The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to a pandemic. The coronavirus disease 2019 (COVID-19) has struck the United States and especially New York, like no disease in recent memory. The SARS-CoV-2 spreads quickly and easily. It is highly virulent and is known to transmit via airborne, fecal-oral, vertical, or most often droplet pathways.1–5 There is still much to learn about the COVID-19, but it has high mortality and most often presents with severe respiratory symptoms and deaths related to hypoxia, mucus plugging, and respiratory failure, although gastroenterological, urological, neurological, and cardiac invasion has been noted.2,6,7 Several treatments, such as azithromycin and hydroxychloroquine, have been suggested; however, there is no clear evidence for any treatment other than supportive care.2 The first case of COVID-19 in New York City (NYC) was on March 1, 2020, and, in just more than 1 mo, on April 13, 2020, there are 106,813 cases in NYC including 29,335 hospitalized and 7349 deaths.8 These numbers are likely an underestimate as not all persons are being tested, and there is a known false-negative rate. The numbers as they exist translate to roughly a 6.9% death rate among known cases of the disease. Although many young and otherwise healthy persons, as well as healthcare providers, have died of COVID-19, most deaths in NYC have been in those 75 yrs or older or with comorbid disease.8 The COVID-19 has and continues to strain the healthcare system in New York and is likely to do the same in other states.
As of April 13, 2020, the Mount Sinai Health System (MSHS) had successfully discharged 2400 people with COVID-19 infections. In addition, as of April 13, 2020, the MSHS had 1955 COVID-19+ patients admitted, including 453 in intensive care units and another 156 patients under investigation for COVID-19. The surge in patient volume and acuity of patients has led to the need for increased bed capacity and beds being placed in many open spaces throughout the Mount Sinai Hospital, including the Atrium Lobby and across the street from the hospital in the East Meadow of Central Park. At first glance, the role of physiatry and rehabilitation in a hospital setting of increased demand for acute beds and sicker patients may not be obvious, but the Department of Rehabilitation and Human Performance at Mount Sinai (Department) has grown to fill the needs within the healthcare system and form part of a greater goal.
The department is made up of practitioners hired by the MSHS as well as healthcare professionals at its affiliate hospitals, including the James J. Peters Bronx Veterans Affairs Hospital (Bronx VA) and Elmhurst Hospital Center in Queens (Elmhurst). Each hospital is caring for persons with COVID-19, including the Bronx VA that is caring for veterans with COVID-19. The Elmhurst is considered the epicenter of the epicenter of the pandemic. The Department covers 140 inpatient rehabilitation beds between the sites. Ninety of these beds are located in the MSHS with 10 beds located at the Elmhurst and 40 at the Bronx VA. As of April 2020, the department is home to a physical medicine and rehabilitation residency training program, sports medicine fellowship, brain injury medicine fellowship, and spinal cord injury medicine fellowship, totaling 28 trainees. Trainees rotate through all MSHS and affiliate sites.
The department finds itself in the epicenter of COVID-19 and despite the previously mentioned numbers; the MSHS and the whole of NYC continue to prepare for a peak in cases that is estimated to come by April 17, 2020. We hope to share our experiences, challenges, and successes to this point so that our colleagues may learn from and improve upon them.
UNDERSTANDING THE SITUATION
The SARS-CoV-2 is highly virulent. It spreads fast and is deadly. Within 2 wks of the first documented infection in NYC on March 1, 2020, the number of new cases of COVID-19 jumped to 1027. Twenty of the 25 days from March 16, 2020, to April 10, 2020, saw more than 3000 new cases of COVID-19 per day and 12 of these days saw more than 4000 new cases per day. During this period, the number of new cases of COVID-19 per day ranged from 2106 to 5872.8 Hospitals across the city also took drastic measures limiting visitors (COVID-19 screened), at first to just one visitor and then to no visitors at all except one for pediatric patients or laboring mothers. Of note, visitor policies are complicated on an acute inpatient rehabilitation unit, especially for those patients with cognitive dysfunction. Visitors were restricted to one for family training on the day of discharge. There was one event when a patient’s mother was not forthcoming with screening and did not reveal that she had a fever. Ultimately, her son acquired COVID-19 from her and several staff members were exposed. This illustrates the importance of following a strict visitor policy.
The number of newly infected patients requiring hospitalization and the acuity of their needs have overwhelmed hospitals in NYC. The presence of COVID-19 has not stopped persons from having strokes, heart attacks, or diabetic ketoacidosis, but the system is so overwhelmed that cancer, cardiac, and other patients with urgent but not immediately life-threatening issues are rerouted to hospitals outside the city for their care. Physicians and healthcare professionals who have not worked an inpatient shift in years have been called back to care for patients with high levels of oxygen demands including high flow nasal cannula, bilevel positive airway pressure, or full ventilator needs. Every patient in the hospital is tenuous. The focus day to day is on saving lives and expanding room, beds, personnel, and equipment within the system to be able to save more lives.
The mindset of hospitals and their personnel must shift to work together toward this new goal of saving lives in the moment, planning and changing course in real time, and pulling together. Physical medicine and rehabilitation is no exception.
EVOLVING DEPARTMENTAL MISSION STATEMENT
The department has been dedicated to advancing human ability and solving barriers for those with disabilities and otherwise since 1910. In pursuit of this mission, the department houses specialists in spinal cord injury, brain injury, sports medicine, pain management, cognition, innovation, technology, and more. The underlying thread is the desire to help people improve their lives and have a better quality of life. The COVID-19 has forced the department to adjust its mission statement during this time of crisis. The mission is simpler now: help people in whatever ways possible. This change was a call to all of those members of the department to remember why they chose health care, a desire to help and make a difference. Developing a common goal that all can relate to and that is motivating is essential during a time when healthcare professionals will be placed in unfamiliar, stressful, and potentially dangerous situations. It also aligns the department to the current mission of the hospital in dealing with the pandemic. All of the MSHS is present for NYC and working hard to save members of our community and our home. All are considered neighbors and important.
During this time, leadership is essential to update and disseminate information, maintain morale, and continue to reinforce the mission at hand. The leaders of the MSHS hold weekly town halls where all are invited. The leadership of the department holds at minimum one but often more video conference calls per week per group of providers. That is to say that there is at least one call a week with each of the following: attending physicians (attendings), residents, fellows, researchers, therapists, etc. These calls allow for persons to raise questions or concerns and for those to be answered. They allow for persons to bring up patient care ideas, many of which have been implemented. They allow for constant updates on departmental, hospital, and system status, and they allow for praise and gratitude from the leadership to the members of the department.
PHYSICAL AND MENTAL HEALTH OF STAFF
The physical and mental health of all staff of MSHS and the department are paramount. The department has a responsibility and obligation to its staff to keep them safe and healthy. Keeping a healthy work force that is able and engaged is also in the best interest of patients. Although the physical and mental health of practitioners and staff within the department are multifactorial, we will focus on prioritized and recurring topics for the MSHS and within the department.
Protecting the physical health of physicians and healthcare workers is more often an issue of resource rather than knowledge. For example, testing all healthcare providers for COVID-19 to deploy those with immunity and take greater precaution with those without immunity and to conserve personal protective equipment (PPE) whenever possible would be ideal, but this has not been possible because of limited numbers of testing kits available. Tests are reserved for those where having a diagnosis of COVID-19 would make a difference to their treatment plan. Regarding PPE, because of particle size of the virus, n95 masks (or equivalent) are the face cover of choice to minimize the risk of airborne or droplet transmission.9,10 Given the virus is thought to transmit most often via droplets, many institutions have policies that a standard surgical mask is sufficient coverage, unless a procedure or interaction, such as a bronchoscopy or chest compressions, is being done that increases the risk of releasing droplets. Different hospitals have different access to n95 masks and other PPE. This leads to mixed messages regarding appropriate use of PPE and what is acceptable. For example, there are hospitals within NYC that will not use donated n95 masks from specific countries as many have been counterfeited, and other hospitals that are in such need that they are accepting donations of any and all type of mask, n95 or not. Some hospitals have also discovered ways to sanitize and reuse n95 masks. It is essential to understand one’s hospital’s stance on n95 masks and PPE to be able to guide and protect one’s staff. Given all of these differences, the department instituted a policy that our practitioners should wear n95 masks during any patient encounter. Ideally, these masks would be changed between each patient, but given the shortage of masks, they are most often changed daily. It is also important to note that small n95 masks have become especially difficult to come by, and this has affected several residents. This is another example of why constant communication is of the essence. Face shields, surgical caps, shoe covers, and gowns can supplement these masks and add protection. The department continues to ask that if any practitioner is placed in a situation without appropriate PPE to contact leadership immediately so that it may provide them PPE. In addition, for example, in cases where a resident was known to be going to a hospital, such as the Elmhurst, that could have issues with stocking of PPE, they were given a “go-bag” containing appropriate PPE. Education on proper donning and doffing of PPE and proper hand washing technique is crucial as well for practitioners not to accidentally self-contaminate. Practitioners should also be reminded to avoid face-to-face conversations between themselves and patients without PPE and to limit physical examinations to as few examiners per patient as possible.
Equally as important is education on social distancing, appropriate donning and doffing of work clothing, and showering after a shift to not contaminate the home. Healthcare workers within the department are instructed to contact health employees with the slightest symptoms, such as fever, cough, dyspnea, rhinorrhea, or malaise. Self-checks every morning before coming into the hospital including check of temperature and pulse oximetry are ideal. Finally, several practitioners in the department had preexisting medical conditions putting them at high risk of mortality if they contracted COVID-19, and there were also practitioners who were caregivers for high-risk individuals. These practitioners have been tasked with performing video visits with patients and offloading any nonclinical work from those attendings who are seeing patients in the hospital. To help regenerate, rest, and recharge frontline providers throughout the MSHS, the department repurposed the Abilities Research Center to create a relief space. The space features recharge rooms, nutritious snacks, and a relaxing environment with serene decor and music to recuperate. The space also has large showers and bathrooms that practitioners can use before or after a shift.
Mental health of practitioners during this time is complicated as it varies by site, deployment, and personal factors.11 Balancing personal health with social obligation can lead to extreme stress.11 It is a commonly held belief within our field that physiatry is made up of different types of personalities and comportments and that it does not attract any one type of person such as other specialties that often have a stereotyped caricature. This variety in personalities within our field should be kept in mind. During an emergency, there are some more comfortable running into the fire and others more comfortable helping in other ways. This does not mean that apprehension should prevent a healthcare practitioner from seeing people with COVID-19, but it should be considered during deployment and when offering guidance and motivation. Persons who volunteer for the call for help, for example, practitioners who volunteer to be on the front lines, are still at risk of emotional distress and burning out. Several of our practitioners were placed in impossible situations, situations for which they could not have been prepared: following algorithms for making someone do not resuscitate, calling families on a daily basis to tell them loved ones were getting sicker or had passed, participating in daily codes, and spending the final minutes of a patient’s life in the room with them because no visitors were allowed. After just a few days, many of those who initially volunteered, attendings and residents alike, needed significant support for their mental health. In response to the incredible emotional toll, the department adjusted rotation lengths for residents and amounts of on and off time for fellows and attendings. It worked with its neuropsychologists to create a program where practitioners could feel safe and express and work through emotions.
Palliative care is leading programs on delivering bad news and for practitioner coping. In addition, programs for mindfulness, sleep hygiene, and nutrition have been created. The NYC and MSHS have also tried to remove as many other stressors as possible by providing child care and places to stay for providers who cannot return home because of quarantine or fear of contamination and by providing significant mental health resources above and beyond what is offered in the department. Several of the department’s ideas were proactive, but because of the speed at which the SARS-CoV-2 spreads, many were reactionary. If possible, we would suggest that departments institute preemptive education on delivering bad news, treatment of COVID-19, mindfulness, and general self-care as quickly as possible. We would also suggest starting a support group and preemptive mental health program. Medical students, residents, and fellows are especially at risk given that many medical students, as in NYC, may be asked to or volunteer to graduate early to help fight COVID-19, many physiatric residents feel the brunt of the gut-wrenching work, and many fellows who are board eligible may be promoted to attending status if needed. Forming a foundation of support and openness will only help a department to adapt and grow with the challenges faced.
INPATIENT REHABILITATION AND COVID-19
During the initial phases of COVID-19, it was the intention of the hospital to maintain acute inpatient rehabilitation to allow throughput for the hospital and allow for a backfill of beds. The thought was that if acute inpatient rehabilitation led to faster discharges, then MSHS would not have to add as many beds during the upcoming surge. However, the increase in cases of COVID-19 came so quickly that 75 of the 100 beds between the Mount Sinai Hospital and the Elmhurst were converted to medical beds almost immediately. The conversion included transition of several rooms to negative pressure rooms, an important consideration, and refitting of the units with appropriate equipment, monitoring, and PPE. Currently, the MSHS’s only remaining acute inpatient rehabilitation beds are 25 at Mount Sinai West. Discussions as to the need to convert these beds to medical beds are ongoing. The 40 inpatient rehabilitation beds at the Bronx VA are dedicated to spinal cord injury with no plans to convert at this time.
The initial idea behind keeping inpatient rehabilitation open was a good one, but the numbers of persons with COVID-19 were so large that there was no way to maintain the rehabilitation beds. The beds were needed to treat persons with acute COVID-19. Although the situation within the MSHS was overwhelming, it is feasible that other cities or institutions would have more manageable surges to a system.
In the first days of COVID-19, traditional rehabilitation patients continued to be admitted, but with a somewhat increased sense of urgency for discharge. What did not happen was a complete rethinking of rehabilitation’s role. Neither nontraditional patients nor those who were COVID-19+ were considered for acute inpatient rehabilitation. As a result, length of stay did not improve enough to help increase throughput of the hospital more than usual. Unfortunately, the relaxing of the rules by the Centers for Medicare & Medicaid Services in response to COVID-19 that included temporary waiving of quality measures, the 60% rule, and qualifying diagnoses for acute inpatient rehabilitation came after NYC was in the mid of the pandemic.12 Had timing been different, then at or before the first signs of the SARS-CoV-2, the focus of acute inpatient rehabilitation could have shifted dramatically to one of minimal functional gain needed to go home and family training with an aim to discharge within a week if at all possible. In that scenario, the unit would have been quicker in accepting nontraditional patients and perhaps dedicated one wing to COVID-19 rehabilitation sooner to help keep those patients from becoming debilitated and having extended stays. Although this may not have changed the ultimate conversion of the inpatient rehabilitation units to medical units, it may have helped or could help another system delay the change or ease the overall burden.
We would suggest thinking proactively in this way to any other departments in cities yet to be affected. We were able to reach out to local subacute rehabilitation facilities and local stand-alone acute rehabilitation centers to facilitate discharge of any patients we had admitted to acute inpatient rehabilitation at the time the unit was transitioned to medical. It would likewise behoove any department to establish similar plans with local facilities, not only for patients admitted to hospital-based acute inpatient rehabilitation units but also for those patients within the main hospitals that are good candidates for acute rehabilitation, so that they might receive a full course of rehabilitation and not an abbreviated family training with discharge home. This allows patients to receive more appropriate care and the hospital-based unit to serve the immediate needs of the institution.
It is our expectation that there will be an immense postacute care need as the COVID-19 pandemic passes. Patients are being cared for, stabilized, and discharged home. Patients are discharged at functionally lower levels to make room for patients in the emergency department (ED) awaiting a bed. Home care services are less effective because of practitioner unavailability. These patients are at high risk of developing postintensive care unit syndrome and should be tracked and followed by rehabilitation departments. They will have long-term cognitive, emotional, and functional needs that we as a field are in prime position to treat. Plan for these patients and seek them out for long-term follow-up.
Redeployment refers to the reassignment of a practitioner or healthcare worker to either a different role than their normal or a different department altogether. The department has redeployed the vast majority of its practitioners including attendings, fellows, residents, and therapists. Part of this redeployment involves virtual video visits that will be discussed later.
The MSHS requested and received stage 3: pandemic emergency status by the Accreditation Council for Graduate Medical Education. This status relaxes trainee metrics needing to be met for graduation and allows for trainees to be redeployed. Of note, the Accreditation Council for Graduate Medical Education has been clear on the continued need for trainee oversight and for the requirement of appropriate PPE at all times. Residents in the department rotate through the Elmhurst, the Bronx VA, and the MSHS. At any given time, four residents are at the Bronx VA, seven at the Elmhurst, and ten at the MSHS. Traditionally, residents and fellows have scheduled lecture time, but because of redeployment, blocked lecture time no longer occurs. Instead, residents and fellows have been broken up into groups based on their time-off between shifts and work in these virtual small groups to cover relevant topics in physical medicine and rehabilitation (PM&R).
After the closure of the inpatient rehabilitation unit and outpatient physiatric care at the Elmhurst, five of the residents assigned at the Elmhurst were deployed to internal medicine (IM). The remaining two continued within the department as part of a rehabilitative consult service to help evaluate patients for appropriateness for therapy and to help with throughput for the hospital. The five deployed residents work on COVID-19 units as IM interns. As mentioned, the Elmhurst is the epicenter of the epicenter of the COVID-19 outbreak in the United States. We allowed residents to volunteer for these positions and shifted resident locations based on this. However, as mentioned previously, it was important to keep constant communication with residents to ensure that no one resident was overburdened. What initially began as 2-wk rotations on the Elmhurst IM with weekend coverage evolved to 1-wk rotations on the Elmhurst IM without weekend coverage. In this way, residents had at least 1 wk on a different rotation to recuperate before returning to the Elmhurst IM. This was due to long hours of work and the emotional strain placed on residents. Residents at the Elmhurst were placed in positions of deciding which patients qualified to remain as full code and which patients should be converted to do not resuscitate based on algorithms. There were several days with codes and deaths of patients in the teens. The emotional distress did not only involve participating in the codes and experiencing the deaths but also involved experiencing the aftermath of having to communicate with these patients’ families and then having to go back and admit another critically ill patient straight away. It also involved fear: fear of not knowing how much longer the pandemic would last, fear of not knowing if or when PPE would run out, and fear of not having a cure or any treatment to offer patients beyond supportive care.
Fellows rotate through the Bronx VA inpatient unit, but residents rotate only through outpatient. The Bronx VA agreed to loan three of their four residents to the MSHS to be redeployed until such time that they were needed again at the Bronx VA.
Three of the seven fellows of the department were granted privileges as attending physicians of PM&R having met requirements set forth by the MSHS of having either board certification or being board eligible and having an unrestricted state license. These fellows played crucial roles in helping transition units from inpatient rehabilitation to medical. Notably, these privileges were only within PM&R. If other hospital systems were open to similar upgrading in privileges, fellows could be used on acute inpatient rehabilitation units, as consultants or to perform virtual video visits.
After the conversion of acute inpatient rehabilitation units at the Mount Sinai Hospital to COVID-19 units, the department was given the option of redeploying the attendings, fellows, and residents to other departments at the discretion of the hospital or converting to a medicine team run by rehabilitation personnel. The department chose the latter and attendings, resident, and fellows within the department, as of the time of this article, to staff a medical COVID-19 unit. The unit is a 25-bed unit that is split with a hospitalist run team. The unit is high acuity and is at capacity daily. From April 6 to 13, 2020, the physiatric run team averaged a census of 12 individual patients and had 6 discharges home, 2 transfers to the intensive care unit, and 7 deaths. The team underwent online education on management of COVID-19, and the team admits, manages, and discharges these patients. A buddy system was established with the hospitalist service of the MSHS for any questions or guidance in care. Residents and fellows staff the service along with attendings. Because persons with COVID-19 require frequent monitoring, a night float system was adapted in lieu of the traditional 24-hour call that existed on the acute inpatient rehabilitation unit. Having attendings, residents, and fellows remains under the umbrella of the department allowed for oversight and coordination of the schedule and access to PPE and a familiar and trusted support system to remain in place. Owning the schedule granted the ability to set time off between shifts, in a way that was not as accessible at the Elmhurst IM, for all practitioners to maintain physical and emotional health.
Outpatient and acute inpatient physical, occupational, and speech therapists were redeployed to the hospital to work with persons with COVID-19 and focus on early and persistent mobilization to improve outcomes. Although no data currently exist on the rehabilitation of persons with COVID-19, there are significant data supporting early and persistent mobilization of persons with acute respiratory distress syndrome and the department considers persons with COVID-19 should be treated like any other person with acute respiratory distress syndrome.13,14
An important part of redeployment and scheduling is the understanding that even with the most appropriate guidelines and use of PPE in place, practitioners will be exposed to and contract COVID-19. The department has had multiple residents and attendings miss time because of suspected and confirmed COVID-19 infections. Building redundancy and time off in scheduling allows for adequate coverage when a practitioner becomes ill and gives the sick practitioner the ability to recover without feelings of guilt that their colleagues are working more because of their illness.
HOME MONITORING PROGRAM
The department had a preexisting, virtual home monitoring program (HMP) for persons that had experienced a stroke. Thus, the infrastructure for a HMP for persons with COVID-19 was already in place. With the help of departmental researchers, the stroke HMP was converted to a precision HMP for persons with true or suspected COVID-19. Patients are referred to the HMP from any service within the MSHS, and then a physician evaluates them via video visit. Daily subjective and objective symptoms are monitored, and patients are guided on basic care and whether they should come in to the ED. The data gathered show trends allowing those practitioners working on the HMP to better understand whether the patient is stable, worsening, or improving. The purpose of the program is not only to limit trips to the ED to those who truly need but also to prevent unnecessary deaths through vigilant monitoring. Within the first days of the program launching, two people’s lives were saved when they triggered certain thresholds and were sent to the ED where they were ultimately intubated but recovered. Residents with medical conditions preventing them from seeing persons with COVID-19 face to face participate in the HMP. The program has been successful and well received by the MSHS.
In addition to the HMP, the department has been able to partner with the MSHS “hospital at home” program as well as providers who perform in-home visits. Although not part of the HMP, leveraging programs that allow for increased care in the home is important for the traditional PM&R patient population to continue to receive appropriate care in the case of disease or illness that is serious, but not severe enough to present to an ED. Partnering with similar programs can also expedite discharge from medical units or from acute inpatient rehabilitation units if needed.
The department canceled all nonessential outpatient visits the week of March 23, 2020. The only visits within PM&R considered to be essential were intrathecal baclofen pump refills, because withdrawal can be deadly. Other appointments, such as for pain management and physical therapy, were transitioned to video visits where medications could be prescribed and therapists could guide on appropriate treatments. Patients were only given an in-person visit if, based on the video visit, it would prevent a trip to the ED. The Centers for Medicare & Medicaid Services relaxed restrictions on video visits because of the COVID-19 pandemic allowing practitioners to perform virtual visits across state lines and using platforms that are non–Health Insurance Portability and Accountability Act compliant.12 This affords practitioners the ability to use easily accessible applications to communicate and have virtual video visits with patients. The removal of state lines as a barrier was crucial in NYC given the amount of practitioners and patients who commute from neighboring states for their work or medical care. Attendings who are unable to care for persons with COVID-19 because of medical considerations perform the bulk of video visits.
Virtual visits allow rehabilitation practitioners the ability to continue long-term connections with and care of patients. For example, a physician could check in on their patient with chronic tetraplegia and review topics such as bowel and bladder while simultaneously educating on the SARS-CoV-2. Many traditional rehabilitation patients are at high risk of contracting COVID-19 and are home bound with no other option beyond virtual visits with physicians. Practitioners can follow up on routine therapy, equipment, and medical needs of their patients. They are also able to see and establish new patient care. Physicians in the department are proactively reaching out to chronic patients to check on their physical and emotional status and remind them that the department is still available to help them whatever the issue.
PREPARATION TAKE HOME POINTS
- - The SARS-CoV-2 is highly infectious with high mortality: education of staff on PPE, disease manifestations and treatment, how to deliver bad news, appropriate hygiene, and self-care is essential.
- - Be attentive and flexible to the needs of the practitioners in your department.
- - Provide a consistent message of helping people.
- - Destigmatize mental health and be proactive in providing these services.
- - Be creative and innovate as the needs of the hospital evolve.
- - Leverage technology to improve patient outcomes and continue relationships with established patients.
- - Prepare for a large influx of rehabilitative need from survivors of COVID-19.