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Assessing long-term rehabilitation needs in COVID-19 survivors using a telephone screening tool (C19-YRS tool)

The COVID-19 pandemic has caused more than 5 million infections and 300,000 deaths worldwide. Many survivors of the illness are likely to have long-term symptoms and disability that will pose a significant burden to the healthcare systems and economies all over the world. Given the scale of the burden and lockdown measures in most countries, there is a need for a pragmatic tele-assessment tool to screen for needs and target rehabilitation interventions in time. A comprehensive multi-system telephone screening tool called COVID-19 Yorkshire Rehabilitation Screening (C19-YRS) tool has been developed by multi-disciplinary-rehabilitation teams from Leeds, Airedale and Hull NHS Trusts to assess and capture symptoms and guide rehabilitation interventions for these individuals. The tool has been shown to cover all the components of the WHO ICF Framework. endocrine musculoskeletal pain, fatigue) systems. The long-term problems in survivors is currently unknown but lessons can be learnt from previous major coronavirus outbreaks of Severe Acute Respiratory Syndrome (SARS) in 2002 and Middle East Respiratory Syndrome (MERS) in 2012. A meta-analysis of follow-up studies in SARS and MERS show reduced lung function and reduced exercise capacity in up to one-fourth of survivors at 6 months after discharge from hospital. 3


Introduction
The first cases of Coronavirus disease 2019 (COVID-19) were reported in Wuhan in Dec 2019 rapidly spreading to other countries and was declared a pandemic by the World Health Organisation (WHO) on 11 th March 2020. The United Kingdom is one of the worst affected countries with over 250,000 infected cases and more than 35,000 deaths at the time of writing this article. The condition is a respiratory illness caused by coronavirus SARS-CoV-2 and presents with a clinical spectrum that varies from asymptomatic or mildly symptomatic forms to life-threatening multi-organ failure and death. Wu et al (2020) reported that majority (81%) of cases have a mild presentation with either no symptoms or mild upper respiratory tract infection symptoms. 1 About 14% of cases have severe disease with dyspnoea, increased respiratory rate, hypoxia and/or lung infiltrates within 24-48 hours. A small but significant minority (5%) develop critical disease with respiratory failure, septic shock and/or multiple organ dysfunction/failure needing management in ITU. Case fatality rate has been reported to range between 2% and 10% in different countries depending on extent of testing and reporting of deaths related to the infection. COVID-19 is truly a multi-system illness with known common complications affecting the respiratory system (ARDS), cardiac (arrhythmias, myocardial injury), renal (acute kidney injury), gastrointestinal, nervous (neuropathy, encephalopathy), endocrine and musculoskeletal (weakness, pain, fatigue) systems. 2 The long-term problems in survivors is currently unknown but lessons can be learnt from previous major coronavirus outbreaks of Severe Acute Respiratory Syndrome (SARS) in 2002 and Middle East Respiratory Syndrome (MERS) in 2012. A meta-analysis of follow-up studies in SARS and MERS show reduced lung function and reduced exercise capacity in up to one-fourth of survivors at 6 months after discharge from hospital. 3 Mental health problems including post-traumatic stress disorder, anxiety and depression were observed in around one-third of survivors at 12 months after discharge. The quality of life was observed to be low even one year after discharge from the hospital. This research recommends rehabilitation clinicians and services to anticipate similar long-term health problems in survivors of COVID-19, investigate them accordingly and plan timely treatments to enable best possible recovery and quality of life for survivors. 3 The NHS Long Term Plan (2019) pledges to improve outcomes for those with serious conditions by investing in out-of-hospital care and community services. 4 The emphasis is to provide personalised digitally-enhanced care that can be sustained long-term. Managing the aftermath of COVID-19 will require a holistic, multidisciplinary team (MDT)-led integrated care in the community, whilst minimising face to face contact. Telemedicine is a well-established method of assessing, monitoring and providing interventions in a wide range of health conditions. Applying telemedicine to the current challenge of aftercare in the COVID-19 pandemic is an obvious choice for healthcare services across the globe.

Aims
We have developed a telephone screening tool (C19-YRS) for the rehabilitation clinician to capture the multi-system impairments and functioning in these individuals and use it as an intervention guide to provide needed support in the community.

Methods
The tool was developed by multidisciplinary teams of clinicians involved in providing COVID-19 rehabilitation care across the three regions of Yorkshire: West Yorkshire (Leeds Teaching Hospitals NHS Trust and Leeds Community Healthcare NHS Trust); North Yorkshire (Airedale NHS Foundation Trust) and East Yorkshire (Hull Hospitals NHS Trust). The teams comprised of physiotherapists, occupational therapists, speech and language therapists, psychologists, dietitians and physicians in Rehabilitation Medicine. Specialists from Respiratory Medicine and Intensive Care Medicine were also consulted.
These teams used virtual meeting methods to discuss and finalise a list of potential long-term problems after Covid-19 infection based on their clinical experience of managing these patients and also from reviewing the literature on SARS and MERS follow-up studies. Through an iterative process they then decided on best pragmatic questions that would capture these domains concisely, without placing undue burden on the patient in the telephone screening process.
The final list of main problems identified by the specialists included breathlessness, voice, swallowing, nutrition, mobility, fatigue, personal care, usual activities, pain/discomfort, anxiety, depression, post-traumatic stress disorder, continence, cognition, perceived health status and family/carers views.

The C19-YRS screening tool
The tool is administered by a specialist clinician who is suitably trained to provide advice and suggestions to the patient during the telephone call (can also be done via video call). Consent of the patient is sought at the beginning of the interview. There are 19 questions capturing the main problems identified by the MDT, each with either yes/no response options and/or ordinal scale 0-10 grading response (Fig 1). The patient is also asked to provide a response for some symptom pre-illness (pre-COVID-19) if possible (this is not mandatory and will be difficult for those with cognitive impairment).
Two introductory questions address medical problems since discharge and utilisation of healthcare services including re-admission to acute care hospital. The structured questions follow, and the tool ends with the opportunity to capture any other new problems or consultation discussions in free text recording. The questionnaire can also be completed (even if not all questions) by family members or carers if the patient is unable to do the telephone consultation themselves due to cognitive or language impairments. The respondent is asked for consent to be called again for future follow-up telephone assessments. The clinician also provides specialist advice and directs the patient to local resources or services which are captured in the free text options of the tool. The tool took around 15 minutes to administer in some of our initial telephone consultations.

Discussion
The C19-YRS telephone screening tool captures the main potential long-term clinical problems COVID-19 survivors are likely to encounter after discharge from acute care services. It is a quick screening tool to be administered over a telephone (or video call) interview and not aimed at this stage to be a valid outcome measure on its own for this population. The tool is likely to be further developed in an iterative fashion based on clinicians' experiences during the consultations and suitable changes will be made to suit the needs and expectations of COVID-19 survivors.

Mapping of tool to the ICF framework
The World Health Organisation (WHO)'s International Classification of Functioning, Disability and Health (ICF) provides us with a framework to understand the relationship between different aspects of any health condition. 5 The domains covered by the C19-YRS tool when mapped to the components of ICF (Fig 2) shows that there is satisfactory capture of all the components (body functions and structures, activities, participation, environmental factors and personal factors) making it suitable for a comprehensive biopsychosocial assessment.

Integration of services
The telephone screen can be administered by rehabilitation clinicians across the hospital and community Trusts. This promotes seamless care for these individuals after discharge from hospital. These work stream have been set up to support the survivors during the pandemic and in the long run will provide a model of integrated MDT follow-up for a wide range of other patient groups, in line with the NHS longterm plan.

COVID-19 MDT Rehabilitation Team
An ideal MDT Rehabilitation Team ( Table 2) should have specialists trained in managing aspects of care of these individuals' and those with skills in managing chronic conditions. The team needs to have strong links with Respiratory Medicine and Intensive Care Unit teams and together develop network pathways for provision of appropriate care to these patients.

Information technology and data sharing
The completed tool can be uploaded to the patient's electronic records by the clinician conducting the telephone consultation. Both acute and community Trusts in Yorkshire have full integrated electronic medical records that are accessible to each other and also to patient's GP service. C19-YRS tool has also been programmed to automatically export responses into a Microsoft Excel file to avoid the need for manual data input. This allows rapid data analysis and generation of summary statistics.

Evaluation and next steps
C19-YRS is currently being used by at least 10 NHS Trusts in the UK to audit the long-term outcomes in Covid-19 discharged patients. Its use as a screening tool to identify those requiring additional rehabilitation interventions can be tailored depending on local pathways, services and available resources. Interventions may include immediate advice from the administering clinician, directing to online resources for further information, signposting to Adult Social Care, or making referrals to community or specialist services. The findings of the audit in all the Trusts using it are likely to influence local policy, commissioning and service delivery that is needed to manage these individuals during the pandemic.

Conclusion
A pragmatic, comprehensive tele-assessment tool C19-YRS has been developed to screen for needs and target rehabilitation interventions in Covid-19 survivors after discharge from hospital care. The tool covers the multiple body systems affected in Covid-19 and covers all domains of the WHO ICF framework.

Using the tool
The C19-YRS tool is free to use and the MS Word/ PDF copy of the tool is available on ACNR website. The programmed version that can automatically export responses to MS Excel can be requested by contacting the corresponding author of this article.