Continued Care for COVID Recovery

[MUSIC PLAYING] Welcome, everyone. You're watching Coronavirus in Context. I'm Dr. John Whyte, chief medical officer at WebMD. We hear a lot about the care of patients with COVID. But we often don't hear about what happens to those patients who are hospitalized, perhaps put on a ventilator. What's that care after the acute setting, what we call post-acute care?

To help provide some insights, I've asked Dr. Sean Muldoon. He's the chief medical officer of Kindred Hospital Division. Dr. Muldoon, thanks for joining me.

Thank you for having me.

Let's start off with if you could explain to our audience kind of what's that time course for those patients who, you know, present seriously ill with COVID and come to the hospital? For many of them, it's not simply, you know, come in for a couple of days and-- and go home, and everything's normal. Can you talk to us about that?

Certainly. You know, one of the great mysteries about COVID is its incredibly wide range of symptoms-- symptomatic to-- to death, really. The part of that continuum that post-acute care gets involved in is that group of people sick enough to be hospitalized, and for those that come to long-term acute care hospitals probably in an intensive care unit, sometimes as extreme as requiring mechanical ventilation, requiring high levels of oxygen, requiring dialysis, just what we call multi-organ system failure as a-- as a result of COVID.

And those folks are just not going to bounce back in a short time. And so consequently, even though they're-- they're diagnosed, they need acute care treatment for a prolonged time. And because they're already figured out and they're relatively stable, they do not need all those assets of a traditional acute care hospital, either on the basis of cost or by tying up a bed that could be used for someone else in a surge. So long-term acute care hospitals become that option for those longer-stay patients.

And do we have a sense of the percentage of patients that present with COVID to the hospital ultimately needing this long-term acute care?

Well, we know that probably 10%, 15% are really, really sick, and about 10% on mechanical ventilation. And if you use that number for mechanically ventilation that does not-- is not because of COVID, then you're talking about less than 1%, certainly, and probably about 1/2%. But that is limited to that group that is actively infected and needs to come to post-acute care. There are other groups that come to post-acute care to help with the-- the-- the COVID situation that aren't actively infected. But think of it as a percent.

And you've been a big proponent of let's talk about outcomes. Let's look at quality measures. What are we seeing in, you know, post-acute care, these long-term hospital settings?

Well, on the good side-- let-- let's do the, you know, Hippocratic oath part of it, the do-no-harm part. The long-term acute care hospitals have been very good at controlling the infections. And part of that is because we've been doing the same thing for 25 years with multidrug-resistant organisms and-- and-- and the like.

So the fact that someone would come in with a respiratory pathogen that was highly infectious, as well as infective, is really not-- nothing new to us. So all of the policies and procedures related to protecting patients from each other and staff from patients and staff from each other really just had to be tweaked and-- and-- and made more wide across the entire hospital. So that-- that part was-- was important, but-- but not particularly dramatic.

On the other extreme, we have the mechanically-ventilated patient, for whom most of those folks that have come to us have been unsuccessful in their attempts to be liberated from mechanical ventilation in the short-term hospital. And so it's a group with a-- you know, as we would say, a prior probability that-- that wasn't that great. But we are doing really well with-- with those folks. And well over half-- it varies quite a bit by hospital and severity of illness-- but-- but somewhere around 60% or 70% of those folks ultimately get liberated from mechanical ventilation. It just takes time.

Liberated is a good term. I like that, because in many ways, we really want to, you know, free patients, you know, from that ventilation and intubation. You know, a lot of listeners may be wondering, hey, should my loved one, my family member go to, you know, a post-acute care hospital. Let's be realistic and talk about geography. Every place doesn't, you know, have such a facility. What guidance can you give to listeners who may have a family member with COVID in a hospital, and they're wondering what should they do about their long-term care?

Well, the first piece of advice is if you have a long-term acute care hospital in your vicinity. Look. Go to it.

How would you know that? Like, you and I know that as physicians. But-- but a listener, how do they differentiate that? It's not going to say long term.

Well, well, the-- the case managers in the hospitals absolutely know. To your question, I would say first of all, if your loved one is in for the long haul, meaning that they're stable, they are not being managed hour-to-hour, it's more a day-to-day kind of management, and it looks like it is going to require more weeks rather than more days, look into it. And when you go to that place, talk to the people. Talk to them about their infection prevention practices. Talk to their respiratory therapy director about how they address delivering medications and the protocols for liberation from mechanical ventilation.

Talk to them about other things that you don't want to happen, their wound prevention program and the ability to go on dialysis if you need it now or if you are teetering and may need it. And build those into an assessment that asks you, do I want to go to a place for whom my loved one is now at the tail end of their care in intensive care unit or short-term hospital? Or do you want to go to a place that is focused on this small group of patients who are really sick, who are going to need a few more weeks?

Now, how has COVID changed what you do? I mean, clearly, you weren't thinking this, you know, in January of this year. What's been the biggest change in your day-to-day work?

Well, as you might guess, the spring was very wild. We-- we didn't know the rules of this virus. We didn't know the behavior of this virus. We didn't know whether touching a surface and touching your eye meant you were going to get infected. We didn't-- we just didn't know the virology.

And so I spent a good bit of my time with the rest of our team just reading all these unpublished reports that-- that were coming out, just trying to build the knowledge base that would say what do we need to do? And we had a group of infectious disease doctors that practice in our long-term acute care hospitals. And they were on weekly calls with me. We were trading articles all the time. So in that way, it-- it changed everything because of the mystery, and to some degree, realistically, the fear.

In another way, it didn't change anything. We have been taking care of sick, infected people for 30 years. And it-- it was just another day at the office with just more-- more of them and more-- more mystery about what best to do. But there really was never a question of where do we start.

Well, Dr. Muldoon, I want to thank you for all that you are doing in terms of making sure that patients infected with COVID get the post-care that they need when, you know, they have had serious infection, as well as helping to shed some light. As you talked about, how do we figure out more about this novel coronavirus?

Well, I appreciate the opportunity to talk about what we do and invite people to look into us, because for many people, we are just the answer for them.

And I want to thank our viewers for watching Coronavirus in Context.