This was a prospective observational cohort study conducted in the 20-bed medical ICU of the Saint-Etienne University Hospital (France). The study is reported in accordance with STrenghtening the Reporting of Observational studies in Epidemiology (STROBE) recommendations (19). During the first (March 2020) and second waves (October 2020) of the pandemic, our ICU was entirely dedicated to COVID-19 patients. Patients were treated by the usual team of highly trained physicians and nurses. Due to the surge and the need to activate more ICU beds, additional physicians and nurses were recruited to reinforce the team. On March 17 2020, visitor access to the ICU was prohibited, with exceptions for end-of-life patients. From April 10, visits were allowed again, but restricted to one person per day for a maximum of 2 h. Progressively, the visitation policy was made more flexible and two visitors per day with no limitation on duration were allowed until the end of the study period. In order to replace the ICU diary, which could not be technically used because of visit restrictions, family members were encouraged to send emails and pictures that were included in a notebook by the team and given to the patient at ICU discharge.

When necessary, patients were transferred to a rehabilitation unit after discharge from the ICU or the hospital. The rehabilitation program is focused on physical rehabilitation and does not include a psychological follow-up. However, while in the ICU, the ICU psychologist identified patients and family members at risk of psychological troubles and proposed an appointment.

As part of routine care in our ICU, a one-year follow-up consultation is proposed at discharge to all ICU survivors with a stay of 7 days or more and their family members, irrespective if they were intubated or not. Patients were included in the study if they were eligible for the one-year post-ICU consultation and if they had been admitted to the ICU for severe COVID-19. Exclusion criteria were patients hospitalized in the ICU for less than 7 days, aged <18 years, or hospitalized in the ICU for COVID-19 without respiratory failure.

All patients hospitalized in the ICU for COVID-19-associated respiratory failure from 3 March 2020 to 20 December 2021 with a length of stay of 7 days or more were invited to attend a follow-up consultation. Two months prior to the date of the consultation, patients received a notification by mail with a scheduled appointment and an explanatory cover letter. Also included was a prescription for a low-dose thoracic computed tomography (CT) scan and laboratory tests, including an ionogram, blood urea and creatinine levels, a hemogram and albumin concentration, as well as self-evaluation questionnaires for themselves and their closest relative. Patients were free to decline or reschedule the consultation by contacting the ICU secretary.

All consultations were performed by a senior intensive care physician and at least one member of the nursing staff (nurse, psychologist, physiotherapist, auxiliary nurse). A psychologist participated in the consultations for some patients, especially those in who were identified or suspected to have psychological troubles before the consultation, or for those who were in contact with the psychologist during the ICU stay. Each consultation was scheduled for 2 h and divided into four parts. First, the medical history, including the ICU stay and post-ICU period, was reviewed with the patient and a family member and additional information was given by the physician or nurse at the patient’s request. Second, the patient’s psychological status was assessed through a free talk and analysis of the questionnaires. If necessary, the patient was referred to a psychologist or a psychiatrist. Third, a physical examination was performed, including resting oximetry, cardiopulmonary auscultation, blood pressure and weight measurements. The CT scan and laboratory tests were interpreted and the results given to the patient. When required, the patient was referred to a general practitioner or a specialist. Four, the family member was interviewed, following by an analysis of his/her questionnaire. If possible, part of this interview was conducted without the presence of the patient. When needed, the family member was referred to a psychologist or a psychiatrist. Finally, at the end of the consultation, a visit to an ICU room was proposed to the patient.

Demographic characteristics and clinical data of the ICU stay were collected for each patient. During the consultation, patient data related to physical, mental, and functional outcomes were also collected, as well as perceptions of ICU discomfort and mental health outcomes of family members. In addition, patients and family members were encouraged to share their feelings through a semi-directive interview focused on three questions: Did this ICU experience change your life on a daily basis? Will it have an influence on your future? Was it difficult to come back to the hospital?

Physical symptoms were collected through the physical examination. Baseline patient characteristics, comorbidities and clinical data were retrieved from the patient’s electronic health record. Severity of the acute illness was assessed by the Simplified Acute Physiology Score (SAPS 2) measured within the first 24 h of the ICU stay (20). Respiratory status was evaluated by the Modified Medical Research Council Dyspnea Scale (mMRC) scale and pulse oximetry was measured at rest.

Self-reported quality of life was measured by the Short-Form General Health Survey (SF-12) (21), which comprises 12 items from the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and provides a Physical Component Summary (PCS-12) and Mental Component Summary (MCS-12) score. Both are measured on a 0 to 100 scale where higher scores represent a better perceived quality of life.

The patient’s mental health status was assessed by the Hospital Anxiety and Depression scale (HADS) and the Revised Impact of Event Scale (IES-R). The level of anxiety and depression was measured with the HADS scale (22), which allocates each patient to one of three categories, based on the individual final scores. A score > 11 indicates a confirmed case and a score > 7 in each domain indicates a moderate or strong probability of anxiety or depression, respectively. PTSD was measured by the IES-R (23, 24). A score > 20 indicates reactions of clinical importance and a score > 33 indicates a high probability of a PTSD diagnosis. A total mean score > 1.6 suggests symptom levels compatible with a diagnosis of PTSD (24).

Assessment of perceived discomfort during ICU stay was measured by the French self-reported discomfort IPREA questionnaire (Inconforts des Patients de REAnimation questionnaire) (25). This questionnaire provides measurements of perceived discomfort such as noise, excessive light, bed-related discomfort, sleep deprivation, thirst, hunger, overall discomfort related to mechanical ventilation, pain, being tied down by perfusion lines, connecting wires, and cables, no respect for intimacy, anxiety, isolation, limited visiting hours, absence of a telephone, and lack of information. Patients were asked to complete the 16 items of the questionnaire and rate the severity of each discomfort source experienced during the ICU stay on a 10-point scale, with 0 representing no discomfort and 10 representing the worst discomfort ever perceived.

Open questions were added to the questionnaires in order to evaluate the patient’s perception of the ICU stay, their feelings about recovery and the return to family, social and professional life. During the 2-h consultation, an open discussion took place and patients and family members were asked about three domains: potential painful experiences during the ICU stay; impact of the ICU stay on the family unit; and impact of the ICU stay on their perception of the future. Striking quotes were collected by the physician or the nurse in charge leading the consultation.

Continuous variables were presented as the mean with standard deviation (SD) or medians with interquartile ranges (IQR 25–75), depending on their distribution. Categorical variables were presented as proportions. For analyses using questionnaires such as the HADS and IES-R, scores were analyzed as dichotomous, according to their respective cutoffs. A multivariate analysis was performed using a logistic model to identify factors involved in the variability of mental disorders. Mental disorders were defined by a HADS score > 10 for anxiety, a HADS score > 10 for depression or an IES-R score > 33. The first group of variables explored demographic characteristics and acute conditions: age, gender, SAPS2, length of ICU stay, length of hospital stay, renal replacement therapy, invasive mechanical ventilation, duration of invasive mechanical ventilation, ventilator-associated pneumonia and shock. The second group of variables explored the long-term physical outcomes: physical activity, dyspnea, mMRC scale, chronic fatigue, sleep disorders and abnormal chest CT-scan. The final model was chosen using Stepwise Akaike Information Criterion backward elimination using the “step” function of R (version 4.3.1).

From March 3 2020, to December 20 2020, 170 patients were hospitalized for severe COVID-19-associated pneumonia. ICU and hospital mortality rates were 22 and 25%, respectively. Of the 126 patients who were discharged alive from the hospital, 71 met the criteria for the one-year follow-up consultation. Fifty-one patients had a length of stay < 7 days or no COVID-19-associated pneumonia and four died after hospital discharge. Seventeen patients declined or did not respond. Finally, a total of 54 patients attended the consultation and were included in the study (Figure 1). Of the 54 patients in the cohort, 31 were transferred to a rehabilitation center after discharge from the ICU. Questionnaires were completed by 48 of 54 patients.

Median age was 66 (IQR, 58–72.5) years; 83% were men. The most common comorbidities were hypertension (57%) and obesity (39%). Most patients (77%) were intubated for a median duration of mechanical ventilation of 14 (IQR, 7–19) days. Patients who did not require intubation were all treated with high flow nasal oxygen. One patient required extracorporeal membrane oxygenation. Median ICU and hospital length of stay were 19 (IQR, 12–26) and 30 (IQR, 23–40) days, respectively. For 31 patients who were transferred to a rehabilitation unit, the total length of stay was 50 (IQR, 29–63) days. Patient characteristics are presented in Table 1. None of these patients were vaccinated because they were all hospitalized during spring and fall of 2020, before vaccines were available. Nine patients were immunocompromised (i.e., solid tumors, hematological malignancies, immunosuppressive drugs). Delirium was observed in 17 patients. All of them were mechanically ventilated and delirium occurred during or after weaning from mechanical ventilation. Twenty-two patients received corticosteroids, all were hospitalized after the results of the Recovery trial were published (26).

A total of 42 family members completed the questionnaires and were included in the study. Of these, 28 were present during the follow-up consultation.

Thirty-four (63%) patients reported chronic fatigue that affected their daily activities. Most patients had returned to their baseline weight at 1 year. Median body weight was 83 kg (IQR, 75–98) before ICU admission and 81 kg (IQR, 75–97) on the day of consultation, despite a substantial weight loss during ICU stay. Albumin dosage was available in 37 (68%) of 54 patients and had mostly returned to normal values [42.5 g/L (40–43.85)]. One year after ICU discharge, 33 (61%) of 56 patients reported that they resumed their hobbies. One-half (9) of the pre-ICU employed patients had returned to work [4 (22%) part-time; 5 (28%) full time].

Among the 54 ICU survivors, 37 (68.5%) expressed symptoms of shortness of breath median range according to the mMRC classification was 2 [IQR, 1–2]; 9 (16%) patients had severe dyspnea (grade 3 on the mMRC scale). At one-year follow-up, none required the use of supplemental oxygen, and median pulse oximetry at rest was 96%. Forty-seven patients (82%) underwent low-dose thoracic CT before the follow-up consultation. Chest CT scans were abnormal in 34 (72.3%) patients at 12 months. When present, radiologic changes included bronchiectasis in most cases (42.5%), ground glass opacities (40.4%), reticulations (31.9%) and anecdotically atelectases, nodules and alveolar consolidations.

Eight patients (16%) had symptoms of anxiety, 6 (12%) had symptoms of depression, and 51% had a high probability of PTSD (whether defined by a score > 10 or by a mean score > 1.6). Among relatives, 17 (44%) had symptoms of anxiety, 8 (21%) had symptoms of depression, and 23 (55%) had a high probability of PTSD (Table 2). In multivariate analysis, the following demographic characteristics were associated with long-term mental disorders: female gender (OR, 26.38 [95%CI, 2.83–668.66]), SAPS 2 (OR, 0.92 [95%CI, 0.84–0.98]) and mechanical ventilation (OR, 100.76 [95%CI, 5.02–9100.73]; Figure 1 ESM). Long-term physical condition associated with long-term mental disorders is mMRC dyspnea scale (OR, 3.29 [95%CI, 1.15–11.47]; Figure 2 ESM).

Forty-six of 54 patients completed the IPREA questionnaire. The mean overall score of discomfort was 3.3/10 (± 1.8). The highest scores were observed for limited visiting hours (mean 7.0 ± 3.1; median 8 [IQR, 5–10]) and perfusion lines (mean 5.1 ± 3.5; median 5 [IQR, 2–8]). The most frequently perceived discomforts with a score > 5/10 were limited visiting hours (n = 31), sleep perfusion lines (n = 21), anxiety (n = 19), isolation (n = 19), noise (n = 18), and sleep deprivation (n = 17). Other items were associated with a mean score < 5. Restrictions of visiting hours was an important discomfort with 62% (n = 28) of responders reporting a score higher than 7 (Figure 2).

The SF-12 score was available in 48 patients. Median PCS and MCS component summary scores were 44 (IQR, 32–52) and 45 (IQR, 41–48), respectively.