The CORE Clinic and Post-ICU Care: Q&A with Leo Ginns, MD, and George Alba, MD

As the COVID-19 pandemic continues to threaten global health, the long-term effects of the virus have become more clear. Severe complications from COVID-19, such as acute respiratory distress syndrome (ARDS), have required many patients to be transported to intensive care units (ICU), which place patients at high risk of developing post-intensive care syndrome (PICS). Patients with COVID-19 who survive an ICU stay often experience cognitive and physical impairment, as well as anxiety, depression and post-traumatic stress disorder (PTSD).

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To address this challenge, Leo Ginns, MD, director of the Center for Advanced Lung Disease in the Division of Pulmonary and Critical Care Medicine at Massachusetts General Hospital, George Alba, MD, pulmonary and critical care physician, and colleagues established the Coronavirus Recovery (CORE) Clinic, which is facilitating research on COVID-19 recovery and defining best practices for post-ICU care. In this Q&A, Drs. Ginns and Alba describe the mission and organization of the CORE Clinic and share advice on care for ICU survivors and their families.

Q: How did the CORE Clinic initially come together?

As the COVID-19 pandemic surged, health care institutions and clinicians focused on providing critical care, particularly for individuals suffering from respiratory failure due to acute respiratory distress syndrome (ARDS). According to the Centers for Disease Control and Prevention, approximately 1 in 10 patients with COVID-19 require admission to the ICU, and around 5% of all patients require mechanical ventilation for ARDS.

As patients began to recover, it became clear that all these survivors of critical illness need appropriate longitudinal care in the ambulatory setting. ICU survivors, especially patients with ARDS, and their families can experience a wide range of physical, cognitive and psychiatric impairments, collectively known as PICS. Some of these impairments can be debilitating and persist for years after the initial episode of critical illness, resulting in a poor quality of life. Based on our backgrounds and experience as pulmonary and critical care physicians, we saw an opportunity to contribute to the ambulatory care of these patients. Thus, the primary driver for establishing the CORE Clinic was the necessity for ongoing outpatient clinical care.

Patients seen in the CORE Clinic will be primarily evaluated for pulmonary problems. However, it is important to recognize the multi-system involvement with COVID-19. Screening for symptoms of anxiety, depression, PTSD and cognitive impairment are important elements of the clinic. We will also facilitate access to neurologic and/or psychiatric consultation, monitor cardiopulmonary function and attempt to promote recovery through physical therapy and pulmonary rehabilitation.

Q: What are the primary goals of the clinic?

Post-ICU clinics have a long history, beginning in the United Kingdom in the 1980s and then expanding globally, and were intended to address the unique needs of the growing population of survivors of critical illness. Our understanding of the long-term sequelae of critical illness emerged in part due to the longitudinal follow up provided by these clinics. In the same spirit, the CORE Clinic was established to investigate these clinical questions by coupling the research initiatives and the longitudinal follow up of these patients. The primary goals are to study the natural history of COVID-19 recovery and to define best practices in the management of COVID-19 survivors.

As we learn more about the recovery phase of COVID-19 in patients with pulmonary symptoms, we aim to disseminate best practices and research information to health care providers, including trainees and community physicians. We also hope to optimize considerations of ethics and equity in order to promote access to all patients, especially vulnerable communities disproportionately impacted by COVID-19.

Q: Can you describe the structure of and the patient experience within the CORE Clinic?

Patients may be referred to the CORE Clinic by their inpatient medical team prior to discharge or by their outpatient medical team. Eligible patients include anyone hospitalized with moderate-to-severe COVID-19 or any patients that have new or persistent shortness of breath following COVID-19. The first clinic visit consists of a thorough clinical history to elicit salient details of the individual's clinical course, in addition to medication reconciliation, screening for the psychological sequelae of their illness (such as symptoms of anxiety, depression and PTSD), and baseline assessment of their cardiopulmonary function with pulmonary function testing, including measurement of spirometry, lung volumes, diffusing capacity and a six-minute walk test. Follow up cardiopulmonary testing will be arranged as indicated, such as echocardiography, computed tomography (CT) of the chest or cardiopulmonary exercise testing (CPET).

The multidisciplinary nature of post-ICU clinics reflects the extent to which critical illness impacts every domain of a patient's health. By bringing together a diverse array of subspecialty clinicians, we aim to care optimally for the host of medical, mental health and social needs that can arise during the recovery from critical illness. Emerging data, published in JAMA, indicate that COVID-19 survivors may experience persistent debilitating symptoms, with half reporting ongoing fatigue and over 40% experiencing persistent shortness of breath at three months follow up.

Referral to additional specialists will also be arranged as indicated. A subset of patients may be eligible for a research study being conducted through the CORE Clinic. The study protocol will enroll patients who required ICU-level care to be seen in the clinic every three months for a year with standardized cardiopulmonary testing along with blood draws, nasal swabs and sputum samples. Patients with COVID-19 have reported persistent neurocognitive impairments of varying severity; as such, we have partnered with David Lin, MD, director of the Mass General Neurorecovery Clinic in the Department of Neurology, to evaluate these patients. Thus, in addition to providing clinical care, the CORE Clinic represents an important infrastructure to determine best practices for the care of COVID-19 survivors.

Q: What do researchers hope to learn from patient blood, nasal swabs and sputum samples?

By collecting both clinical data along with these biological specimens, we aim to link relevant clinical history, physiological data and patient health-related quality-of-life measures with important biological signatures from their samples. As we follow these patients and their samples over time, we can learn about the long-term immunologic consequences of infection with SARS-CoV-2, assess the long-term impacts of the therapies administered to patients in the hospital and profile the pathophysiology of recovery from COVID-19, all of which can aid in the development of biomarkers, vaccines and therapeutics. Additionally, as new tests and therapies emerge in the future, we can go back to these samples and study their relevance in a well-phenotyped cohort linked to long-term clinical outcomes.

Q: What factors should physicians consider when treating a critically ill patient with mental health symptoms?

Preliminary reports in patients with COVID-19 suggest the psychological ramifications are similar to the ARDS and general critical care survivorship literature. However, there a number of unique circumstances that may exacerbate the psychiatric consequences of COVID-19, including prolonged mechanical ventilation and sedation with multiple sedative-analgesics, enhanced patient-family isolation due to stringent infection control policies and the additional trauma of having multiple sick family members at one time. The key for any physician seeing a patient who has survived critical illness is to first be aware of how prevalent symptoms of anxiety, depression and PTSD are among patients and their family members. Once recognized, it is important to ensure patients and their families are linked to mental health providers for evaluation, counseling and treatment. Many regions have established peer support groups that have also been shown to aid patients and their families with the long-term mental health consequences of critical illness.

Q: What are some of the ways that physicians or organizations can screen for and address PICS in patients and family members?

PICS refers to the constellation of physical, cognitive and psychiatric sequelae experienced by survivors of critical illness. Some of these impairments can be debilitating and persist for years after the initial episode of critical illness, resulting in a poor quality of life. For example, approximately half of ICU survivors who require prolonged mechanical ventilation develop anxiety and depression, one-quarter develop PTSD and half demonstrate neurocognitive impairments that, in some, might persist for two years following hospital discharge, as reported in Critical Care Medicine.

Family members of the survivors of critical illness may also experience post-intensive care syndrome, termed PICS-family (PICS-F). While symptoms of anxiety, depression and PTSD are highly prevalent among ICU survivors and their family members, the primary barrier to their detection is under-recognition of the mental health toll of critical illness. We would recommend routine screening of all patients and their family members for symptoms of anxiety, depression and PTSD at several points following their ICU stay: on the general medical floor prior to hospital discharge; during their inpatient rehabilitation stay; and at their first outpatient follow up with their primary care physician. Due to the additional barriers to outpatient care during the COVID-19 pandemic, televisits provide a valuable mechanism to screen patients and their caregivers for PICS and PICS-F, respectively.

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