Adapting Your Practice During a Pandemic: COVID-19

Overview and Description:

In 2020, a newly emerging SARS-CoV 2 virus (better known as Coronavirus Disease 2019 (COVID-19)) spread through the world swiftly causing a global pandemic. According to the Johns Hopkins Coronavirus resource center, by January 11, 2021 the number of US Confirmed cases was 22,575,985 and 375,838 U.S. deaths. The COVID-19 pandemic precipitated changes in physiatric practice across a multitude of settings. Most prominently, the use of personal protective equipment (PPE) during a patient encounter, types of encounters (in person vs. telemedicine), and the redesign of the interactions between the multi-disciplinary team members has challenged the way rehabilitation care is delivered. In addition, we are serving a new patient population, COVID-19 survivors, whose needs we are just starting to understand. About 10% of patients become “Long COVID” or “long-haulers”, remaining unwell beyond three weeks and some for months (Greenhalgh et al 2020). The transformation of clinical care triggered by COVID-19 has impacted rehabilitation in the acute, subacute, chronic, and pre-terminal stages. Rapid adaptation has been critical to continue supporting the patients we typically serve and caring for a new population of patients throughout the rehabilitation continuum.

This article describes changes in practice in the acute hospital, inpatient rehabilitation unit, home health care, subacute rehabilitation facility and outpatient setting. Specifically, we will address how the acute hospital has addressed needs of patients with COVID-19, the transition of patient care to an inpatient rehabilitation setting, and ongoing care in the outpatient setting.

Relevance to Clinical Practice:

Acute Care Hospital

Physiatric practice in the acute hospital may be adapted in several ways.  Heightened communication with the acute care therapy team is of paramount importance. Both in person and remote evaluations can be used to augment patient care. In acute care hospitals, physiatric consultations for rehabilitation management and discharge disposition continued without interruption. If necessary, some of the evaluations were completed with the use of a tablet or cellphone to connect to the patient with a televisit via suitable platforms (e.g. zoom or doximity).

As an example, in the Johns Hopkins COVID ICU, charts were screened remotely to assist in identifying patients for early mobility intervention. Early mobilization of patients with respiratory failure on mechanical ventilation has been shown to improve strength, physical function, and quality of life while length of stay (LOS), cost, delirium, sedations, and duration of mechanical ventilation have been reduced (Morriss et al, 2008; Needham et al 2010, Thomsen et al, 2008; Needham et al, 2008; Schweichert et al, 2009).  After physiatry screened a chart and determined appropriateness to begin early mobility activity, primary teams were engaged to initiate therapy consultations.

Tools to formally assess functional capacity and outcomes are important to provide adequate recommendations for physical, occupational and speech therapists.  The Activity Measure for Post-Acute Care (AM-PAC™) “6-Clicks” Inpatient Short Forms are tools that can be used by nurses and therapists to document function. At our institution, the initial physical and occupational therapy evaluation scores on these short forms for basic mobility and daily activity are used to determine the levels of therapy care needed.  Patients whose raw scores are 6-12 received standard of care, scores of 13-21 Acute hospital Rehabilitation Intensive SErvice (ARISE), and scores of 22-24 Enhanced Recovery After Covid (ERAC). The categories of standard of care, ARISE, and ERAC remain fluid, and dependent on a patient’s progress and tolerance to rehabilitation services. Patients can progress into the next category when they make improvements in AMPAC. This system allows for staff to provide care based on the patient’s needs. For patients who need speech language pathology services, ARISE includes patients that are nil per oral (NPO), recommended for pureed solids, and/or recommended for thickened liquids. When classified as ARISE, the patient receives swallowing intervention Monday through Friday as long as they remain medically stable (Kim et al, 2020). Table 1 visually represents the patient stratification tool. Additionally, therapists can review with proning teams proper positioning to prevent complications such as brachial plexopathies or musculoskeletal injuries.

Table 1: Patient Stratification Tool

Physiatry care during the pandemic focuses on patients for whom increased intensity rehabilitation can result in less need for post-acute care.  In our case, this translated into focused attention on patients who were in the ARISE category for any discipline. The physiatrist monitored the patient’s dysphagia, neuromuscular complications, cognitive concerns, and functional mobility from the ICU to home. Patients who were unable to make significant functional recovery to discharge home were admitted to the comprehensive inpatient rehabilitation unit (once recovered from the infection) or transitioned to physiatry’s care while in the acute care COVID-19 units to receive comprehensive inpatient rehabilitation level of care.

Inpatient Rehabilitation

Changes to Admissions

Rehabilitation during the COVID-19 pandemic requires physiatrists to focus on the needs of the patients typically treated and on a new population of patients recovering from COVID-19. The CMS 1135 waiver declared during the public health emergency (PHE) allowes for changes in practice. The waiver permitted easier transfer from acute care to post-acute care such as inpatient rehab facility (IRF) and subacute rehabilitation facility. In IRF, the 60% rule and 3-hour rule were waived (CMS, 2020).  The changes in the regulation for inpatient rehabilitation enabled completing rehabilitation in negative pressure rooms, beyond the typical rehabilitation unit, when necessary to protect staff and other patients while COVID-19 patients remained infectious.

Some rehabilitation networks redefined pathways for rapid admission to IRF facilities by implementing direct physician-to-physician referral and discussion rather than the traditional referrals made through social work or case management (Gitkind, et al 2020). This system was noted to improve triage of patients in the acute hospital and increase acceptance rate of referred patients to IRF (Gitkind et al, 2020). Patients were also able to get streamlined into admission immediately upon medical acceptance with registration, pre-admission screen note and bed assignment all occurring in a parallel process (Gitkind et al, 2020).

Changes to Visitation

In the beginning of the pandemic, multiple institutions did not permit visitors in the hospital unless the patient was granted a visitor exception. In certain cases, visitors exceptions were allowed for patients with cognitive impairments or at the end of life who were not in a COVID unit. As the pandemic evolved, these restrictions were liberalized based on the risk of community transmission.   Immunocompromised patients, defined as those who had a transplant, HIV, or active chemotherapy, had more restrictive visitation policies at some institutions. However, as the number of COVID patient’s increase and there is a predicted surge, hospitals may return to limited visitation.

Changes to Team Conference

In multiple institutions, to achieve appropriate social distancing to minimize potential staff exposures to COVID-19, team meetings moved to a videoconference format. For example, in our institution, nursing, care management, and the attending physiatrist were the only team members physically present.  Therapy representatives, advanced practice providers, psychologist, resident physicians, and home care team members participated through video conferencing. Certain rehabilitation team members worked remotely. For example, social workers and case managers alternated in person work weeks. While teleworking, they contacted patient’s by phone; a challenge for patient assessments.  Rehabilitation psychology services were provided through video conferencing using bedside tablets. Bluetooth speakers were used to facilitate communication. Additionally, all hospital consultants were able to contact their patients through tablets available in the patient rooms or in person as appropriately.

Discharge

To complete family training, families had the option of participating in video chat, pre-recorded videos, curb-side training, or in person if a visitor exception was obtained. At our institution, patients were assisted in setting up applications to access their electronic medical record if not yet activated. All patient’s left with home exercise programs and follow up tele-medicine physiatry visits.

Resident Education

The COVID-19 pandemic has significantly affected PM&R residency education with the implementation of social distancing guidelines, modified clinical demands, and redeployment. The pandemic has placed emotional, cognitive, and physical stressors on health care workers. Residency training programs have noted the important actions to take during a crisis include clear ongoing communication, implementing changes to resident education and clinical rotations, staying up-to-date on guidelines, and ensuring compliance (Siedel et al 2020).

Outpatient Practice

Outpatient clinics had to shut down in most states immediately as required by government agencies except for emergent care (e.g., baclofen pump refills). Visits were transitioned to telemedicine using several of the platforms available in the market based on patient’s need and ability to access the technology. As the pandemic progressed, patients who required procedures were evaluated and brought in for care if there was an urgent need and to prevent emergency room visits. In person visits were limited to conserve PPE (gowns, face shields, n95 or surgical masks) and limit exposure of vulnerable individuals and avoid waiting area overcrowding. The expansion of telemedicine during COVID-19 pandemic has been well-received by a majority of patients and physicians (Tenforde A, 2020).

Screening       

Outpatient clinics screened for COVID-19 by asking for the following symptoms: cough, fever or chills, shortness of breath or difficulty breathing, muscle or body aches, sore through, new loss of taste or smell, diarrhea, headache, new fatigue, nausea or vomiting, congestion or runny nose. Additionally, questions regarding household COVID-19 exposure or recent contact with someone known to have COVID-19 are used. Many facilities have implemented screening badges that demonstrate successful completion of a screen 24 hours prior to the appointment.

Clinic Practice

All patients are required to wear a face mask, recommended to perform frequent handwashing, and placed in waiting rooms with adequate social distancing. For in person visits, patients with disabilities were allowed one visitor otherwise no visitors were permitted in outpatient areas. As the initial wave was controlled, outpatient clinics opened with proper social distancing and PPE. Early in the reopening process, visit times were limited to prevent crowding and to promote distancing. When appropriate, telemedicine was encouraged. In person visits were reserved at first to those who had been waiting for procedures such as spinal injections or botulinum toxin injections. Later, professional guidelines were developed for when patients should return to clinic for procedures. For example, the Spine Interventional Society developed guidelines for interventional pain procedures during the COVID-19 global emergency to assist in determining risk/benefit of obtaining the procedure (SIS, 2020). For botulinum toxin injections it has been suggested that if two or more of the following issues are present at screening the patient should receive the injections: last inoculation >3 months ago, increased spasticity impacting function or autonomy, presence of hypertonus in untreated muscles that affects function or autonomy, severe degree of spasticity that can lead to long term damage, significant presence of pain potentially related to spasticity, or impossibility of wearing orthoses/aids in use due to the presence of spastic hypertonicity (Baricich et al, 2020). For patients who need to undergo procedures at a surgical centers COVID-19 testing 72 hours prior to procedure was required at several institutions.

Post COVID-19 Survivor Clinics

Telemedicine COVID-19 survivor clinic were established at several institutions.  The National Institute for Health and Care Excellence (NICE) developed guidelines regarding managing the long-term effects of COVID-19 and recommended patients to be referred to integrated multidisciplinary rehabilitation to develop a personalized prescription (NICE, 2020). At Johns Hopkins, on discharge from either the acute hospital or inpatient rehabilitation patients continued with home therapy. Patients were given a follow up appointment with a physiatrist and a pulmonologist via telemedicine.  Physiatrist monitored recovery and assisted in establishing outpatient therapy services. Screening tools were administered, and patients were referred to physical therapy if outpatient AMPAC <50, to occupational therapy if MoCA Blind ≤ 18, speech language pathology if EAT-10 ≥ 3, and rehabilitation psychology if PHQ-9≥10, GAD-7 ≥ 10, IES ≥ 9.

Cutting Edge/ Unique Concepts/ Emerging Issues:

Covid-19 has shifted physiatry practice to integrate in person and tele-medicine in outpatient and inpatient settings. It is critical to quickly adapt a practice to be resilient in the face of the healthcare infrastructural challenges precipitated by COVID-19. Remote patient monitoring CPT codes 99453, 99454, 99457 can be utilized for COVID-19 patients that remain at home during treatment and recovery (AMA, 2020). In the inpatient setting, stratification tools can be developed to meet the needs of patients and appropriately allocate resources. Some of the care can be delivered through telemedicine should there be tablets in a patient’s room. This can be particularly advantageous to conserve PPE. Telemedicine visits can be appropriately modified to meet the patient’s needs. When necessary, patients can be brought to in person clinics with safe social distancing and proper personal protective equipment. A complete assessment of a COVID recovered patient should be addressed in survivor clinics that focus on function and disability to maximize the patient’s function and quality of life. Many concepts learned from ARDS survivors and Post Intensive Care Syndrome (PICS) survivors can be utilized as a foundation for principles of management in this emerging disease.

Gaps in Knowledge/ Evidence Base:

We are still learning about long term impairments from COVID-19. Currently, there is no data to predict who will develop “long COVID” and there is no clear definition for patients who have long standing deficits after COVID-19 infection. Long COVID is used to describe signs and symptoms that continue or develop after acute COVID-19 for ongoing symptomatic COVID-19 (4-12 weeks) and post-COVID-19 syndrome (12 weeks or more) (NICE,2020). A study conducted in Italy, found 87.4% of patients with persistence of at least 1 symptom particularly fatigue and dyspnea at a mean time of 60 days after onset of first COVID-19 symptom (Carfi et al, 2020). There are studies showing that symptomatic adults tested in an outpatient setting may require weeks to resolve symptoms and return to usual health (Tendforde et al. 2020, Couzin-Frankel, J 2020). Continued symptoms may be more likely to occur in patient over 50, who have multiple chronic illness and became very ill with COVID-19 (Couzin-Frankel, J 2020). Lastly, as vaccinations have recently begun, we do not know how long the current practice will continue.

References:

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Author Disclosures

April Pruski, MD
Nothing to Disclose

Nicole Frost, MA CCC-SLP, BCS-S
Nothing to Disclose

Sowmya Kumble, PT, MPT, NCS
Nothing to Disclose

Holly Russell, MS, OTR/L
Nothing to Disclose

Marlis Gonzalez-Fernandez, MD PHD
Nothing to Disclose