The novel coronavirus disease 2019 (COVID-19), a pandemic declared by the World Health Organization on March 12, 2020,1 represented an unexpected challenge for the global healthcare systems greatly impacting and requiring reorganization of patient care. First reported in December 2019 in Wuhan, Hubei province, China, to date (January 2, 2021), there have been 81,947,503 confirmed cases of COVID-19 and 1,808,041 deaths.2 In Europe, Italy was the first country to be affected by COVID-19 pandemic: the virus was first confirmed to have spread to Italy on January 31, 2020,3 and clusters of cases were later detected in the Italian regions of Lombardy and Veneto on February 21.4 By the beginning of March, the virus had spread to all regions of Italy.5 Although, in most cases (80%), the infection proceeds asymptomatically or with mild symptoms, 13.8% of cases have severe disease and 6.1% are critical, requiring hospitalization.6 As a result, when Italy unexpectedly experienced an increase in contagions, the Italian national healthcare system had to deal with several hospital admissions and the rapid reorganization of healthcare activities, without established guidelines. The most important challenges for the Italian national healthcare system became fighting the pandemic, avoiding the spread of the infection, and treating patients affected from COVID-19. Nevertheless, patients experiencing other diseases have continued to need treatments and care; in addition, in the rehabilitation field, it was necessary to provide early interventions for patients with recent outcomes of diseases, which, if untreated, could lead to disability.7,8 It was also required to maintain a therapeutic-rehabilitative contact with those patients affected by musculoskeletal and neurological disorders needing follow-up visits and treatments to avoid the worsening of their condition and quality of life, as well as the possible interruption of rehabilitation treatments once the prevention measures had been lifted.9
In conformity with the recommendations of the Italian Physical and Rehabilitation Medicine Society,7 our rehabilitation unit adapted care provision establishing priority criteria in the different settings and limiting the spread of the infection among patients and professionals.
In this article, we share our experience as an Italian rehabilitation unit in a national healthcare system hospital to provide suggestions to promptly reorganize rehabilitation activities during the pandemic.
It was essential to continue to ensure all the adequate activities and interventions to prevent major disabling complications in the acute conditions needing early rehabilitation. Physiatrists have an important role in the development of early mobilization programs in the intensive care unit,10 in acute inpatient wards for stroke survivors,11 and, after fractures,12 in particular in older patients because of their greater risk for adverse consequences. For these patients, rehabilitation consultations continued at the patient’s bedside, using personal protective equipment (PPE) identified as gloves and surgical masks. An exception was consultations performed on dysphagic patients for which class 2 filtering face-piece particle masks, face shields, and gloves were used by the medical staff, because the evaluation was performed in proximity to the aerodigestive tract.13
Rehabilitation Care for COVID-19 Patients
Medical rehabilitation staff and physiotherapists were involved early in consultations and treatments for COVID-19 patients admitted to infectious disease wards and intensive care units to prevent the mid- to long-term outcomes of the infection. Acute respiratory distress syndrome, prolonged prone positioning, and long hospital stay can lead to respiratory, physical, and psychological dysfunctions including neuromuscular weakness, critical illness myopathy/neuropathy, plantar-flexion contractures, fatigue, decreased mobility, recurrent falls, deconditioning, anxious or depressed mood, sleep and memory disturbances, and poor concentration.14,15 The consultations in the intensive care unit wards were fundamental to evaluate the patients early and draw a rehabilitation program including neuromotor rehabilitation, muscle strengthening exercises, balance exercises, respiratory rehabilitation, and neuropsychological rehabilitation to prevent and treat these outcomes.15 During these evaluations, the physicians wore PPE such as class 2 or 3 filtering face-piece respirators, safety glasses or face shields, long-sleeve water-resistant gowns, and gloves. Physiotherapists who provided chest physiotherapy and neuromuscular re-education to COVID-19 patients wore the same PPE.
Inpatient Rehabilitation Settings
Because our hospital was located in a surge area, at the outbreak of the pandemic, the inpatient beds were cleared with early discharges to leave the beds to the acute wards, in accordance with the recommendations of the members of the Archives of Physical Medicine and Rehabilitation Editorial Board.16 As suggested by McNeary et al.,14 a running list of patients who were almost ready for discharge and had good caregiver support was constantly updated. These patients and the caregivers were warned about the early discharge. The readiness for discharge was determined through Functional Independence Measure and Barthel index scores. If, after the discharge, further care was needed, the discharged patients continued to receive the treatments at home.
During the entire pandemic period, the personnel working in our unit (medical staff, nurses, healthcare assistants, secretarial staff, etc) had been swabbed for COVID-19 every 20 days.
Some rehabilitation residents and physicians were voluntarily reassigned to emergency activities joining multiprofessional teams, dealing mainly with triage of patients with suspicious symptoms of COVID-19 infection.
Outpatient and Home-Based Rehabilitation Services
Because of the limitations imposed by the national authorities in the movement of people to prevent the spreading of the infection,17 there were great difficulties in providing diagnosis and appropriate rehabilitation treatments in the outpatient setting. Because of the shortage of professional figures (physiotherapists and physicians have been massively involved in the treatment of COVID-19 patients) and the rapid rise in the contagion, on March 4, 2020, almost all the appointments for outpatient evaluations and all the ongoing rehabilitation treatments were canceled. Outpatient activities were reserved for patients with subacute neurological impairments due to severe acquired brain lesions or stroke and neurodegenerative diseases,8 and their daily rehabilitation was continued. Alternative communication methods were implemented to postpone other outpatient evaluations while maintaining the therapeutic relationship with patients experiencing chronic diseases without risk of rapid functional deterioration. Before the pandemic, less than the 10% of follow-up evaluations were conducted through telephone calls and contacts by e-mail. From March, the evaluations of imaging and hematochemical tests and the collection of feedback from patients with chronic diseases took place through telephone calls and via e-mail in place of face-to-face meetings. In addition, a specific website was developed in a short time to maintain contact with patients, providing them with videos and images of rehabilitative protocols that could be performed at home. Among younger patients, alternative methods of communication were well received; for young patients with scoliosis, specific protocols were available on the website and bimonthly telephone contacts were exploited as valid alternative to ambulatory follow-ups. However, technological skills were required to successfully use these methods and older patients and those with neurological disorders could poorly exploit them.12 Preliminary data collected through a questionnaire at the reopening of outpatient activities (from May to August 2020) in our rehabilitation unit have shown that 81% of patients preferred face-to-face visits rather than alternative communication methods and only 9% preferred to avoid the ambulatory visit because of the fear of contagion.
Overall, during the suspension of the ambulatory evaluations, the volume of ambulatory visits had decreased by 70%. Of the remaining visits, approximately 50% were performed via e-mail, 30% telephonically and 20% (nonpostponable evaluations) in person. In addition, elective procedures such as joint injections, ozone therapy, gait analysis, and injections of botulinum toxin were suspended.
If an appointment for an outpatient assessment was necessary, the day before the visit, the acceptance staff called the patients to confirm it and to ask questions focused on identifying possible signs and symptoms of COVID-19 infection (respiratory symptoms, fever, and diarrhea).
Considering that current data suggest that hospital-associated transmission is possible in a high percentage of patients (29% among health professionals and 12.3% in hospitalized patients),18 an adequate reorganization of the hospital space had been essential to reduce the spread of the virus. Healthcare assistants were charged with the controls at the entrance of the building in which our clinics and gyms are located. All the patients were screened with a preliminary interview related to the onset of COVID-19 symptoms and possible contacts at risk in the previous days and with body temperature measurement. In addition, all the staff entering the building were screened with body temperature measurement. The room in which the extracorporeal shockwave treatments were normally administered was converted into a room where COVID-19 swabs were performed for all the workers of our building (physiatrists, orthopedists, residents, nurses, etc).
Access to the hospital was guaranteed for the patient only; one accompanying person was allowed for non–self-sufficient or pediatric patients. The need to involve family members in the rehabilitative decision making and treatments was therefore weakened by the need to reduce crowding.
Waiting for the visit, the patients had to maintain at least a 2-m distance from each other and to use surgical masks and gloves, according to national guidelines.19 Inbound and outbound routes were differentiated to further reduce the possibility of infection. Between one visit and another, the healthcare assistants were in charge of sanitizing the environments and the objects touched by medical staff and patients (handles, chairs, desks, couches, keyboards, etc). To make a later appointment or to inform healthcare workers of any change in clinical status, each patient was given a dedicated phone number to call.
However, the postponement or interruption of treatments in patients already experiencing limitations in social participation can result to additional difficulties in social integration leading to a decrease in quality of life and to an increase in functional disabilities.20 Even in the patients with scoliosis as mentioned previously, the excessively delayed evaluations can lead to the worsening of the deformity and the inability to use the orthosis (it becomes small, worn, etc). All these reasons led our unit in May 2020, when Italy entered the so-called phase 2,21 to restart a selected part of rehabilitation treatments and outpatient evaluations. In doing so, it had been essential to maintain preventative measures to avoid the spread of the infection. The suspended evaluations were rescheduled, and each patient received a phone call to make another appointment. According to the authorities’ guidelines,19 social distancing, body temperature measuring, wearing of surgical masks, and sanitizing hands had been and are still respected. Between one patient and the other, a half-hour period had been maintained to allow the rooms and the objects to be sanitized after the visit and to reduce the number of people in the waiting room. Inbound and outbound routes had continued to be differentiated, and the dedicated phone number had remained active to facilitate subsequent appointments.
Residents and Fellows
As reported by Stein et al.,12 the pandemic deeply influenced residents and fellows’ activities. Although the infections increased, all the medical students’ internships in our rehabilitation unit were suspended. Residents and fellows continued to attend the unit, contributing to acute care consultations and outpatient assessments also through alternative communication methods. The training rotations were temporarily suspended and then resumed during phase 2. The hospital and the occupational health service gave additional flexibility to the director to program diversified activities for the residents who were immunocompromised or pregnant to ensure each individual’s safety.
Limited PPE availability influenced the decision to take shifts to attend the unit. Lessons were carried out using a video call platform, and peer teaching was encouraged; because of the reduction of outpatient evaluations and the discharge of all the patients in the ward, the residents were able to deepen their knowledge on rehabilitation topics and to discuss them with their colleagues.
Finally, some residents were employed in the emergency departments.
From this experience, it is possible to derive some lessons that can be applied to every rehabilitation unit to provide the best possible care during COVID-19 pandemic or in similar situations that may arise in the future, although hopefully it will not happen. The main lessons learned are as follows:
- - the reorganization of the activities of a rehabilitation unit by establishing treatment priorities can help rationalize the deployment of staff and PPE in an emergency;
- - the instruction of the staff to wear PPE correctly can prevent the spread of the infection;
- - the organization of specific routes for outpatients, promoting social distancing, can limit contagion in the hospital environment;
- - the implementation of the use of technology for follow-up visits can play a key role in maintaining therapeutic continuity;
- - the reorganization of educational activities by improving distance learning may be important to ensure continued education.
At this moment, when the world is witnessing a new wave of the pandemic and some Italian regions are facing a further lockdown, the lessons from our experience can contribute to draw a plan of measures that can be promptly applied in similar situations, to reorganize the activities early and adequately. The alternative modalities to maintain therapeutic-rehabilitative contact with patients, the training to use PPE correctly and judiciously, and the distance learning for residents’ education should become part of the traditional rehabilitative practice.
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