It’s been reported today that survivors of hospital admission with COVID-19 are at increased risk of readmission or even death in the 6 months following hospital discharge.
The study – by the Office for National Statistics, University College London and the University of Leicester – examined the records of nearly 48,000 people admitted to hospital between January and August 2020 and compared them with ‘matched controls’ (similar people who had been admitted to hospitals with something other than COVID-19). It found that 29.4% of survivors were readmitted to hospital and 12.3% died. Just over 10% of people included in the study had been treated in Intensive Care Units, with the majority receiving only ward-based care.
The news is alarming, but not altogether surprising. This article aims to present a balanced view and offer pragmatic advice to people who have recently survived severe COVID-19 and are, quite understandably, concerned about the news. It should be noted that the study did not look at people who had managed their symptoms at home. It’s likely that people who were not hospitalised are a lower risk, but of course not immune to the ‘adverse events’ described. These were:
The authors found that people were more likely to have one of these ‘adverse events’ if they were over 70 years of age, or from black, Asian or ethnic minority backgrounds, but of course they happened to people without underlying risk factors too.
It’s critically important to note that this article is what’s known as a preprint – as such, it hasn’t yet been through a rigorous process of peer review and might ultimately be published with different or softer conclusions, or not at all. It’s also important to note that more than half of people admitted to hospital with COVID-19 had underlying high blood pressure and more than 40% had underlying respiratory disease.
Why’s this important? Because it’s quite likely that, amongst the 1 in 5 people who had a new diagnosis of respiratory disease made after their admission with COVID-19, a proportion will have had underlying lung disease which has not previously been diagnosed (for example, the ex-smoker who had stopped because they had found they were getting a little more breathless but who hadn’t been to see their doctor). Again, adverse events did happen in otherwise healthy people but less frequently, meaning that someone who is relatively young and otherwise healthy will have a much lower risk of an adverse event than reported.
It’s already been widely reported that COVID-19 can cause long-standing damage to lungs in some sufferers, and that abnormal findings on echocardiogram (a scan which shows how well the heart is working) are identified in some survivors.
This new study also reinforces that COVID-19 is a multiorgan disease, with (for example) around 1 in 100 survivors having a ‘new’ diagnosis of diabetes and a slightly smaller number having a new diagnosis of kidney disease. Indeed, a previous study, also in the UK, found that 1 in 4 people who’d survived the disease had evidence of ‘mild’ impairment of more than one organ, with the risk being far higher in those who’d been admitted to hospital.
This is the largest and most complete study of its kind, adding hugely to the evidence around the after-effects of COVID-19. Similar studies have been previously published elsewhere, and this new study reinforces their findings. One of the most significant studies looked at just over 2,000 people discharged from 132 hospitals in North America, tracking their progress for 60 days, and found that 20% of people were readmitted and 9% died. The most common readmission diagnoses were COVID-19 (30.2%), sepsis (8.5%), pneumonia (3.1%), and heart failure (3.1%) – by far the most common reason for readmission was infection.
What was really interesting about the earlier American study was the context it offered – death or readmission within 60 days was actually less common for COVID-19 survivors than for people who’d been admitted for non-COVID pneumonia (26% vs. 32%) or for heart failure (27% vs. 37%). Although there were differences (people who were readmitted or died after COVID-19 were more likely to do so within the first 10 days after discharge), this reinforces that readmission to hospital and death after hospital admission are not rare occurrences and certainly not specific to COVID-19.
Another study from North America also reported that nearly 16% of all people admitted to hospital with any condition were readmitted within 30 days, with a much higher percentage of people readmitted (27%) if their original illness had been sepsis. The reason this is relevant is that, as a condition characterised by the immune system overreacting to an infection causing organ damage, sepsis is intrinsically interlinked with COVID-19. In the most severe cases of COVID-19, particularly those which progress to multiorgan failure, this is sepsis.
Readmission to hospital following discharge after sepsis occurs in as many as 60% of survivors within the first year. Many of these readmissions will be due to the existence of other conditions which make infection more likely, and a few from original infections which were incompletely treated. However, we also know that the risk of recurrent infection after sepsis persists for as long as seven years, and can be demonstrated in people with no other underlying risk factors for the development of infection. It’s believed that this is a consequence of a dysfunctional immune system after sepsis, possibly also contributed to by changes in the bacteria in the gut brought about by often long courses of antibiotics.
It is highly likely, therefore, that people who have survived COVID-19 are at increased risk of infections for some months or even years after the event. It is partly for this reason that, in April 2020, the UK Sepsis Trust announced its intent to provide support to survivors of COVID-19.
At the risk of repetition, it’s important that we reinforce the context. This new study examines people who were most severely ill with COVID-19, In that they had required admission to hospital. It identifies that the risk of adverse events is highest in those over 70 years of age and with underlying illness. The risk of adverse events for those who managed their symptoms at home, particularly in people who are younger and in previously good health, is likely to be substantially lower than the figures reported.
Notwithstanding this context, we should acknowledge that not only do we see chronic after-effects of COVID-19, but also sudden, or acute, deterioration. Quite rightly, people need information to guide them as to when to seek help.
We need to delineate between LongCOVID, or Post-COVID Syndrome, and these acute episodes. LongCOVID follows a prolonged and fluctuating time course, and survivors will have some reasonably good days and some very bad days. Symptoms are a mixture of physical, cognitive and psychological. There is some early, if anecdotal, evidence that people who survived COVID-19 in early 2020 are finding that they continue to improve, though of course this is not universal. Again, this recovery profile bears stark similarity to that seen after hospital admission with sepsis, meaning that the UK Sepsis Trust Support Team have directly transferable skills.
What’s important is that we help people to understand what a ‘bad day’ on their recovery journey is, and what is a critical deterioration which means that they need to get to hospital urgently.
Some aspects of LongCOVID carry risk of deterioration, particularly in those survivors with pulmonary fibrosis (lung scarring) and myocarditis (inflammation of the heart). Both conditions occur in a minority of survivors of COVID-19, and both will be characterised by ongoing breathlessness. Each of these complications can deteriorate, particularly in the early days after hospital discharge, or if they exist in combination with previous disease of these organs. However, such deterioration would tend to be gradual in most cases and not require emergency attendance at hospital. Similarly, people who have been identified as having kidney or liver damage following COVID-19 require monitoring carefully, but only in rare cases would require emergency attendance at hospital.
Most emergency readmissions to hospital following COVID-19 will be either a consequence of increasing severity of original symptoms, due to a thrombotic event (such as a blood clot in the lungs, a stroke or a heart attack) or as a consequence of a new infection or sepsis.
The following guidance is in line with current NHS England recommendations, and draws on the experience of the UK Sepsis Trust.
It is important that you also discuss your symptoms and recovery with other people, preferably people who know you well. Talking on your phone, by video messaging or through a doorway might be better than text messages – it will help them hear or see if you are becoming very much more unwell. Even if you live alone, you should arrange to contact someone regularly. Ask them to ring you, if you don’t make contact as planned, ask them to seek help.
Go straight to A&E or call 999 if:
Or if you develop one of the following symptoms (agreed with Public Health England 2016):
S lurred speech, confusion or agitation or extreme drowsiness
E xtreme pain in the muscles or joints
P assing no urine in a day
S evere breathlessness
‘I t feels like I’m going to die’
S kin that’s mottled, pale or blotchy or a rash that doesn’t fade when you press it
Severe breathlessness means that you are unable to complete short sentences when at rest due to breathlessness, or your breathing gets very much worse suddenly.
Call 111 if: