General Clinical Considerations
Evaluating and Caring for Patients with Post-COVID Conditions: Interim Guidance
Follow-Up Care from Hospital Admission
For patients who were hospitalized for COVID-19, follow-up visits should be arranged in accordance with general standard practice, optimally within 1–2 weeks of hospital discharge. The visit should include medication reconciliation, discussion of the clinical course prior to, during, and after the hospitalization, and a comprehensive physical examination. Healthcare professionals should consider additional evaluation for other specific illnesses as indicated, such as impaired renal function, critical illness myopathy and polyneuropathy, residual cardiac or pulmonary manifestations, and psychiatric sequelae (e.g., post-traumatic stress disorder [PTSD]), among other possible conditions, particularly among patients admitted to the intensive care unit (ICU). Approaches to evaluating and managing post-intensive care syndrome (PICS), including consultation with physiatry, may be helpful for patients who experience physical, cognitive, and mental health challenges following an ICU stay for COVID-19.(21)
Healthcare professionals should consider additional follow-up visits as indicated by on-going need. Studies suggest that approximately 9–15% of patients who were hospitalized with COVID-19 are readmitted within two months of discharge, and nearly 30% are readmitted within six months of discharge, underscoring the need for close follow-up in the months after initial hospital discharge, whether for post-COVID conditions or for other health concerns.(22-24) Reasons for hospital readmission in these patients have included respiratory distress, sepsis, pneumonia, heart failure, thrombotic episodes, psychiatric illness, and falls, among other causes.(25, 26) Risk factors for readmission have included older age, certain underlying conditions (e.g., chronic obstructive pulmonary disease, hypertension), shorter initial length of stay, and lower rates of in-hospital treatment-dose anticoagulation.(27, 28) Resources are available for up-to-date information concerning COVID-19-associated hypercoagulability, including management of anticoagulationexternal icon.
Follow-Up Care for COVID-19 Treated in an Outpatient Setting
Some patients who were asymptomatic or mildly to moderately ill with COVID-19 may develop new, continued, or worsening symptoms and conditions following their acute infection. A workup can be conducted to establish history of COVID-19 based on earlier clinical illness and antibody testing, recognizing that persons with COVID-19 can have asymptomatic infection and that among persons with diagnosed SARS-CoV-2 as many as 10-20% (29, 30) may have no detectable antibodies (see the Assessment and Testing section).
Patients with asymptomatic infection to moderate illness might benefit from follow-up within 3–4 weeks from initial infection if they experience ongoing or new symptoms. For children or adolescents, many of whom have had asymptomatic to mild infection, the American Academy of Pediatrics (AAP) has developed interim guidance on return to physical activity/sports.(31)
General Post-COVID Care Considerations
Many post-COVID conditions can be diagnosed clinically based on history and findings on physical examination. Others might require directed diagnostic testing with the understanding that such clinical assessments may be uninformative and that potential harms could arise from excessive testing such as the increased risk for incidental findings, anxiety about abnormal results that do not have clinical significance, imaging-related radiation exposure, and cost. For most patients with possible post-COVID conditions, healthcare professionals might choose a conservative diagnostic approach in the first 4 to 12 weeks following SARS-CoV-2 infection. Laboratory and imaging studies can often be normal or nondiagnostic in patients experiencing post-COVID conditions and symptoms may improve or resolve during the first few months after acute infection in some patients, further supporting an initial conservative approach to diagnostic testing. However, workup and testing should not be delayed when there are signs and symptoms of urgent and potentially life-threatening clinical conditions (e.g., pulmonary embolism, myocardial infarction, pericarditis with effusion, stroke, renal failure). Symptoms that persist beyond three months should prompt further evaluation.
Most post-COVID conditions can be diagnosed and managed by primary care providers,(32-34) and a patient-centered medical home modelexternal icon could be helpful, with coordinated comprehensive care and open communication among a core group of specialty care providers and support services (e.g., occupational therapy, physical therapy, social work) to maximize functional improvement and rehabilitation efforts. Healthcare professionals may also consider referral to multidisciplinary post-COVID care centers, where available, for additional care considerations. Multidisciplinary post-COVID care centers based in a single physical location can provide a comprehensive and coordinated treatment approach to COVID-19 aftercare.(1, 35-38) Based on clinical evaluation and response to treatment, healthcare professionals might consider using a stepwise approach to other specialist referrals. Healthcare professionals should be mindful of the additional burden (e.g., financial, time, and psychological burden) multiple specialist visits may place on patients and the possibility of fragmented care that can increase the risk of contradictory medical advice.
Approaches that incorporate telemedicine, including phone calls and virtual visits, can be helpful for ongoing follow-up and might lessen the burden on patients with limited energy from post-COVID conditions or who have other concerns about in-person visits. Although an in-person initial assessment might be ideal, under some circumstances it may not be possible. Evaluation and care should not be delayed if only telemedicine options are available.
Effective post-COVID care might include:
- Providing holistic patient-centered management approaches to improve patient quality of life and function and partnering with patients to identify achievable health goals.
- Facilitating standardized, trauma-informed approaches to assessing symptoms and conditions.
- Setting expectations with patients and their families that outcomes from post-COVID conditions differ among patients. Some patients may experience symptom improvement within the first three months, whereas others may continue to experience prolonged symptoms.
- Continuing follow-up over the course of illness, with considerations of broadening the testing and management approach over time if symptoms do not improve or resolve, while remaining transparent that there is much more to learn about post-COVID conditions.
- Establishing partnerships with specialists for physical and mental health care, when needed, which may include comprehensive rehabilitation services.
- Connecting patients to social services when available, including assistance for other hardships (e.g., financial, family illness, bereavement, caregiving) and resources on disability and reasonable accommodations for work or school, and connections to patient support groups.
Overall, it is important for healthcare professionals to listen to and validate patients’ experiences, recognizing that diagnostic testing results may be within normal ranges even for patients whose symptoms and conditions negatively impact their quality of life, functioning (e.g., with activities of daily living), and ability to return to school or work.
- Nalbandian A, Sehgal K, Gupta A, Madhavan MV, et al. Post-acute COVID-19 syndrome. Nat Med. 2021 Apr;27(4):601-615. doi:10.1038/s41591-021-01283-zexternal icon
- Policy Brief 39 – In the Wake of the Pandemic Preparing for Long COVID. Accessed at: https://apps.who.int/iris/bitstream/handle/10665/339629/Policy-brief-39-1997-8073-eng.pdfexternal icon
- Huang Y, Pinto MD, Borelli JL, et al. COVID Symptoms, Symptom Clusters, and Predictors for Becoming a Long-Hauler: Looking for Clarity in the Haze of the Pandemic. medRxiv. 2021 Mar 5. doi: 10.1101/2021.03.03.21252086external icon
- Havervall S, Rosell A, Phillipson M, Mangsbo SM, Nilsson P, Hober S, Thålin C. Symptoms and Functional Impairment Assessed 8 Months After Mild COVID-19 Among Health Care Workers. JAMA. 2021 Apr 7. doi:10.1001/jama.2021.5612external icon
- Office of National Statistics. Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK: 1 April 2021. Accessed at: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/prevalenceofongoingsymptomsfollowingcoronaviruscovid19infectionintheuk/1april2021external icon
- Chevinsky JR, Tao G, Lavery AM, et al. Late conditions diagnosed 1-4 months following an initial COVID-19 encounter: a matched cohort study using inpatient and outpatient administrative data - United States, March 1-June 30, 2020. Clin Infect Dis. 2021 Apr 28. doi: 10.1093/cid/ciab338external icon
- Hernandez-Romieu AC, Leung S, Mbanya A, et al. Health Care Utilization and Clinical Characteristics of Nonhospitalized Adults in an Integrated Health Care System 28-180 Days After COVID-19 Diagnosis - Georgia, May 2020-March 2021. MMWR Morb Mortal Wkly Rep. 2021 Apr 30;70(17):644-650. doi: 10.15585/mmwr.mm7017e3external icon
- Lund LC, Hallas J, Nielsen H, Koch A, Mogensen SH, Brun NC, Christiansen CF, Thomsen RW, Pottegård A. Post-acute effects of SARS-CoV-2 infection in individuals not requiring hospital admission: a Danish population-based cohort study. Lancet Infect Dis. 2021 May 10. doi:10.1016/S1473-3099(21)00211-5external icon
- Huang C, Huang L, Wang Y, et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet. 2021 Jan 16;397(10270):220-232. doi:10.1016/S0140-6736(20)32656-8external icon
- Pavli A, Theodoridou M, Maltezou HC. Post-COVID syndrome: Incidence, clinical spectrum, and challenges for primary healthcare professionals. Arch Med Res. 2021 May 4. doi:10.1016/j.arcmed.2021.03.010external icon
- Cabrera Martimbianco AL, Pacheco RL, Bagattini ÂM, et al. Frequency, signs and symptoms, and criteria adopted for long COVID: a systematic review. Int J Clin Pract. 2021 May 11:e14357. doi:10.1111/ijcp.14357external icon
- Rando HM, Bennett TD, Byrd JB, et al. Challenges in defining Long COVID: Striking differences across literature, Electronic Health Records, and patient-reported information. medRxiv. 2021 Mar 26. doi:10.1101/2021.03.20.21253896external icon
- Office of National Statistics. Update on long COVID prevalence estimate. Accessed at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/962830/s1079-ons-update-on-long-covid-prevalence-estimate.pdfexternal icon
- Buonsenso D, Munblit D, De Rose C, et al. Preliminary evidence on long COVID in children. Acta Paediatr. 2021 Apr 9. doi:10.1111/apa.15870external icon
- Say D, Crawford N, McNab S, et al. Post-acute COVID-19 outcomes in children with mild and asymptomatic disease. Lancet Child Adolesc Health. 2021 Apr 20. doi:10.1016/S2352-4642(21)00124-3external icon
- Osmanov I, Spiridonova E, Bobkova P, et al. Risk factors for long covid in previously hospitalised children using the ISARIC Global follow-up protocol: A prospective cohort study. medRxiv. 2021 Apr 26. doi:10.1101/2021.04.26.21256110external icon
- Assaf G, Davis H, McCorkell L, et al. What does COVID-19 recovery actually look like? An analysis of the prolonged COVID-19 symptoms survey by Patient-Led Research Team. Patient Led Research for COVID-19, 2020. external icon
- Lam MH, Wing YK, Yu MW, et al. Mental morbidities and chronic fatigue in severe acute respiratory syndrome survivors: long-term follow-up. Arch Intern Med. 2009 Dec 14;169(22):2142-7. doi:10.1001/archinternmed.2009.384external icon
- Lee SH, Shin HS, Park HY, et al. Depression as a Mediator of Chronic Fatigue and Post-Traumatic Stress Symptoms in Middle East Respiratory Syndrome Survivors. Psychiatry Investig. 2019 Jan;16(1):59-64. doi:10.30773/pi.2018.10.22.3.external icon
- Lambert N, Survivor Corps, El-Azab SA, et al. COVID-19 Survivors’ Reports of the Timing, Duration, and Health Impacts of Post-Acute Sequelae of SARS-CoV-2 (PASC) Infection. medRxiv 2021.03.22.21254026; doi:10.1101/2021.03.22.21254026external icon
- Colbenson GA, Johnson A, Wilson ME. Post-intensive care syndrome: impact, prevention, and management. Breathe (Sheff). 2019 Jun;15(2):98-101. doi:10.1183/20734735.0013-2019external icon
- Lavery AM, Preston LE, Ko JY, et al. Characteristics of Hospitalized COVID-19 Patients Discharged and Experiencing Same-Hospital Readmission - United States, March-August 2020. MMWR Morb Mortal Wkly Rep. 2020 Nov 13;69(45):1695-1699. doi: 10.15585/mmwr.mm6945e2
- Chopra V, Flanders SA, O'Malley M, et al. Sixty-Day Outcomes Among Patients Hospitalized With COVID-19. Ann Intern Med. 2020 Nov 11. doi: 10.7326/M20-5661external icon
- Ayoubkhani D, Khunti K, Nafilyan V, et al. Post-covid syndrome in individuals admitted to hospital with covid-19: retrospective cohort study. BMJ. 2021 Mar 31;372:n693. doi:10.1136/bmj.n693external icon
- Atalla E, Kalligeros M, Giampaolo G, et al. Readmissions among patients with COVID-19. Int J Clin Pract. 2020 Sep 7:e13700. doi:10.1111/ijcp.13700external icon
- Donnelly JP, Wang XQ, Iwashyna TJ, et al. Readmission and Death After Initial Hospital Discharge Among Patients With COVID-19 in a Large Multihospital System. JAMA. 2021 Jan 19;325(3):304-306. doi:10.1001/jama.2020.21465external icon
- Somani SS, Richter F, Fuster V, et al. Characterization of Patients Who Return to Hospital Following Discharge from Hospitalization for COVID-19. J Gen Intern Med. 2020 Oct;35(10):2838-2844. doi:10.1007/s11606-020-06120-6external icon
- Jeon WH, Seon JY, Park SY, et al. Analysis of Risk Factors on Readmission Cases of COVID-19 in the Republic of Korea: Using Nationwide Health Claims Data. Int J Environ Res Public Health. 2020 Aug 12;17(16). doi:10.3390/ijerph17165844external icon
- Akinbami LJ, Petersen LR, Sami S, et al. COVID-19 symptoms and SARS-CoV-2 antibody positivity in a large survey of first responders and healthcare personnel, May-July 2020. Clin Infect Dis. 2021 Jan 30. doi:10.1093/cid/ciab080external icon
- Petersen LR, Sami S, Vuong N, et al. Lack of antibodies to SARS-CoV-2 in a large cohort of previously infected persons. Clin Infect Dis. 2020 Nov 4.
- American Academy of Pediatrics. COVID-19 Interim Guidance: Return to Sports and Physical Activity. Accessed at: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-interim-guidance-return-to-sports/external icon
- Greenhalgh T, Knight M, A’Court C, et al. Management of post-acute covid-19 in primary care. BMJ. 2020;370:m3026. doi:10.1136/bmj.m3026external icon
- COVID-19 Rapid Guideline: Managing the Long-Term Effects of COVID-19. Accessed at: https://www.nice.org.uk/guidance/NG188external icon
- Sisó-Almirall A, Brito-Zerón P, Conangla Ferrín L, et al. Long Covid-19: Proposed Primary Care Clinical Guidelines for Diagnosis and Disease Management. Int J Environ Res Public Health. 2021 Apr 20;18(8). doi:10.3390/ijerph18084350external icon
- Parkin A, Davison J, Tarrant R, et al. A Multidisciplinary NHS COVID-19 Service to Manage Post-COVID-19 Syndrome in the Community. J Prim Care Community Health. 2021 Jan-Dec;12:21501327211010994. doi:10.1177/21501327211010994external icon
- Brigham E, O'Toole J, Kim SY, et al. The Johns Hopkins Post-Acute COVID-19 Team (PACT): A Multidisciplinary, Collaborative, Ambulatory Framework Supporting COVID-19 Survivors. Am J Med. 2021 Apr;134(4):462-467.e1. doi:10.1016/j.amjmed.2020.12.009external icon
- Santhosh L, Block B, Kim SY, Raju S, Shah RJ, Thakur N, Brigham EP, Parker AM. How I Do It: Rapid Design and Implementation of Post-COVID-19 Clinics. Chest. 2021 Mar 31. doi:10.1016/j.chest.2021.03.044external icon
- O'Brien H, Tracey MJ, Ottewill C, et al. An integrated multidisciplinary model of COVID-19 recovery care. Ir J Med Sci. 2021 May;190(2):461-468. doi:10.1007/s11845-020-02354-9external icon
- Lopez-Leon S, Wegman-Ostrosky T, Perelman C, et al. More Than 50 Long-Term Effects of COVID-19: A Systematic Review and Meta-Analysis. Res Sq. 2021 Mar 1. doi:10.2139/ssrn.3769978external icon
- Al-Aly Z, Xie Y, Bowe B. High-dimensional characterization of post-acute sequalae of COVID-19. Nature. 2021 Apr 22. doi:10.1038/s41586-021-03553-9external icon
- Sudre CH, Murray B, Varsavsky T, et al. Attributes and predictors of long COVID. Nat Med. 2021 Apr;27(4):626-631. doi:10.1038/s41591-021-01292-yexternal icon
- Lund LC, Hallas J, Nielsen H, et al. Post-acute effects of SARS-CoV-2 infection in individuals not requiring hospital admission: a Danish population-based cohort study. Lancet Infect Dis. 2021 May 10. doi:10.1016/S1473-3099(21)00211-5external icon
- Carfì A, Bernabei R, Landi F, et al. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020 Aug 11;324(6):603-605. doi:10.1001/jama.2020.12603external icon
- Cellai M, O'Keefe JB. Characterization of Prolonged COVID-19 Symptoms in an Outpatient Telemedicine Clinic. Open Forum Infect Dis. 2020 Oct;7(10):ofaa420. doi:10.1093/ofid/ofaa420external icon
- Logue JK, Franko NM, McCulloch DJ, et al. Sequelae in Adults at 6 Months After COVID-19 Infection. JAMA Netw Open. 2021 Feb 1;4(2):e210830. doi:10.1001/jamanetworkopen.2021.0830external icon
- del Rio C, Collins LF, Malani P. Long-term health consequences of COVID-19. JAMA. 2020. doi:10.1001/jama.2020.19719external icon
- Taquet M, Geddes JR, Husain M, et al. 6-month neurological and psychiatric outcomes in 236 379 survivors of COVID-19: a retrospective cohort study using electronic health records. Lancet Psychiatry. 2021 May;8(5):416-427. doi:10.1016/S2215-0366(21)00084-5external icon
- Barker-Davies RM, O'Sullivan O, Senaratne KPP, et al. The Stanford Hall consensus statement for post-COVID-19 rehabilitation. Br J Sports Med. 2020 Aug;54(16):949-959. doi:10.1136/bjsports-2020-102596external icon
- Li Z, Zheng C, Duan C, et al. Rehabilitation needs of the first cohort of post-acute COVID-19 patients in Hubei, China. Eur J Phys Rehabil Med. 2020 Jun;56(3):339-344. doi: 10.23736/S1973-9087.20.06298-X. PMID: 32672029. doi:10.23736/s1973-9087.20.06298-xexternal icon
- Daynes E, Gerlis C, Chaplin E, et al. Early experiences of rehabilitation for individuals post-COVID to improve fatigue, breathlessness exercise capacity and cognition - A cohort study. Chron Respir Dis. 2021 Jan-Dec;18:14799731211015691. doi:10.1177%2F14799731211015691external icon
- Berger Z, Altiery DE Jesus V, Assoumou SA, et al. Long COVID and Health Inequities: The Role of Primary Care. Milbank Q. 2021 Mar 30. doi:10.1111/1468-0009.12505external icon
- Waltenburg MA, Victoroff T, Rose CE, et al. Update: COVID-19 Among Workers in Meat and Poultry Processing Facilities ― United States, April–May 2020. MMWR Morb Mortal Wkly Rep 2020;69:887-892. Accessed at: https://www.cdc.gov/mmwr/volumes/69/wr/mm6927e2.htm
- DT Arnold, A Milne, E Samms, et al. Are vaccines safe in patients with Long COVID? A prospective observational study. medRxiv. 2021 March 11; 21253225. Accessed at: https://www.medrxiv.org/content/10.1101/2021.03.11.21253225v2external icon
- Santoli JM, Lindley MC, DeSilva MB, et al. Effects of the COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and Administration - United States, 2020. MMWR Morb Mortal Wkly Rep. 2020 May 15;69(19):591-593.