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SPECIAL SECTION on COVID-19 and PM&R

Lessons Learned From Implementing Rehabilitation at a COVID-19 Field Hospital

McLaughlin, Kevin H. DPT; Simon, Lauren DPT; Friedman, Michael PT, MBA; Siddiqui, Zishan K. MD; Ficke, James R. MD; Kantsiper, Melinda E. MD; CONQUER COVID Consortium

Author Information
American Journal of Physical Medicine & Rehabilitation: November 2021 - Volume 100 - Issue 11 - p 1027-1030
doi: 10.1097/PHM.0000000000001878

Abstract

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.

FIGURE 1
FIGURE 1:
Layout (A) and typical patient room (B) of the Baltimore Convention Center Field Hospital.

Patient Population

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).

Staff

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.

Training

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 Criteria Level of Care
Rehabilitation-personnel directed 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 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.

Interdisciplinary Communication

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.

Rehabilitation Equipment

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).

CONCLUSIONS

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.

ACKNOWLEDGMENT

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.

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Keywords:

Health Services; Mobile Health Units; Pandemic; Public Health; Rehabilitation

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