Post-ICU Care in the Outpatient Setting

Jason Wilbur; Jessica Rockafellow; Brian Shian

JASON WILBUR, MD, JESSICA ROCKAFELLOW, MD, AND BRIAN SHIAN, MD

Am Fam Physician. 2021;103(10):590-596

Published online February 2, 2021.

Author disclosure: No relevant financial affiliations.

More than 5 million patients in the United States are admitted to intensive care units (ICUs) annually, and an increasing percentage of patients treated in the ICU survive to hospital discharge. Because these patients require follow-up in the outpatient setting, family physicians should be prepared to provide ongoing care and screening for post-ICU complications. Risk factors for complications after ICU discharge include previous ICU admissions, preexisting mental illness, greater number of comorbidities, and prolonged mechanical ventilation or higher opioid exposure while in the ICU. Early nutritional support and mobilization in the ICU decrease the risk of complications. After ICU discharge, patients should be screened for depression, anxiety, insomnia, and cognitive impairment using standardized screening tools. Physicians should also inquire about weakness, fatigue, neuropathy, and functional impairment and perform a targeted physical examination and laboratory evaluation as indicated; treatment depends on the underlying cause. Exercise regimens are beneficial for reducing several post-ICU complications. Patients who were treated for COVID-19 in the ICU may require additional instruction on reducing the risk of virus transmission. Telemedicine and telerehabilitation allow patients with COVID-19 to receive effective care without increasing exposure risk in communities, hospitals, and medical offices.

More than 5 million patients in the United States are admitted to intensive care units (ICUs) annually.¹ Mortality rates among these patients decreased by 35% between 1988 and 2012, despite increasing illness severity and increasing patient age; current mortality rates are estimated at 10% to 29%.¹ Because a greater number of patients are surviving to ICU discharge and require follow-up in the outpatient setting, family physicians should be prepared to provide ongoing care and screening for post-ICU complications.

Clinical recommendation	Evidence rating	Comments
Patients should be screened for weakness after ICU discharge and referred for physical rehabilitation when appropriate.^5–8	B	Small randomized controlled trials and professional guideline
Patients should be screened for cognitive impairment after ICU discharge.^20–22	C	Observational and retrospective cohort studies
Patients should be screened for depression, anxiety,and posttraumatic stress disorder after ICU discharge.^5,24,25	C	Prospective cohort studies
Partners and family members of patients discharged from the ICU should be screened for depression, anxiety, and posttraumatic stress disorder.^27,28	C	Prospective cohort studies

With no universally accepted guidelines, the timing and frequency of post-ICU follow-up should be individualized and based on the patient's comorbidities and severity of illness. Although about 20 medical centers in the United States have post-ICU transition clinics,² there is no evidence that such programs decrease readmission or mortality rates.³

Although the term post-ICU syndrome has been used to describe the various complications reported in ICU survivors (Table 1⁴ ), there is no universally accepted definition for such a syndrome. Family physicians must be familiar with the complications that can occur after discharge (e.g., physical and psychological impairments), including in patients recovering from COVID-19.

Complication	Potential causes	Evaluation
Amenorrhea	Hypothalamic amenorrhea secondary to severe weight loss or major illness	Gonadotropin-releasing hormone, luteinizing hormone, follicle-stimulating hormone, estrogen, and human chorionic gonadotropin measurements
Anxiety	Generalized anxiety disorder, PTSD	Anxiety screening tool, such as General Anxiety Disorder-7 (available at https://www.mdcalc.com/gad-7-general-anxiety-disorder-7)
Deconditioning	Anemia, critical illness myopathy or poly-neuropathy, muscle atrophy, malnutrition, drug therapy	CBC, iron panel, serum chemistries, serial body weight measurements
Depressed mood	Major depressive disorder, familial anxiety or depression, frustration with slow recovery, drug therapy, PTSD	Depression screening tool, such as the Patient Health Questionnaire (available at https://www.aafp.org/afp/2018/1015/p508.html)
Fatigue	Anemia, insomnia, depression, muscle atrophy, poor nutrition, drug therapy, hypoxia	CBC, iron panel, serum chemistries, serial body weight measurements, physical therapy, sleep/depression questionnaire, oxygen saturation
Hair loss	Telogen effluvium secondary to severe weight loss or major illness	Thyroid-stimulating hormone measurement, CBC, ferritin measurement, antinuclear antibody testing to rule out other causes
Impaired memory, poor concentration, nightmares, hallucinations, distressing flashbacks, hyperarousal	PTSD	Primary Care PTSD Screen
Insomnia	Depression, anxiety disorders, PTSD	Sleep/depression questionnaire
Mobility issues	Critical illness myopathy or polyneuropathy, joint pain, joint stiffness, muscle weakness, deconditioning	Physical therapy, neurology consultation
Peripheral neuropathy, numbness, paresthesia	Critical illness polyneuropathy, iatrogenic causes (e.g., needle injury)	Neurology consultation, electromyography, nerve conduction velocity studies
Reduced appetite	Altered taste, swallowing difficulties, weakness of the pharyngeal muscles, drug therapy, psychological condition precluding patients from feeding themselves	Swallowing study
Shortness of breath	Newly acquired cardiopulmonary pathologies (e.g., pulmonary embolism, heart failure) or worsening pre-ICU pulmonary or cardiovascular disease; anemia, neuropathy, muscle atrophy, psychological factors	Imaging studies (e.g., chest radiography, chest computed tomography) if warranted, CBC, iron panel, reticulocyte count, pulmonary function tests, electrocardiography, echocardiography
Stridor	Tracheal stenosis	Magnetic resonance imaging of the neck or upper endoscopy

Physical Considerations

DECONDITIONING

One year after ICU discharge, more than 20% of patients without functional limitations before admission experience some difficulty in completing activities of daily living.⁵ The National Institute for Health and Care Excellence recommends reassessing patients' physical function two to three months following discharge.⁶ Exercise and self-help rehabilitation programs improve muscle function and cardiopulmonary function after critical illness.^7,8 Patients with deconditioning should be instructed on starting a home exercise regimen or referred to physical therapy.

In general, patients should be screened for weakness at follow-up and referred for physical rehabilitation when appropriate.^5–8

CRITICAL ILLNESS POLYNEUROPATHY

Patients treated in the ICU are at risk of critical illness (or ICU-acquired) polyneuropathy, a disease of the peripheral nerves secondary to axonal degeneration. This condition is caused by complex and poorly understood processes that include microcirculatory abnormalities, metabolic derangements, and other factors.^9–11 Critical illness polyneuropathy is diagnosed by the presence of limb weakness and unexplained difficulty in weaning from mechanical ventilation. Sepsis, prolonged mechanical ventilation, hyperglycemia, and multiorgan failure increase the risk of critical illness polyneuropathy.^9,10

Although nerve function usually begins to improve when major medical issues are resolved, weakness and numbness may persist in severe cases. There is little evidence for physical rehabilitation or pharmacologic interventions in the treatment of critical illness polyneuropathy, but early mobilization in the ICU may improve mobility and muscle strength. ^12,13 For painful polyneuropathy, gabapentin (Neurontin), pregabalin (Lyrica), or serotonin-norepinephrine reuptake inhibitors should be considered.

CRITICAL ILLNESS MYOPATHY

Critical illness (or ICU-acquired) myopathy also presents as muscle weakness and difficulty weaning from mechanical ventilation. The pathophysiology of critical illness myopathy is believed to be similar to that of critical illness polyneuropathy.^10,11 Electromyography and nerve conduction velocity studies can assist with distinguishing between these two clinically similar diseases. Muscle biopsy is considered the diagnostic standard for critical illness myopathy.¹² Unlike critical illness polyneuropathy, critical illness myopathy may improve with exercise. Early mobilization and physical therapy have the greatest evidence of benefit.^10,11

MALNUTRITION

Early nutritional support has become the standard of care in the ICU and other inpatient settings and is associated with decreased rates of infection, length of hospitalization, and risk of readmission.^14,15 Pre- and postadmission weight, appetite, and caloric intake should be assessed during post-ICU follow-up.

INSOMNIA

Among patients treated in the ICU, 10% to 61% report difficulty with sleep six months after discharge.¹⁶ Risk factors for insomnia include coexisting mental illness and higher opioid exposure in the ICU. Post-ICU insomnia is associated with increased levels of pain and decreased physical function.¹⁷ Patients should be asked about sleep quality and insomnia during post-ICU follow-up. Those with difficulty sleeping should be treated with nonpharmacologic interventions, including sleep hygiene, cognitive behavior therapy, and relaxation techniques.¹⁸

SEXUAL DYSFUNCTION

Sexual dysfunction occurs in up to 44% of patients treated in the ICU.¹⁹ There are no studies comparing the prevalence of sexual dysfunction in patients treated in the ICU with the general population, and there are no recommendations to screen for sexual dysfunction during post-ICU follow-up.

Psychological health should be assessed when sexual dysfunction is diagnosed because of the strong correlation between sexual dysfunction and posttraumatic stress disorder (PTSD). Treatment of post-ICU sexual dysfunction targets the underlying cause. Typical pharmacologic therapies, such as phosphodiesterase inhibitors, have not been studied in the post-ICU population.

Psychological Considerations

COGNITIVE IMPAIRMENT

There is a high prevalence of cognitive impairment in the ICU population, and several studies have shown persistence in cognitive impairment after discharge in more than 20% of patients.^20,21 Up to 2.5% of patients develop new and persistent cognitive impairment post-ICU, with increasing risk associated with a higher number of comorbidities and ICU admissions.²⁰ Hypotension, hypoxia, hyperthermia, delirium, and vancomycin or quinolone use may also increase the risk of cognitive impairment.^20,21

Although there is limited evidence for specific treatments of cognitive impairment in the post-ICU setting, patients should be screened for cognitive impairment and, when present, evaluated for underlying reversible causes, such as depression, nutritional deficiencies, and metabolic disorders.^20–22 Exercise, mental activity, and optimizing cardiovascular risk factors may be beneficial.²²

DEPRESSION

Depressed mood and other mental health concerns are common in patients after ICU admission. Among patients treated in the ICU, 30% have at least mild depression 12 months after discharge.^23,24 One study showed that depressive symptoms in patients treated in the ICU are more often somatic (e.g., fatigue, decreased appetite), and those with severe depression are more likely to experience concurrent PTSD.⁵ Depression has been associated with increased rates of mortality up to two years after ICU discharge.²³

Patients should be screened for depression using a validated screening tool, such as the two- or nine-question Patient Health Questionnaire (available at https://www.aafp.org/afp/2018/1015/p508.html).^5,24,25 If depression is diagnosed, appropriate behavior and/or pharmacologic therapy should be initiated.

ANXIETY

The prevalence of anxiety 12 months after ICU discharge ranges from 12% to 43%.²⁵ More than 60% of patients with post-ICU anxiety disorder also have PTSD or depression.²³ Patients should be screened for anxiety using a standardized screening tool, such as the General Anxiety Disorder-7 (available at https://www.mdcalc.com/gad-7-general-anxiety-disorder-7).^5,24,25 If anxiety is diagnosed, appropriate behavior and/or pharmacologic therapy should be initiated.

POSTTRAUMATIC STRESS DISORDER

Among patients treated in the ICU, 7% to greater than 20% experience PTSD 12 months after discharge.^5,23 Patients should be screened for PTSD using a standardized tool, such as the Primary Care PTSD Screen (available at https://www.ptsd.va.gov/professional/assessment/screens/pc-ptsd.asp).^5,24,25 Review of an ICU diary (i.e., account of a patient's daily experiences while in the ICU) during the convalescence period has been shown to reduce the risk of PTSD.²⁶

Because 18% to 31% of partners and family members of patients treated in the ICU also have PTSD symptoms six months after discharge, family physicians should consider screening them for PTSD, anxiety, and depression.^27,28 Female sex, preexisting mental health disorders, personal history of recent serious illness, and being a partner or family member of a previously healthy patient are associated with higher rates of PTSD in this population.^27,28

Medications

Reconciliation of pre- and post-ICU medications is vital for avoiding complications after discharge. Unintentional discontinuation of medications that treat chronic conditions is common on admission to the ICU.²⁹ Family physicians should determine the indication, appropriateness, and duration for new medications prescribed at discharge. In one study, there were differences between medications prescribed at ICU discharge and medications documented in the outpatient setting in more than 40% of cases.³⁰ Older patients may be prescribed potentially inappropriate medications (e.g., opioids, anticholinergics) in the ICU, and these medications are often continued at discharge.³¹ Medications for chronic conditions that were discontinued at discharge should be assessed and reinitiated only if appropriate.

Care Planning

Compared with the general population, patients treated in the ICU have increased rates of mortality up to 10 years after discharge.¹ During post-ICU follow-up, family physicians should address patients' health care goals and end-of-life wishes and identify proxy health care decision-makers. Patient preferences regarding code status, artificial feeding, mechanical ventilation, and future ICU admission should be discussed. Tools such as the Serious Illness Conversation Guide (available at https://www.aafp.org/afp/2019/0301/p281.html) can help facilitate these conversations.

COVID-19 Considerations

Patients admitted to the ICU with COVID-19 are at risk of the typical post-ICU complications as well as additional complications, such as thrombotic and vascular issues.³² Management of COVID-19 after ICU treatment is evolving. A recent observational study showed that although the toll of COVID-19 extends well beyond hospitalization, one out of five patients hospitalized with COVID-19 have no primary care follow-up visit within 60 days of discharge.³³

FOLLOW-UP AFTER HOSPITAL DISCHARGE

Although there is no universal agreement on when and how follow-up should occur after COVID-19 treatment in the ICU, public health and other expert recommendations promote close follow-up with extensive patient and caregiver education.^34,35

The Centers for Disease Control and Prevention recommends discontinuation of transmission precautions in those with initial mild to moderate illness when at least 10 days have passed since the onset of symptoms, the patient is afebrile without the use of antipyretics for at least 24 hours, and symptoms have improved.³⁵ For patients with severe to critical illness or patients who are severely immunocompromised, transmission precautions should be continued for up to 20 days, and consultation with infection control experts should be considered. Because the Centers for Disease Control and Prevention no longer recommends a test-based strategy, patients discharged home must adhere to self-isolation and self-monitoring recommendations if transmission-based precautions remain in effect. Medications for chronic conditions should be continued with some exceptions (Table 2).^34–36

Medication	Considerations
Immunosuppressant medications	Weigh overall risks and benefits. Close communication with specialists is recommended.
Medications for chronic lung disease	Administering nebulized medications generates aerosol, which may contribute to SARS-CoV-2 transmission. Caregivers and health care workers should minimize contact and wear appropriate personal protective equipment when patients with COVID-19 are using inhaled or nebulized medications, continuous positive airway pressure, or bilevel positive airway pressure.
NSAIDs	Concern has been raised that NSAIDs theoretically may worsen COVID-19. Although there is no strong evidence to support this claim, safer alternatives (e.g., acetaminophen) are generally available and should be administered in place of NSAIDs when possible.
Renin-angiotensin system blockers	Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers should be continued, unless discontinuation is indicated (e.g., acute kidney injury, hypotension, shock).

REHABILITATION

Exercise and self-help rehabilitation programs improve muscle function and cardiopulmonary function after critical illness.^7,8 With the emergence of telemedicine to allow for social distancing, telerehabilitation is a viable alternative for patients in isolation. Studies of patients with heart failure or stroke have shown that telerehabilitation is not inferior to traditional physical therapy.^37,38 However, unsupervised exercise and competitive athletics should be avoided during the initial outpatient phase of recovery because up to 22% of patients hospitalized with COVID-19 have evidence of myocardial injury and/or myocarditis.³⁹ Although evidence is limited, expert consensus suggests a gradual return to activity if recent cardiac biomarkers and electrocardiogram and echocardiogram findings were normal during admission and the patient has been asymptomatic for at least two weeks.³⁹ Further cardiac testing may be considered in previously highly active individuals who did not undergo such testing during admission.³⁹

TELEMEDICINE

Previous studies have shown similar health outcomes in those receiving care via telemedicine vs. traditional health care, and many patients report that they prefer virtual visits to in-person visits.^40,41 Care provided via telemedicine was observed to be noninferior to traditional health care during other disease outbreaks, including severe acute respiratory syndrome, Middle East respiratory syndrome, and influenza.⁴² Advantages of telemedicine visits for patients who are recovering from COVID-19 or who have mild symptoms include reduced use of personal protective equipment and decreased exposure risk in communities, hospitals, and medical offices.

NURSING HOME CARE

Advance directives should be reviewed before transferring nursing home residents with suspected COVID-19 to the hospital for higher levels of care. Patients hospitalized with COVID-19 should be discharged to a nursing home or group care facility only if personal protective equipment is available and the patient can be isolated from other residents. Care facilities should implement screening protocols for staff and enhanced infection control policies.⁴³

This article updates a previous article on this topic by Volk and Grassi.^⁴

Data Sources: A literature search was conducted using PubMed, the Cochrane database, and Essential Evidence Plus. Search terms included post-ICU, post intensive care, and post critical care, individually and collectively. These terms were also paired with the following terms: mental illness, weakness, malnutrition, rehabilitation, cognition, COVID-19, and SARSCoV2. Search dates: May through December 2020.

Society of Critical Care Medicine. Critical care statistics. Accessed September 9, 2020. https://www.sccm.org/Communications/Critical-Care-Statistics

Kuehn BM. Clinics aim to improve post-ICU recovery. JAMA. 2019;321(11):1036-1038.

Stelfox HT, Bastos J, Niven DJ, et al. Critical care transition programs and the risk of readmission or death after discharge from ICU. Intensive Care Med. 2016;42(3):401-410.

Volk B, Grassi F. Treatment of the post-ICU patient in an outpatient setting. Am Fam Physician. 2009;79(6):459-464. Accessed October 29, 2020. https://www.aafp.org/afp/2009/0315/p459.html

Jackson JC, Pandharipande PP, Girard TD, et al.; Bringing to light the Risk Factors And Incidence of Neuropsychological dysfunction in ICU survivors (BRAIN-ICU) study investigators. Depression, post-traumatic stress disorder, and functional disability in survivors of critical illness in the BRAIN-ICU study: a longitudinal cohort study. Lancet Respir Med. 2014;2(5):369-379.

National Institute for Health and Care Excellence. Rehabilitation after critical illness in adults. September 7, 2017. Accessed June 10, 2020. https://www.nice.org.uk/guidance/qs158

Jones C, Skirrow P, Griffiths RD, et al. Rehabilitation after critical illness: a randomized, controlled trial. Crit Care Med. 2003;31(10):2456-2461.

Lau HMC, Ng GYF, Jones AYM, et al. A randomised controlled trial of the effectiveness of an exercise training program in patients recovering from severe acute respiratory syndrome. Aust J Physiother. 2005;51(4):213-219.

Hough CL, Steinberg KP, Taylor Thompson B, et al. Intensive care unit–acquired neuromyopathy and corticosteroids in survivors of persistent ARDS. Intensive Care Med. 2009;35(1):63-68.

Shepherd S, Batra A, Lerner DP. Review of critical illness myopathy and neuropathy. Neurohospitalist. 2017;7(1):41-48.

Zhou C, Wu L, Ni F, et al. Critical illness polyneuropathy and myopathy: a systematic review. Neural Regen Res. 2014;9(1):101-110.

Tipping CJ, Harrold M, Holland A, et al. The effects of active mobilisation and rehabilitation in ICU on mortality and function: a systematic review. Intensive Care Med. 2017;43(2):171-183.

Shepherd SJ, Newman R, Brett SJ, et al.; Enhancing Rehabilitation After Critical Illness Programme Study Investigators. Pharmacological therapy for the prevention and treatment of weakness after critical illness: a systematic review. Crit Care Med. 2016;44(6):1198-1205.

Marik PE, Zaloga GP. Early enteral nutrition in acutely ill patients: a systematic review [published correction appears in Crit Care Med. 2002;30(3):725]. Crit Care Med. 2001;29(12):2264-2270.

Philipson TJ, Snider JT, Lakdawalla DN, et al. Impact of oral nutritional supplementation on hospital outcomes. Am J Manag Care. 2013;19(2):121-128.

Altman MT, Knauert MP, Pisani MA. Sleep disturbance after hospitalization and critical illness: a systematic review. Ann Am Thorac Soc. 2017;14(9):1457-1468.

Parsons EC, Hough CL, Vitiello MV, et al. Insomnia is associated with quality of life impairment in medical-surgical intensive care unit survivors. Heart Lung. 2015;44(2):89-94.

Maness DL, Khan M. Nonpharmacologic management of chronic insomnia. Am Fam Physician. 2015;92(12):1058-1064. Accessed October 29, 2020. https://www.aafp.org/afp/2015/1215/p1058.html

Griffiths J, Gager M, Alder N, et al. A self-report-based study of the incidence and associations of sexual dysfunction in survivors of intensive care treatment. Intensive Care Med. 2006;32(3):445-451.

Sakusic A, Gajic O, Singh TD, et al. Risk factors for persistent cognitive impairment after critical illness, nested case-control study. Crit Care Med. 2018;46(12):1977-1984.

Marra A, Pandharipande PP, Girard TD, et al. Co-occurrence of post-intensive care syndrome problems among 406 survivors of critical illness. Crit Care Med. 2018;46(9):1393-1401.

Langa KM, Levine DA. The diagnosis and management of mild cognitive impairment: a clinical review. JAMA. 2014;312(23):2551-2561.

Hatch R, Young D, Barber V, et al. Anxiety, depression and post traumatic stress disorder after critical illness: a UK-wide prospective cohort study. Crit Care. 2018;22(1):310.

Wang S, Mosher C, Perkins AJ, et al. Post-intensive care unit psychiatric comorbidity and quality of life. J Hosp Med. 2017;12(10):831-835.

Myhren H, Ekeberg O, Tøien K, et al. Posttraumatic stress, anxiety and depression symptoms in patients during the first year post intensive care unit discharge. Crit Care. 2010;14(1):R14.

Jones C, Bäckman C, Capuzzo M, et al.; RACHEL group. Intensive care diaries reduce new onset post traumatic stress disorder following critical illness: a randomised, controlled trial. Crit Care. 2010;14(5):R168.

Lee RY, Engelberg RA, Curtis JR, et al. Novel risk factors for posttraumatic stress disorder symptoms in family members of acute respiratory distress syndrome survivors. Crit Care Med. 2019;47(7):934-941.

Wintermann GB, Petrowski K, Weidner K, et al. Impact of post-traumatic stress symptoms on the health-related quality of life in a cohort study with chronically critically ill patients and their partners: age matters. Crit Care. 2019;23(1):39.

Bell CM, Brener SS, Gunraj N, et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA. 2011;306(8):840-847.

Moore C, Wisnivesky J, Williams S, et al. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646-651.

Morandi A, Vasilevskis E, Pandharipande PP, et al. Inappropriate medication prescriptions in elderly adults surviving an intensive care unit hospitalization. J Am Geriatr Soc. 2013;61(7):1128-1134.

Holshue ML, DeBolt C, Lindquist S, et al.; Washington State 2019-nCoV Case Investigation Team. First case of 2019 novel coronavirus in the United States. N Engl J Med. 2020;382(10):929-936.

Chopra V, Flanders SA, O'Malley M, et al. Sixty-day outcomes among patients hospitalized with COVID -19 [published online November 11, 2020]. Ann Intern Med. Accessed December 2, 2020. https://www.acpjournals.org/doi/10.7326/M20-5661

National Institutes of Health. Coronavirus disease 2019 (COVID-19). Treatment guidelines. Accessed July 11, 2020. https://covid19treatmentguidelines.nih.gov

Centers for Disease Control and Prevention. Discontinuation of transmission-based precautions and disposition of patients with COVID-19 in healthcare settings (interim guidance). Updated August 10, 2020. Accessed December 2, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html

University of California San Francisco Health. UCSF inpatient adult COVID-19 interim management guidelines. March 28, 2020. Accessed July 11, 2020. https://infectioncontrol.ucsfmedicalcenter.org/content/ucsf-inpatient-adult-covid-19-interim-management-guidelines

Hwang R, Bruning J, Morris NR, et al. Home-based telerehabilitation is not inferior to a centre-based program in patients with chronic heart failure: a randomised trial. J Physiother. 2017;63(2):101-107.

Tchero H, Tabue Teguo M, Lannuzel A, et al. Telerehabilitation for stroke survivors: systematic review and meta-analysis. J Med Internet Res. 2018;20(10):e10867.

Phelan D, Kim JH, Chung EH. A game plan for the resumption of sport and exercise after coronavirus disease 2019 (COVID-19) infection [published online May 13, 2020]. JAMA Cardiol. Accessed July 17, 2020. https://jamanetwork.com/journals/jamacardiology/fullarticle/2766124

Flodgren G, Rachas A, Farmer AJ, et al. Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2015(9):CD002098.

Boehm K, Ziewers S, Brandt MP, et al. Telemedicine online visits in urology during the COVID-19 pandemic-potential, risk factors, and patients' perspective. Eur Urol. 2020;78(1):16-20.

Ohannessian R. Telemedicine: potential applications in epidemic situations. Eur Res Telemed. 2015;4(3):95-98.

American Geriatrics Society policy brief: COVID-19 and nursing homes. J Am Geriatr Soc. 2020;68(5):908-911.