What Is Known
- Rehabilitation services, especially those provided by physical and occupational therapists, are important components of care for patients with COVID-19. However, it is unclear how rehabilitation services should be implemented in field hospitals given the limited resources available in this setting.
What Is New
- This article describes several strategies for maximizing the impact of a small team of physical and occupational therapists in a COVID-19 field hospital, as well as recommendations for other field hospitals that plan to implement rehabilitation services during the COVID-19 pandemic or other future health crises.
Coronavirus disease 2019 (COVID-19) can cause rapid deconditioning and necessitate prolonged bedrest, which increases the risk of hospital-acquired debility.1–3 Many patients with COVID-19 develop impairments in mobility and muscle strength and experience oxygen desaturation with exertion. Rehabilitation experts, such as physical and occupational therapists, work with patients recovering from COVID-19 to improve their ability to perform activities of daily living and return home after completing in-hospital treatment.4–8 Rehabilitation services have become increasingly important as surges of critically ill patients and concerns regarding infection control have led to shortages in postacute placement options for patients with COVID-19 who cannot return home.9 Rehabilitation interventions for those with or recovering from COVID-19 include aerobic conditioning, strength training, energy conservation training, breathlessness management, and activity-specific training.10,11 These interventions can improve walking speed, endurance, and lung function among those recovering from severe acute respiratory syndrome and COVID-19.12–14
The confluence of a surge in intensive care unit patients, decreased postacute facility access, and longer hospital stays has put health systems under pressure to consider alternate strategies to facilitate hospital throughput and maintain capacity.15 These factors have necessitated the opening of field hospitals to treat the growing number of infected patients. Although rehabilitation experts may improve the ability of field hospitals to discharge patients to their homes, most field hospitals do not have the resources needed to offer comprehensive in-house rehabilitation services.
In this article, the authors describe the implementation of a small rehabilitation team at a COVID-19 field hospital, the strategies used to support a “hospital-to-home” discharge framework, and make recommendations for implementing rehabilitation services in other field hospitals during the COVID-19 pandemic or future health crises.
The Field Hospital
The Baltimore Convention Center Field Hospital (BCCFH) is a 250-bed COVID-19 alternate care site established in the Baltimore City Convention Center to increase Maryland’s capacity to care for inpatients during the pandemic (Fig. 1). The BCCFH is licensed and funded by the state of Maryland and led by senior staff from The Johns Hopkins Hospital and the University of Maryland Medical Center. It has served more than 1200 patients since opening in April 2020.
The BCCFH patients comprise convalescing or newly diagnosed patients with COVID-19 who have complicating conditions or circumstances that do not allow them to be cared for at home. The BCCFH does not accept patients requiring high-flow oxygen or intubation, those who are bed bound, or those who have severe mobility impairments. These criteria reflect the limits of the physical setting, such as the lack of electric hospital beds and ventilators and the distance from patient beds to restrooms.
When screening patients for major mobility deficits, the BCCFH uses the Activity Measure for Postacute Care Inpatient Mobility Short Form, a reliable and valid measure scored without requiring observation of actual patient performance.16,17 According to previously established cutoffs,18–21 local hospitals are advised that patients with Activity Measure for Postacute Care raw scores of 19 or greater are eligible for transfer to the BCCFH and that those with raw scores of 13–18 are likely eligible, but more information is required. Patients with scores less than 13 are ineligible for care at the BCCFH. The triage form used by the BCCFH is in Appendix 1 (Supplemental Digital Content 1, https://links.lww.com/PHM/B369).
Providers at the BCCFH include physicians, nurse practitioners, and physician assistants from various settings. Nurses and their support staff comprise three tiers. Tier 1 staff are registered nurses. Tier 2 staff are personnel other than nurses with some medical training (e.g., nursing students). Tier 3 staff are nonmedical staff who support nonclinical functions. Every effort was made to avoid recruiting inpatient clinical staff from existing hospitals, so that inpatient units were not depleted of personnel. This staffing model meant that a substantial number of staff were recruited from outpatient settings, such as urgent care, specialty care, and primary care.
Implementation of Rehabilitation Services at the BCCFH
Rehabilitation services were implemented at the BCCFH to meet three objectives: (1) maximize patient activity and mobility to improve patient health and prevent adverse events (e.g., blood clots, falls), (2) facilitate timely discharge, and (3) maximize the proportion of patients discharged to home. The steps to implementing rehabilitation services in the BCCFH and the strategies used to maximize their impact are described hereinafter.
Rehabilitation Practice Model
Based on evidence supporting early engagement of patients with COVID-19 and other severe respiratory conditions in physical activity,22–25 the World Health Organization recommends actively mobilizing patients with COVID-19 to prevent hospital-acquired debility and adverse events.26 Therefore, the BCCFH rehabilitation practice model prioritizes early and frequent mobilization of patients. In addition, the rehabilitation team provides assistive-device training for falls prevention, graded aerobic exercise to support weaning from supplemental oxygen, and education about pacing strategies to avoid over-exertion. These interventions are delivered in a similar manner as on an acute-care unit. The rehabilitation practice model uses elements of a previously described activity and mobility promotion program that emphasizes efficient utilization of rehabilitation personnel, fosters a culture of mobility, and facilitates interdisciplinary commmunication.27
Initial rehabilitation staffing consisted of two full-time-equivalent (80 hrs/wk) physical therapists and a part-time (20 hrs/wk) occupational therapist. Although the BCCFH was designed to serve 250 patients, we anticipated that the census would average 60 patients based on the capacity of surrounding hospitals. Therapist staffing was based on this anticipated volume, as well as the criteria for admission, which excluded those with major mobility deficits.
Members of the rehabilitation team were oriented to the unit, the BCCFH electronic medical record system, BCCFH objectives, and trained in infection control measures.
All other clinical staff were educated about the rehabilitation model and their roles in facilitating patient mobility and exercise. Clinical staff were coached on how to safely assist patients to transfer, how to encourage safe ambulation, and how to wean patients from oxygen and assess for progress or worsening status. Tier 2 and tier 3 staff were trained to supervise patients while walking and performing daily activities (e.g., dressing, grooming). These staff members were also trained in energy conservation strategies and how to recognize signs of excessive fatigue or cardiopulmonary distress. Last, they were trained to assist high-functioning patients with their assigned daily exercises. Training was conducted at the point of care by BCCFH therapists.
Rehabilitation Triage System
Once admitted to the BCCFH, each patient is triaged to one of three levels of rehabilitation care by the treating therapist using a triage process developed in real time as the BCCFH began accepting patients. The triage system described in Table 1 was developed retrospectively according to the experiences of the rehabilitation team and may serve as a model for future field hospitals implementing rehabilitation services. In real time, the therapy team determined which patients required any rehabilitation interventions and, among those, who required direct care from a therapist. This resulted in many patients with low/no functional impairment receiving no direct rehabilitation care and many of those with high levels of impairment being seen 5–6 days per week, often twice a day. This approach was used to maximize the impact of our small rehabilitation team and direct care toward patients in most need, in alignment with the Choosing Wisely campaign.28
TABLE 1 -
Triage system used by the Baltimore Convention Center Field Hospital to determine the level of rehabilitation
care that patients with COVID-19 require
|Rehabilitation Triage Level
||Level of Care
||Requires assistance with ambulation or transfers
||Direct care by physical therapist and/or occupational therapist
|Requires monitoring of vitals
|Requires intervention techniques for musculoskeletal impairment
|Any level of cognitive impairment
|Tier 2/3-personnel directed
||Supervision with ambulation
||Encouraged to walk with tier 2/3 providers 3–5 times daily; sitting or standing home exercise program dependent on safety/balance
|Independent with transfers
|Does not require monitoring of vitals
|Reports fatigue or mild shortness of breath with walking, requiring a wheelchair follow or reminders for pacing
|No major musculoskeletal impairment
||Independent ambulation and transfers
||Encouraged to ambulate 3–5 times a day independently; independent home exercise program
|Does not require monitoring of vitals
|No signs of fatigue or shortness of breath with walking >250 ft
|No major musculoskeletal impairment
Culture of Mobility
To support interdisciplinary efforts to promote patient mobility, the rehabilitation team created an environment at the BCCFH that supported a culture of mobility. One component of this effort was the addition of signage that focused on three elements: (1) the harms of immobility, (2) the benefits of ambulation, and (3) the benefits of engaging in activities of daily living throughout the day. These messages are displayed in key locations, such as nursing stations, near rest rooms and showers, and in patients’ rooms. In addition, a walking track labeled with the distance to other locations encourages patients to work toward daily walking goals, set by the rehabilitation team. All providers and staff members are trained to reinforce patient engagement by asking patients if they have walked/exercised each day and by encouraging patients to perform these activities frequently.
A member of the rehabilitation team attends rounds daily, reports the level of rehabilitation care needed for all new admissions, and provides updates on patients receiving rehabilitation services. The rehabilitation team is critical to coordinating discharge because they make recommendations about the level of care patients require after discharge based on functional impairment. In addition to rounds, all members of the healthcare team are trained on how to complete the Activity Measure for Postacute Care. The use of a common mobility assessment tool allows all members of the team to track patient progress and set daily mobility goals.
Challenges and Recommendations for Future Sites
Staff Turnover and Education
Ever-changing patient volumes and the difficulty of predicting local surges in the number of infected patients have made staffing the BCCFH complex, as the administration has had to balance efforts to ensure adequate staff-to-patient ratios while avoiding wasteful expenditures. As such, the BCCFH used a “PRN” staffing model, which resulted in frequent staff turnover. Unlike traditional hospitals that have dedicated nurse educators, the BCCFH rehabilitation team took on the role of staff educators for topics related to mobility and safe patient handling. High rates of turnover necessitated frequent point-of-care training by the rehabilitation team, which reduced time available for direct patient care.
Promoting patient mobility is crucial, and the authors believe the time spent by the rehabilitation team educating other staff members on this topic was important. However, there are likely more efficient ways to provide training. We suggest that future sites consider incorporating mobility training into their onboarding process and require staff to complete short refresher courses at regular intervals. Much of this information can be delivered through prerecorded presentations, which would not detract from the rehabilitation team’s availability to provide care.
Communication Surrounding Mobility
Although the rehabilitation team was able to promote a culture of mobility through staff training and communicated mobility status and goals during rounds, nonrehabilitation staff often required repeated communication regarding individual patient’s mobility levels (e.g., “How far have you been walking with this patient?”). To improve communication between the rehabilitation team and other field hospital staff, the authors suggest using white boards on patient doors to communicate each patient’s current level of mobility, daily mobility goals, and need for oxygen or assistive devices. This practice will help decrease redundant communication and increase patient mobility and safety.
The BCCFH is equipped with few pieces of rehabilitation equipment, including parallel bars and a small set of stairs. Although this equipment is helpful in training patients with substantial mobility impairments, it has less utility among higher-functioning patients. Because of the admission criteria for the BCCFH, most patients are able to walk without major difficulty but may experience excessive fatigue or become hypoxic with low levels of exertion. Because of the limited equipment available, most of these patients spend their therapy sessions ambulating with therapists or performing body weight exercises (e.g., squats). Future sites should consider including additional exercise equipment that can be used by patients at higher levels of function (e.g., stationary bicycles).
The BCCFH rehabilitation team believes that it achieved its stated objectives to maximize patient activity and mobility, facilitate timely discharge, and maximize the number of patients discharged to home. Based on our experiences, we recommend these strategies to other field hospitals in the event of future health crises. It is important to note that although the described strategies were implemented successfully at the BCCFH with the described level of staffing, the strategies described in this study may be less suited for field hospitals with different patient populations and physical environments.
The authors thank Jenni Weems, MS, Kerry Kennedy, BA, and Rachel Box, MS, in the editorial services group of The Johns Hopkins Department of Orthopedic Surgery for their editorial assistance. The authors also thank Laura Schiller, DPT, and Matthew Weber, DPT, for their contributions to the implementation efforts described in this article.
1. de Jonghe B, Lacherade JC, Sharshar T, et al.: Intensive care unit-acquired weakness: risk factors and prevention. Crit Care Med
2. Kress JP, Hall JB: ICU-acquired weakness and recovery from critical illness. N Engl J Med
3. Nordon-Craft A, Moss M, Quan D, et al.: Intensive care unit-acquired weakness: implications for physical therapist management. Phys Ther
4. Demeco A, Marotta N, Barletta M, et al.: Rehabilitation
of patients post–COVID-19 infection: a literature review. J Int Med Res
5. Kiekens C, Boldrini P, Andreoli A, et al.: Rehabilitation
and respiratory management in the acute and early post-acute phase. “Instant paper from the field” on rehabilitation
answers to the COVID-19 emergency. Eur J Phys Rehabil Med
6. Kim SY, Kumble S, Patel B, et al.: Managing the rehabilitation
services for COVID-19 survivors. Arch Phys Med Rehabil
7. Lew HL, Oh-Park M, Cifu DX: The war on COVID-19 pandemic: role of rehabilitation
professionals and hospitals. Am J Phys Med Rehabil
8. Thomas P, Baldwin C, Bissett B, et al.: Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations. J Physiother
9. Tumlinson A, Altman W, Glaudemans J, et al.: Post-acute care preparedness in a COVID-19 world. J Am Geriatr Soc
10. De Biase S, Cook L, Skelton DA, et al.: The COVID-19 rehabilitation
pandemic. Age Ageing
11. Zeng B, Chen D, Qiu Z, et al.: Expert consensus on protocol of rehabilitation
for COVID-19 patients using framework and approaches of WHO International Family Classifications. Aging Med (Milton)
12. Goodwin VA, Allan L, Bethel A, et al.: Rehabilitation
to enable recovery from COVID-19: a rapid systematic review. Physiotherapy
13. Lau HM, Ng GY, Jones AY, 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
14. Puchner B, Sahanic S, Kirchmair R, et al.: Beneficial effects of multi-disciplinary rehabilitation
in postacute COVID-19: an observational cohort study. Eur J Phys Rehabil Med
15. Cavallo JJ, Donoho DA, Forman HP: Hospital capacity and operations in the coronavirus disease 2019 (COVID-19) pandemic—planning for the nth patient. JAMA Health Forum
16. Jette DU, Stilphen M, Ranganathan VK, et al.: Interrater reliability of AM-PAC “6-Clicks” basic mobility and daily activity short forms. Phys Ther
17. Jette DU, Stilphen M, Ranganathan VK, et al.: Validity of the AM-PAC “6-Clicks” inpatient daily activity and basic mobility short forms. Phys Ther
18. Hoyer EH, Young DL, Friedman LA, et al.: Routine inpatient mobility assessment and hospital discharge planning. JAMA Intern Med
19. Jette DU, Stilphen M, Ranganathan VK, et al.: AM-PAC “6-Clicks” functional assessment scores predict acute care hospital discharge destination. Phys Ther
20. Pfoh ER, Hamilton A, Hu B, et al.: The six-clicks mobility measure: a useful tool for predicting discharge disposition. Arch Phys Med Rehabil
21. Young DL, Colantuoni E, Friedman LA, et al.: Prediction of disposition within 48 hours of hospital admission using patient mobility scores. J Hosp Med
22. Dirkes SM, Kozlowski C: Early mobility in the intensive care unit: evidence, barriers, and future directions. Crit Care Nurse
23. Larsen T, Lee A, Brooks D, et al.: Effect of early mobility as a physiotherapy treatment for pneumonia: a systematic review and meta-analysis. Physiother Can
24. Morris PE, Griffin L, Berry M, et al.: Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure. Am J Med Sci
25. Needham DM, Korupolu R, Zanni JM, et al.: Early physical medicine and rehabilitation
for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil
26. World Health Organization: Clinical management of COVID-19. Available at: https://www.who.int/publications/i/item/clinical-management-of-covid-19
. Accessed October 30, 2020
27. Hoyer EH, Friedman M, Lavezza A, et al.: Promoting mobility and reducing length of stay in hospitalized general medicine patients: a quality-improvement project. J Hosp Med
28. Probasco JC, Lavezza A, Cassell A, et al.: Choosing wisely together: physical and occupational therapy consultation for acute neurology inpatients. Neurohospitalist