New report on functional impairment following critical illness from COVID-19


A new study by researchers from Monash University has alarmingly found that six months after recovering from COVID-19 critical illness, one in five people had died, and almost 40% of survivors had a new disability.

The study findings were published in the peer reviewed journal: Critical Care.

In this nationally representative cohort of critically ill patients with COVID-19, at 6 months, 26.9% patients died and 38.9% survivors reported new disability. In survivors, disability was widespread across all areas of functioning.

There was a significant decrease in health-related quality of life, with over one third of the cohort reporting new problems in mobility, usual activities and pain. In addition, one third of survivors had cognitive impairment and one fifth of the cohort reported anxiety, depression and/or PTSD.

More than one in ten survivors were unemployed due to poor health. Higher severity of illness and the clinical frailty score were independent predictors of death or new disability. The majority of our cohort (70%) had ongoing symptoms of COVID-19 at 6 months, most commonly shortness of breath, weakness or fatigue.

While the long-term effects of critical illness are well-recognized [23, 29, 30], the scope and scale of “Long COVID” may be greater than previously described in survivors of COVID-19. During the COVID-19 pandemic, the Australian government enacted several healthcare policies that may have influenced the characteristics and outcomes of this group of patients compared with patients from other countries.

Australia has a liberal testing policy, and until November 2020, Australia has conducted 9,670,186 COVID-19 tests, representing 377,527 tests per 1,000,000 population and with a positive rate of 0.3% [16]. As a comparison, the entire USA has a rate of 533,967 tests per 1,000,000 population, with a positive rate of 6.9% [31].

The healthcare system in Australia has not been overwhelmed due to COVID-19, and the outcomes of our survivors represent a cohort provided with care from a critical care system operating within capacity [15]. Despite this, the present data are similar to other data of COVID-19 patients in intensive care in terms of age, comorbid conditions and ARDS severity [15, 32], and suggest that COVID-19 survivorship was associated with substantial new disability and reduced health-related quality of life.

Increased disability, both in the number of patients and in the severity of functional limitations, are associated with increased caregiver burden, unemployment, psychological problems, mortality and healthcare costs [23, 29, 30]. Patients should be screened at hospital discharge for new functional impairments. Outpatient follow-up should be recommended early, within the first few weeks of discharge.

It should include medication optimization and screening for physical, psychological or cognitive problems, with referral for additional services such as physical therapy or psychology as required [11]. In the present study, new disability was present in all areas of function, particularly emotionally (such as anxiety, depression, PTSD) and walking.

We used the WHODAS, a validated outcome measure for disability, grounded in the framework of the International Classification of Functioning (ICF) which has previously been used to described the critically ill population with a defined minimum clinically important difference [23, 24, 33, 34]. The baseline disability of this relatively young cohort was very low prior to COVID-19, and there was a clinically significant increase in the level of disability at 6 months.

Recently, the COMEBAC Investigators have reported the 4-month outcomes of 478 hospitalized patients with COVID-19 in a single center in France [27]. Of this cohort, 142 had been critically ill and approximately 50% had been mechanically ventilated, similar to the present study. New onset dyspnea was one of the most common symptoms, and lung CT scan in survivors showed persistent abnormalities in 75% who had received invasive ventilation.

Similarly, in a recent single-center cohort study in China, nearly one third of the 122 critically ill patients with COVID-19 had a mean 6-min walking distance less than the lower limit of the normal range at 6 months after hospitalization [35]. In addition, 56% had diffusion impairment on pulmonary function tests. The results of both these studies are aligned with the high prevalence of shortness of breath in survivors of our cohort.

Pulmonary rehabilitation in patients with ongoing shortness of breath may improve outcomes and reduce symptoms [36]. Further, pulmonary rehabilitation may be delivered by telehealth [37,38,39], improving the access to care during a pandemic.

The strengths of this study include its prospective, multicenter design with collection of detailed clinical and physiologic parameters. We included baseline measures of frailty, health-related quality of life, disability and comorbidities to distinguish new disability and new problems. The outcome measures include validated, reliable measures of function, most of which are in a core outcome set for survivors of acute respiratory failure [22].

We acknowledge limitations to our study. A proportion of eligible patients were not available for follow-up assessment, mainly due to loss to follow-up. This was higher than similar studies of disability at 6 months from our group, and we speculate that it may be due to stigma or psychological distress associated with a positive diagnosis of COVID-19 which should be investigated further in future studies.

We contacted primary practitioners and reviewed national online resources for death notices to ensure they were not deceased. The responders had similar baseline characteristics and interventions to the non-responders, and it is likely a good representation of the overall cohort. Baseline disability and health-related quality of life were measured retrospectively in survivors, which may introduce recall bias.

There was no control group, and the outcomes of survivors of COVID-19 critical illness from this study may be similar to disability reported after critical illness from other cohorts [23, 25]. We did not conduct in-person assessments or radiological tests as part of the follow-up which would improve the understanding of sequelae of COVID-19.

TERMINOLOGY AND STAGES OF RECOVERYThe recovery process from COVID-19 exists on a continuum; early in the course of acute COVID-19, management is focused on detecting and treating acute COVID-19-related complications, while after recovery from the acute phase, some patients require evaluation and management for persistent or new symptoms.

Although there are no widely accepted definitions of the stages of COVID-19 recovery, we generally agree with the following categories as proposed by the Centers for Disease Control and Prevention (CDC) [7]:

Acute COVID-19 – Symptoms of COVID-19, up to four weeks following the onset of illness.

Post-COVID conditions – Broad range of symptoms (physical and mental) that develop during or after COVID-19, continue for ≥2 months (ie, three months from the onset), and are not explained by an alternative diagnosis.

These stages reflect symptomatic recovery and are not related to active viral infection and infectivity. (See “COVID-19: Epidemiology, virology, and prevention”, section on ‘Viral shedding and period of infectiousness’.)

Several other terms have been used to describe prolonged symptoms following COVID-19 illness, such as “long COVID,” “post-acute sequelae of SARS-CoV-2 infection (PASC),” “post-acute COVID-19,” “chronic COVID-19,” and “post-COVID syndrome” [8-12]. Despite the creation of case definitions, there are no widely accepted clinical diagnostic criteria for “long COVID” [13]. However, as of October 1, 2021, there is a new International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) for unspecified post-COVID conditions, which is U09.9, which was approved by the CDC.

Whether the constellation of symptoms and persistent issues experienced by these patients represents a new syndrome unique to COVID-19 or if there is overlap with the recovery from other infectious and critical illnesses has not been determined. The symptoms reviewed in this topic refer to those seen in any patient, including those recovering from mild, moderate, and severe (including critical) illness.

The World Health Organization has also created a global COVID-19 clinical platform case report form for clinicians and patients to collect and report information, to allow for better understanding of the spectrum of post-COVID-19 conditions and recovery [14].

The United States Department of Health and Human Services and the Department of Justice released a guidance statement on “long COVID” as a disability under the Americans with Disabilities Act, the Rehabilitation Act of 1973, and the Patient Protection and Affordable Care Act.

These acts provide protections for individuals with disabilities to allow for full and equal access to civic and commercial life. This statement classifies “long COVID” as a disability if it substantially limits, either physically or mentally, one or more major life activities. An individualized assessment is needed to determine whether a person’s symptoms fit these criteria [15].

PREVENTION OF POST-COVID CONDITIONSThe most effective means by which to prevent post-COVID conditions also is to prevent COVID-19 (eg, social distancing, masking, hand hygiene, and vaccination). It is likely that any measure that decreases the incidence or severity of acute COVID-19 infection will in turn decrease the incidence and severity of post-COVID conditions.

A case-control study found that both symptom intensity in the first week of illness and persistent symptoms, defined as symptoms at 28 days or more, were significantly less common among those who developed postvaccination SARS-CoV-2 infection compared with unvaccinated cases [16]. In addition, those who were vaccinated were more likely to be asymptomatic.


Persistent symptoms — Persistent physical symptoms following acute COVID-19 are common and typically include fatigue, dyspnea, chest pain, and cough. Patients recovering from COVID-19 may also have additional psychological (eg, anxiety, depression, posttraumatic stress disorder [PTSD]) and cognitive (eg, poor memory and concentration) symptoms, similar to the syndrome experienced by patients recovering from other critical illnesses known as post-intensive care syndrome (PICS). This syndrome is discussed in detail separately.

Studies on the prevalence of persistent symptoms are often limited by lack of control groups and surveillance, reporting, nonresponse, and selection biases.

Prolonged symptoms can follow mild or severe illness and include:

●Physical symptoms – Several observational series describe persistent symptoms in patients following acute COVID-19 with one-third or more experiencing more than one symptom (table 1) [1,4,5,17-52]. Common persistent physical symptoms include:

•Fatigue (13 to 87 percent)

•Dyspnea (10 to 71 percent)

•Chest pain or tightness (12 to 44 percent)

•Cough (17 to 34 percent)

Less common persistent physical symptoms include anosmia, joint pain, headache, sicca syndrome, rhinitis, dysgeusia, poor appetite, dizziness (from orthostasis, postural tachycardia, or vertigo), myalgias, insomnia, alopecia, sweating, and diarrhea.

●Psychological or cognitive – Psychological and cognitive complaints are also common during recovery from acute COVID-19 and may be seen more commonly than in those recovering from similar illnesses [1,4,22,28,29,34,38,48,49,52-55]. In one study of 100 patients with acute COVID-19 who were discharged from the hospital, 24 percent reported PTSD, 18 percent had new or worsened problems with memory, and 16 percent had new or worsened problems with concentration; numbers were higher among patients admitted to the intensive care unit (ICU) [22].

In other studies, almost one-half of COVID-19 survivors reported a worsened quality of life [1,24], 22 percent had anxiety/depression [24], and 23 percent of patients were found to have persistent psychological symptoms at three months [4]. Among ICU survivors, another study reported anxiety in 23 percent, depression in 18 percent, and posttraumatic symptoms in 7 percent [34]. In a prospective cohort study of nonhospitalized Ecuadorian patients with COVID-19, most of whom had mild disease, 21 percent had memory impairment as evidenced by a four-point decrease in their Montreal Cognitive Assessment (MoCA) scores [55].

Psychological complaints may be seen more commonly than in those recovering from similar illnesses. As an example, a retrospective examination of electronic health records in the United States reported that the risk of developing a new psychiatric illness following COVID-19 was higher compared with those recovering from other medical illnesses such as influenza [53].

●PICS – Among ICU survivors, one single center analysis reported that over 90 percent of individuals with COVID-19 suffered from at least one component of PICS [56]. Another prospective observational study found that 9.9 percent of individuals who were discharged from the ICU with COVID-19 developed critical illness polyneuropathy or myopathy versus 3.4 percent of other patients discharged from the ICU [57]. Details regarding the identification and management of PICS and weakness related to critical illness are discussed separately.

Persistent symptoms can affect functional ability [23,28,34,38,46,58]. As examples:

●In one retrospective study of approximately 1300 hospitalized COVID-19 patients discharged to home, despite home health services, only 40 percent of patients were independent in all activities of daily living (ADLs) at 30 days [23].

●In another study, almost 40 percent of patients were unable to return to normal activities at 60 days following hospital discharge [58].

●In another study of 219 patients who were hospitalized with COVID-19, 53 percent had limited functional impairment (as measured by the Short Physical Performance Battery [SPPB] score and two-minute walking test) at four months [28].

Whether symptoms can develop after initial asymptomatic infection is unknown. Limited data from self-reporting questionnaires, subgroup analyses of larger observational studies, and health care claim databases (some of which are not peer-reviewed), suggest that a small proportion of patients with asymptomatic COVID-19 subsequently report post-COVID symptoms (eg, fatigue) [59-61]. Further data are needed to clarify the scope of post-COVID symptoms in this population.

Limited data suggest a lower prevalence of persistent symptoms in children, although data are sparse. One retrospective study of children and adolescents (median age 11 years) described at least one symptom lasting beyond 12 weeks in 4 percent of the study cohort [47].

The most frequently reported symptoms were tiredness (3 percent) and poor concentration (2 percent). (See “COVID-19: Clinical manifestations and diagnosis in children”, section on ‘Clinical course’.)

Persistent symptoms do not appear to worsen (and may improve) following the administration of the SARS-CoV-2 vaccine. This was illustrated in one study of 163 patients who had a heavy burden of post-COVID symptoms at eight months who subsequently received the Pfizer-BioNTech (BNT162b2) or Oxford-AstraZeneca (ChAdOx1nCoV-19) vaccine [62]. One month after vaccination, symptoms that existed prior to vaccination in the majority of patients had either improved or remained unchanged, while only 5 percent had worsened.

Expected recovery time course — The time to symptom resolution appears to depend upon premorbid risk factors as well as the severity of the acute illness and spectrum of symptoms experienced by the patient [1,2,63-66]. However, despite early data suggesting a shorter recovery (eg, two weeks) for those with mild disease and a longer recovery (eg, two to three months or longer) for those with more severe disease [67,68], there is wide variability in time to symptom resolution.

Early data suggested a longer recovery course in patients requiring hospitalization, older patients with preexisting comorbidities, patients who experienced medical complications (eg, secondary bacterial pneumonia, venous thromboembolism), and patients who had a prolonged stay in the hospital or ICU [1,2,17,22,49,69]. However, subsequent data suggest that even patients with less severe disease who were never hospitalized, including those with self-reported COVID-19, have often reported prolonged and persistent symptoms [4,5,17,36,64,70].

As examples:

Hospitalized patients (moderate to severe COVID-19) – Data suggest that a significant proportion of patients who are admitted with acute COVID-19 experience symptoms for at least two months and even longer (eg, up to 12 months) following discharge (52 to 87 percent) [1,22,27,49,58,71].

•In an observational study of 1600 patients in United States hospitals with acute COVID-19, at 60 days after discharge, 33 percent reported persistent symptoms and 19 percent reported new or worsening symptoms [58]. The most common symptoms included dyspnea with stair climbing (24 percent), shortness of breath/chest tightness (17 percent), cough (15 percent), and loss of taste or smell (13 percent).

•In a study including approximately 1700 patients previously hospitalized with COVID-19 in Wuhan, China, at six months, 74 percent continued to experience one or more symptoms. Fatigue or muscle weakness (63 percent), sleep difficulties (26 percent), dyspnea (26 percent), and anxiety or depression (23 percent) were among the most commonly reported persistent symptoms [27].

In a follow-up study of the same cohort, although the proportion of patients with at least one symptom had improved at 12 months, 49 percent of patients remained symptomatic [49]. Fatigue or muscle weakness remained the most common symptom (20 percent), but the proportion of patients with dyspnea (30 percent) and anxiety (26 percent) increased slightly.

Outpatients (mild COVID-19) – Data also suggest that a significant proportion of patients with mild disease may experience symptoms for up to several months, if not longer, following acute illness [5,36,38,70-72].

•In a telephone survey of 292 outpatients with COVID-19, one-third had not returned to baseline health by three weeks [36]. Younger patients were less likely to have residual symptoms compared with older patients (26 percent among those 18 to 34 years versus 47 percent of those >50 years). In addition, an increasing number of medical comorbidities was associated with prolonged illness among all age groups. Young and healthy patients with mild disease typically recovered sooner, while patients with multiple comorbidities had a more prolonged recovery.

•In a study of 410 Swiss outpatients with mild illness, 39 percent reported persistent symptoms seven to nine months following initial infection. The most common symptoms included fatigue (21 percent), loss of taste or smell (17 percent), dyspnea (12 percent), and headache (10 percent) [70].

•In a prospective study, 177 patients recovering from acute COVID-19 (16 inpatients and 161 outpatients, 11 of whom had asymptomatic infection) were followed for an average of six months after acute illness [71]. Of the outpatients with symptomatic infection, 19 percent had one to two persistent symptoms at six months, 14 percent had ≥3 persistent symptoms, and 29 percent reported a decreased quality of life. The most common reported persistent symptoms were fatigue, loss of sense of taste or smell, and dyspnea.

•In a Swedish survey of over 300 health care workers with mild disease, 26 percent had at least one moderate or severe symptom lasting more than two months, compared with 9 percent of seronegative control patients [38]. A higher proportion also had symptoms lasting longer than eight months (15 versus 3 percent). Approximately 8 to 15 percent reported that their symptoms interfered with their work, social, or home life compared with 4 percent of seronegative control patients.

Some symptoms resolve more quickly than others. For example, fevers, chills, and olfactory/gustatory symptoms typically resolve within two to four weeks, while fatigue, dyspnea, chest tightness, cognitive deficits, and psychological effects may last for months (eg, 2 to 12 months) [1,4,5,18-22,25,36,49]. Data regarding individual symptoms are included below:

Fatigue, weakness, and poor endurance – Fatigue is by far the most common symptom experienced by patients regardless of the need for hospitalization. Although the fatigue resolves in most patients, it can be profound and may last for three months or longer, particularly among ICU survivors [1,4,22,73].

Dyspnea – In patients with COVID-19 and dyspnea, the shortness of breath may persist, resolving slowly in most patients over two to three months, sometimes longer (eg, up to 12 months) [4,22,49,74-76].

Chronic cough – In several studies, many patients experienced persistent cough at two to three weeks following initial symptoms [36]. Cough resolved in the majority of patients by 3 months [4] and rarely persisted by 12 months [49].

Chest discomfort – Among patients with COVID-19, chest discomfort is common and may resolve slowly. Chest discomfort persists in 12 to 22 percent of patients approximately two to three months after acute COVID-19 infection, rarely longer [1,4,49].

Altered taste and smell – Several studies have examined the recovery of olfactory and gustatory symptoms in COVID-19 patients [18-21,58,77,78]. The majority have complete or near-complete recovery at one month following acute illness, although in some studies these symptoms persisted longer [49]. Patients with hyposmia and male patients may recover more rapidly compared with those who have anosmia or are female [19,21].

Neurocognitive symptoms – Data suggest that concentration and memory problems persist for six weeks or more in COVID-19 patients after discharge from the hospital [22].

Psychological – Observational studies report that psychological symptoms (eg, anxiety, depression, PTSD) are common after acute COVID-19 infection, with anxiety being the most common. In general, psychological symptoms improve over time but may persist for more than six months for a subset of survivors. Those hospitalized are likely at greater risk for persistent psychological symptoms [4,22,23,49,53,79]. (See “COVID-19: Psychiatric illness”, section on ‘Patients critically ill with COVID-19’.)

Risk of rehospitalization — Most patients hospitalized with COVID-19 are successfully discharged, although approximately 10 to 20 percent require rehospitalization within 30 and 60 days, respectively [23,35,58,80,81]. As examples:

●In a retrospective study of over 100,000 patients admitted to United States hospitals with COVID-19, among those who were discharged, 9 percent were rehospitalized within two months to the same hospital [80]. Among those readmitted, 1.6 percent had multiple hospital readmissions. The median time for first readmission was eight days. Risk factors for rehospitalization included age ≥65 years, discharge to skilled nursing facility (SNF) or with home health services, or the presence of one or more comorbidities (ie, chronic obstructive pulmonary disease, heart failure, diabetes mellitus with complications, chronic kidney disease, and/or a body mass index [BMI] ≥30 kg/m²).

●In another retrospective cohort of 1409 patients admitted with COVID-19, 10 percent were rehospitalized. Risk of rehospitalization or death was higher among male patients, White patients, and those with heart failure, diabetes, frequent emergency department visits within the previous six months, daily pain, cognitive impairment, or functional dependency [23].

●In another study of 1775 patients discharged following COVID-19, 20 percent were readmitted within 60 days [82]; readmissions were associated with older age. Common readmission diagnoses were COVID-19 (30 percent), sepsis (8.5 percent), pneumonia (3.1 percent), and heart failure (3.1 percent). Over 20 percent required ICU admission, and the mortality was 9 percent. Rates of readmission or death were highest during the first 10 days following discharge.

●In a United Kingdom study of nearly 50,000 patients who were discharged following an admission with COVID-19, 30 percent were readmitted and 10 percent died after discharge [35]. There were higher rates of respiratory disease, diabetes, and cardiovascular disease in patients discharged following COVID-19 compared with patients discharged with non-COVID diagnoses.

GENERAL EVALUATIONPatients recovering from COVID-19 range from those with mild illness not requiring medical attention to those with severe illness requiring prolonged critical care support.

Several organizations have developed guidelines to address the evaluation and management of patients recovering from COVID-19, and many institutions have established dedicated, interdisciplinary outpatient COVID-19 recovery clinics to address the long-term needs of patients after recovery from acute illness [6,9,83-94]. Given the unknown long-term sequelae of those with persistent symptoms following COVID-19, clinic protocols generally include a comprehensive physical, cognitive, and psychological assessment. High quality data on the outcomes of these evaluation and management strategies are lacking. Care should not be delayed if patients experience a long wait time for evaluation in a dedicated COVID-19 recovery clinic; referral to pulmonary, neurology, and/or physical medicine and rehabilitation specialists may be appropriate if referral to a COVID-19 recovery clinic is unavailable.

Our approach is based upon our clinical experience with patients who have recovered from acute COVID-19, accumulating data on patients with persistent symptoms following acute COVID-19, and data extrapolated from patients recovering from similar illnesses (eg, sepsis) and is consistent with expert advice from international societies and guideline groups [84-90,94-96].

Timing and location of follow-up evaluation — The optimal timing and location of follow-up evaluation for patients who have recovered from acute COVID-19 are unknown and depends upon several factors, including the severity of acute illness, current symptomatology, patient age, risk factors for severe illness (table 2), and resource availability.

The timing and location of follow-up for outpatients during the acute illness (eg, up to two to three weeks following illness onset) is reviewed in detail elsewhere. (See “COVID-19: Outpatient evaluation and management of acute illness in adults”, section on ‘Management and counseling for all outpatients’ and “COVID-19: Outpatient evaluation and management of acute illness in adults”, section on ‘Telehealth follow-up’.)

Our approach to the follow-up of patients after the acute illness has “resolved” (eg, after approximately three to four weeks) is discussed in this section. The recovery process exists on a continuum; follow-up early in the course of acute COVID-19 is focused on detecting and managing acute COVID-19-related complications, while later follow-up focuses on the evaluation and management of persistent symptoms after recovery from the acute phase (see ‘Terminology and stages of recovery’ above). While there is no guidance on timing or location for COVID-19 follow-up after the acute illness, we suggest the following:

●In an otherwise healthy young patient with mild disease not requiring medical intervention or hospitalization and who is improving, we do not routinely schedule a COVID-19 follow-up visit (telemedicine or in-person), unless the patient requests it or has persistent, progressive, or new symptoms.

●In an older patient or a patient with comorbidities (eg, hypertension, diabetes) with mild to moderate acute disease but not requiring hospitalization, we typically schedule a telemedicine or in-person visit approximately three weeks following the onset of illness.

●For patients with more severe acute COVID-19 disease requiring hospitalization (with or without the need for subsequent post-acute care such as inpatient rehabilitation), we ideally follow-up within one week but no later than two to three weeks after discharge from the hospital or rehabilitation facility. We typically use telemedicine visits to facilitate early follow-up given that hospital readmissions may be reduced with early post-discharge follow-up based upon data reported for patients recovering from sepsis [96].

●For all patients with persistent symptoms, particularly those with multisystem complaints or symptoms lasting beyond 12 weeks, we refer for an evaluation in a specialized outpatient COVID-19 recovery clinic, if available, or a subspecialty clinic relevant to the patient’s specific symptoms.

Assess disease severity, complications, and treatments — During the initial follow-up evaluation, we obtain a comprehensive history of the patient’s acute COVID-19 illness, including the illness timeline, duration and severity of symptoms, type and severity of complications (eg, venous thromboembolism, presence and degree of kidney injury, supplemental oxygen requirements [including the need for noninvasive or invasive ventilation], cardiac complications, delirium), COVID-19 testing results, and initial treatments used. We review hospital and outpatient records and the patient’s medication list. This information is compared with their pre-COVID-19 medical history.

Laboratory testing

General laboratory testing — The need for laboratory testing in patients who have recovered from acute COVID-19 is determined by the severity and abnormal test results during their acute illness and current symptoms. Most patients who have abnormal laboratory testing at the time of diagnosis improve during recovery [30].

●For most patients who have recovered from mild acute COVID-19, laboratory testing is not necessary.

●For patients recovering from more severe illness, those with identified laboratory abnormalities, patients who were discharged from hospital or an inpatient rehabilitation facility, or for those with unexplained continuing symptoms, it is reasonable to obtain the following:

•Complete blood count

•Blood chemistries, including electrolytes, blood urea nitrogen (BUN) and serum creatinine

•Liver function studies, including serum albumin

●Additional laboratory tests that might be appropriate for select patients include:

•Brain natriuretic peptide (BNP) and troponin in patients whose course was complicated by heart failure or myocarditis or in those with possible cardiac symptoms from covert myocarditis (eg, dyspnea, chest discomfort, edema).

•D-dimer in patients with unexplained persistent or new dyspnea or in any patient in whom there is a concern for thromboembolic disease.

•Thyroid studies in those with unexplained fatigue or weakness.

•Antinuclear antibody and creatinine kinase in patients with arthralgias, myalgias, or other symptoms concerning for rheumatologic disorders.

We generally do not monitor coagulation parameters (eg, fibrinogen, fibrinogen degradation products, activated thromboplastin time, international normalized ratio, and D-dimer levels) or inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein, ferritin, interleukin-6) to resolution.

COVID-19 testing and serology — We do not routinely re-test patients for active infection with SARS-CoV-2 at the time of follow-up outpatient evaluation. Instead, we follow a non-test-based approach to removing infectious precautions. This approach is supported by the World Health Organization and the Centers for Disease Control and Prevention (table 3). (See “COVID-19: Infection control for persons with SARS-CoV-2 infection”, section on ‘Discontinuation of precautions’ and “COVID-19: Diagnosis”, section on ‘Persistent or recurrent positive NAAT during convalescence’ and “COVID-19: Epidemiology, virology, and prevention”, section on ‘Viral shedding and period of infectiousness’ and “COVID-19: Epidemiology, virology, and prevention”, section on ‘Immune responses following infection’.)

In addition, there is no clinical utility in obtaining SARS-CoV-2 serology (antibodies) in patients who had their acute infection documented by a positive molecular test (ie, nucleic acid amplification test [NAAT], reverse transcriptase polymerase chain reaction [RT-PCR] test) or antigen test. However, for patients with prior COVID-19 based upon symptoms but without a documented positive molecular or antigen test, the value of obtaining SARS-CoV-2 serology is unclear. Regardless, we sometimes obtain serology to guide additional testing or decision-making (eg, convalescent plasma donation, evaluation of unexplained symptoms).

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