoms. Wu and McGoogan 2 reported that 81% of people with COVID-19 in China presented with mild symptoms; 14% presented with symptoms of severe respiratory dysfunction; and 5% developed a critical illness with respiratory failure, septic shock, and multiple organ dysfunction or failure.
The medium and long-term problems experienced by survivors of COVID-19 after discharge from hospital are currently unknown, but there is some emerging evidence. An Italian study followed-up 143 individuals 7 weeks postdischarge and found 53% reporting fatigue, 43% breathlessness, and 27% joint pain. 3  At 1 year, posttraumatic stress disorder (PTSD), depression and anxiety, and reduced quality of life were observed. This study suggested that the impact of COVID-19 is likely to be similar.
We believe that it is vital to develop rehabilitation services to address the impact of COVID-19 in people who survive the infection.
In the United Kingdom, guidance from NHS England on the needs of COVID-19 survivors predicts a high burden of physical, neuropsychological, and social need following discharge, drawing largely from literature on Acute Respiratory Distress Syndrome. 5 However, COVID-19 is a truly multisystem disease, with common extrarespiratory complications affecting the cardiac (arrhythmias and myocardial injury), renal (acute kidney injury), gastrointestinal, nervous (neuropathy, encephalopathy), endocrine and musculoskeletal (weakness, pain, and fatigue) systems. 6 Specific data concerning the rehabilitation needs of this group is therefore urgently required.
To inform service development, our multidisciplinary rehabilitation team examined the impact of COVID- 19  We were particularly keen to evaluate the needs of participants who were treated in the intensive care unit (ICU) at any point during their hospital admission. Participants who received treatment on the ICU were expected to present as a distinct group with more severe needs, therefore, as many as possible of this group were included in follow-up.
Participants who had received ward-based care were then selected randomly from the list and we continued to recruit participants until a total of 100 participants had been successfully followed up. Our results are presented with two groups disaggregated participants who received ward-level care only (who will be referred to as "ward group") and participants who received ICU treatment ("ICU group").

| Development of the telephone screening tool
A COVID-19 rehabilitation telephone screening tool was developed by the multidisciplinary team using an iterative peer review process. Domains captured in the tool were breathlessness, fatigue, swallowing, nutrition, voice quality, laryngeal sensitivity, communication, PTSD disorder, continence, cognition, perceived health status, vocation, and family/carers' views. The impact of each domain on the participant functioning was graded using a Likert scale to assess the impact pre-and post-COVID-19 disease. Additionally, the domains of mobility, personal care, usual activities, pain and anxiety/depression were addressed using the EQ-5D-5L Version for Interviewer Administration. 7 A version of the telephone screening tool has been mapped to WHO ICF Framework and been shown to incorporate all domains. 8,9 2.4 | Telephone follow-up of patients postdischarge Demographic data and admission details of the 100 identified participants were extracted from electronic patient records using a predetermined pro forma. Members of the COVID-19 rehabilitation multidisciplinary team (MDT) conducted telephone follow-up using the screening tool. Patients were called at various times throughout the day to allow for increased chances of success with calls. Informed verbal consent was taken to proceed with the telephone consultation. Patients were directed to self-management resources, given specialist advice, and referred to relevant rehabilitation services as required. The completed Microsoft Word telephone screening tool was uploaded to the patients' electronic records and imported to a Microsoft Excel spreadsheet.
Patient information was stored securely and accessed via NHS computers. Only the relevant and necessary patient data was shared with individual clinicians involved in conducting the telephone surveys, via secure nhs.net email systems.

| Analysis
Data analysis was carried out using Microsoft Excel with descriptive statistics. Mean (and SD) is used to present average values for normal data and median (and interquartile range) used to present nonnormal data. Prevalence is reported as number of and percentage of patients reporting the symptom within the group (ICU or ward).

| RESULTS
One hundred and ninety-one potential participants were identified from the central list, 33 were deemed inappropriate for telephone follow-up due to dementia, cognitive impairment or receiving palliative care; 56 had wrong numbers or did not answer repeated phone calls; and 2 declined to participate. One hundred participants completed the telephone screen over a 4-week period from May to June 2020. Participants were between 29 and 71 days postdischarge (mean 48 days and SD 10.3 days).
Demographics and comorbidities (pre-COVID-19) of the cohort are displayed in Table 1. Table 2 provides details of the index admission. Patients predominantly had single-organ (respiratory) dysfunction requiring oxygen or noninvasive ventilation and only one patient in this cohort was intubated. This low rate of intubation reflects the timing of this study in relation to the pandemic wave seen in our hospitals. As such, those who required intubation had largely not been discharged for long enough to be included in this study.
The prevalence of reported problems detected on telephone screening after hospital discharge are reported in Table 3 and Figure 1

| Fatigue
Extremely high levels of fatigue were reported. The severity of the impact of this fatigue was high, with a mean rating of 4.8 out of 10 across both groups. Moderate or severe fatigue (rated 4 + /10) was reported more frequently by female patients than male patients in both groups. Overall, 61% of those with moderate or severe fatigue were female and 54.3% of all female patients reported moderate or severe fatigue, compared to 29.6% of male patients. There was no marked difference in ethnicity or body mass index (BMI) between those with moderate to severe fatigue and those without. In the ward T A B L E 1 Demographics and pre-COVID-19 comorbidities of patients discharged from hospital following COVID-19 infection  This duration of symptom persistence appears to be greater than that seen in community-acquired bacterial pneumonia. A longitudinal study of time to symptom recovery in patients with communityacquired pneumonia hospitalized for an identical median length of stay to our ward group (6 days) found that on average patients had recovered 97% of their symptoms by 10 days. 11 A further longitudinal study including 201 patients hospitalized with community-acquired pneumonia showed that breathlessness settled after an average of 14 days from symptom onset, and fatigue after 20 days. 12 The findings in this study are similar to the Italian COVID-19 Post-Acute Care Study. 3 Fatigue, breathlessness, joint pain, and reduced QoL were the most common problems observed in that prospective study involving 143 individuals. Our study in addition measures the severity of symptoms and rehabilitation needs of the individuals. We have also investigated the difference between ward and ICU-managed individuals.
Current literature on previous coronavirus outbreaks also suggests similar postdischarge symptoms. A systematic review and meta-analysis of the short-and long-term clinical outcomes after SARS and MERS identified respiratory compromise, reduced exercise tolerance, PTSD, and reduced QoL as key issues in survivors, which can persist up to 12 months after hospital discharge. 4 However, our results contrast with an early report of COVID-19 postdischarge symptoms, which emerged from China. 13 A prospective cohort study of 131 COVID-19 patients who had been discharged from hospital in Wuhan found that by 3 to 4 weeks postdischarge 86% of patients were symptom-free, only 1.5% had shortness of breath and 0% had fatigue. This study had a younger population (median age 49) with less comorbidity than that presented in our study; however, the magnitude of the differences seen between these findings suggest additional factors. The fact that this study was oriented around detecting ongoing transmissibility, and patients were also questioned on their quarantine status and contacts raises the possibility of underreporting.
Fatigue is a multidimensional health problem, which overlaps with breathlessness, cognitive dysfunction, and psychological distress as demonstrated in this study (those with moderate or severe fatigue F I G U R E 2 EQ-5D 5 L scores in the ward group pre-and post-COVID-19 (each domain of EQ-5D 5 L is scored on a 5-point scale: 1, no problem; 2, slight problem; 3, moderate problem; 4, severe problem; and 5, unable to do) had higher incidence of these symptoms).  To conclude, COVID-19 is a new illness, with symptoms postdischarge yet to be researched. This study is first of its kind to capture these symptoms in a cohort of patients discharged from a large tertiary teaching hospital. New illness-related fatigue, breathlessness, and psychological distress were commonly reported with greater prevalence in those needing ICU care when compared with those managed in wards without needing ICU treatment. There was a clinically significant drop in quality of life in many participants. Rehabilitation care for COVID-19 survivors must, therefore, be needfocused, delivered by specialist MDT and planned for the longer term to meet the needs of these individuals.