One hundred seventy-four patients were discharged from Beaumont Hospital between March 15 and June 30, 2020, after treatment for COVID-19 pneumonia. Sixty-seven percent were male with a median age (IQR) of 66.5 (51–97). Twenty-two percent were admitted to the ICU for mechanical ventilation, 11% had non-invasive ventilation or high flow oxygen on a specialist respiratory ward, and the remaining 67% had their care on a medical ward without the need for specialist respiratory support.
The COVID recovery outpatient service consists of an enhanced and virtual pathway, supported by a weekly multidisciplinary meeting involving all supporting specialties (Fig. 1). Enrolment into the service is based on a diagnosis of pneumonia on the admission chest X-ray, with a positive PCR test or a clinical diagnosis of COVID-19. All patients have a follow-up chest X-ray, blood testing, and complete a standardized phone-based assessment of symptoms, mental health status, and quality of life. Subsequently, their cases are discussed at the COVID recovery multidisciplinary meeting (MDM). All patients who were admitted to the ICU, or who required non-invasive ventilation at ward level, have enhanced follow-up at an in-person clinic. Patients who were admitted to the ward, but did not require ICU admission or non-invasive ventilation, have a virtual follow-up and are discharged to community services unless a significant residual impairment is identified. This is then discussed at the COVID recovery MDM. This multidisciplinary approach encourages appropriate discharge to integrated community care with referral to relevant community services. Patients with greater medical, rehabilitation, and psychiatric and psychological needs will have an in-person assessment and may need a follow-up in a specialized survivorship clinic for 12 months.
Virtual multidisciplinary assessment
British Thoracic Society guidelines  recommend that all patients who were admitted to the hospital with COVID-19 pneumonia receive clinical follow-up regardless of severity. The RCSI COVID recovery service will carry out an initial assessment of all patients by phone at 8–12 weeks post-discharge from the hospital or ICU. This virtual follow-up will ascertain their level of residual symptoms after COVID-19, functional capacity, quality of life scores, and the presence of mental health difficulties using a standardized questionnaire. The 36-Item Short Form Health Survey (SF-36) is a standardized evaluation of a patient’s physical and mental health status and has previously been utilized as a tool to quantify disability for survivors of acute respiratory distress syndrome (ARDS) [13, 14].
This virtual clinic is run by a physician associate (PA) with oversight and governance from respiratory and infectious diseases, psychiatry, and ICU consultants. After initial basic investigations, including chest X-ray and blood tests (full blood count, renal, liver and bone biochemistry, BNP, D-dimer, and serum sample for SARS-CoV-2 antibody), each case is discussed at the COVID recovery MDM. A consensus is reached by the MDM to triage the patient to in-person or virtual follow-up and also if mental health follow-up is required. If no further specialist follow up is necessary, patients will be discharged to their GP with community follow-up as required.
Thus far, 50 patients have been reviewed at the MDM, 26/50 have been discharged to their GP, while 24/50 will require follow-up in the in-person COVID recovery clinic and with other specialty clinics.
COVID recovery in-person clinic
Patients identified as having persistent symptoms or radiographic changes at their initial virtual clinic review are offered an in-person clinic follow-up. Patients who were critically ill due to COVID-19, i.e., requiring ICU or non-invasive ventilation, are automatically offered an in-person follow-up at 12 weeks. This cohort of patients then receives an enhanced schedule of investigations including pulmonary function testing and 6-min walk testing, and some may require a CT thorax or an echocardiogram depending on clinical indications. All of these investigations will be reviewed at the COVID recovery MDM prior to being reviewed in the in-person clinic, where a personalized management plan is created for each patient. Patients with severe functional impairments may be referred onward to the COVID survivorship clinic or to a specialist clinic as deemed necessary. The COVID recovery clinic will also receive referrals from other RCSI group hospitals for discussion at the MDM.
COVID survivorship clinic
Established guidelines recommend that all critical care survivors should be reviewed 2–3 months after discharge, with the majority requiring a follow-up to at least 1 year [15, 16]. The best practice post-ICU recommendations include a follow-up for all patients with an ICU stay of > 72 h, selected patients with an ICU stay of > 48 h, and any ICU patient with risk factors for psychological dysfunction . Many COVID-19 survivors fulfill these criteria and are an at-risk group that requires follow-up.
Although it is difficult to quantify improvement in outcomes, qualitative studies have shown improvement for patients, and subjective outcomes studies have demonstrated improvements in SF36 scores, a surrogate for quality of life .
COVID recovery mental health service
The COVID recovery service implements a brief telephone triage (Figs. 2 and 3), which includes both mental health and cognitive symptoms. Following the initial screening, those deemed in need of further mental health assessment and intervention are followed-up with stage 2 screening, which comprises of a telephone call and postal questionnaires from the COVID mental health service (COVPSYCH) team. The telephone call will include a brief objective and subjective screen of cognition. If the stage 2 screen is positive, a clinic or virtual appointment will be arranged with the COVPSYCH team within 4 weeks, whereby a full clinical assessment will be carried out, including cognitive testing where appropriate. If required, pharmacological and therapeutic intervention is instigated on a case-by-case basis.