Physical Therapy Practice for Critically Ill Patients With COVID-19 in the Intensive Care Unit : Cardiopulmonary Physical Therapy Journal

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Physical Therapy Practice for Critically Ill Patients With COVID-19 in the Intensive Care Unit

Stolboushkin, Catherine PT, DPT, CCS1; Mondkar, Rajashree PT, MS, CCS1; Schwing, Terrence PT, DPT, CCS1; Belarmino, Bobby PT, DPT, PhD, CCS2

Author Information
Cardiopulmonary Physical Therapy Journal: April 2022 - Volume 33 - Issue 2 - p 60-69
doi: 10.1097/CPT.0000000000000188
  • Open

Abstract

INTRODUCTION

The first COVID-19 surge in Houston, Texas occurred between March and May 2020.1 COVID-19 primarily affects the respiratory system2,3 and can cause a range of complications within the cardiovascular,4–6 neurological,7,8 and musculoskeletal9 systems. These complications, along with prolonged time in the intensive care unit (ICU), can contribute to reduced functional mobility and quality of life,10,11 increased mortality,10,11 and increase the risk for developing postintensive care syndrome10 (PICS) and ICU-acquired weakness11,12 (ICUAW). Physical therapists (PTs) have an important role in addressing patient function and quality of life during and after ICU admission. There are multiple published guidelines related to mobilizing patients in the ICU and patients on mechanical ventilation (MV).13–22 Physical therapist intervention and early mobilization in the ICU are proven to be safe and feasible23 to diminish the consequences of PICS and ICUAW,24–26 and to decrease ICU and hospital length of stay.27 Patients who participate with physical therapy demonstrate better functional outcomes, are more likely to discharge home, and are more likely to return to an independent functional status.23

In the beginning of the COVID-19 pandemic, PT involvement seemed to be limited, especially in the ICU.28,29 After discussion with clinicians at other hospitals and reviewing the available literature, PT intervention seemed to primarily focus on proning, range of motion, and bed exercises.28,29 During physical therapy sessions, the authors observed that these patients could tolerate more mobility than anticipated. However, some of the patients were outside of our normal parameters for initiating PT intervention and continuing mobility during physical therapy sessions. The authors realized that to adapt to this unique clinical situation, a new algorithm was needed to assist in the clinical decision-making process.

Multiple guidelines for PT intervention have been published throughout this pandemic.28–30 Initial publications focus primarily on personal protective equipment, infection control procedures, airway clearance, and postacute care.28–30 A few publications mention patients in the ICU; however, the information seems to focus on respiratory care, range of motion, and bed mobility with limited out-of-bed activity and ambulation.28,31–34 Thomas et al28 published guidelines for physiotherapy management for patients with COVID-19 in the acute care setting, providing a general overview of basic concepts of patient management. Levi et al32 published a decision-making tree to address functional and respiratory impairments. Li et al33 published information about their experience with patients with COVID-19 in the ICU and reported no adverse events associated with PT intervention in the ICU, including during ambulation. Felten-Barentsz et al suggested relative contraindications for mobility and recommendations for active mobilization of patients with COVID-19; however, these recommendations continued to restrict physical therapy involvement in the care of patients with COVID-19 in the authors' ICUs.34 Also, the publications mentioned above provide limited information to assist clinicians with the clinical decision-making process required at the bedside to safely and effectively provide PT intervention and mobilize patients in ICU.

To fill this gap in the literature, the authors created a clinical decision-making algorithm to assist with identifying appropriate patients and timing for intervention for patients with COVID-19 in the ICU. The aim of this study is to describe our PT practice for patients with critical illness due to COVID-19 at a tertiary hospital; and describe a novel clinical decision-making (nCDM) algorithm and its use in enhancing clinical practice for patients with COVID-19 in the ICU.

METHODS

This study is a retrospective chart review that was approved by the Houston Methodist Hospital (HMH) Investigational Review Board. The medical records of patients admitted to ICUs at HMH with a physical therapy consult were screened from March to May 2020 (Fig. 1). Inclusion criteria required patients to have a positive COVID-19 test during their hospital admission, have a referral for physical therapy while in the ICU, be able to actively participate with physical therapy, and have acceptable medical stability (Fig. 2). Patients who were expected to recover without skilled PT intervention, bedbound at baseline, unable to follow commands or hemodynamically unstable with poor medical prognosis were screened and discharged from physical therapy (Fig. 1). Clinical and demographic data and all pertinent physical therapy encounters were collected by reviewing electronic medical records.

F1
Fig. 1.:
Consort Diagram.
F2
Fig. 2.:
Clinical Decision-Making Algorithm.

Before the COVID-19 pandemic, the ICU Liberation ABCDEF Bundle was implemented for the management of patients in the ICU.19 Standard practice involved early physical therapy consultation and interdisciplinary rounding every weekday to designate mobilization of patients to appropriate disciplines (Physical Therapy, Nursing or Mobility Technician) and to establish a daily mobility plan for each patient. An informal clinical decision-making process, derived from evidence-based practice and clinical experience, was used by the PTs working in the ICU. This process allows patients to achieve the safest and highest level of mobility for that day, whereas also recognizing limitations, such as hemodynamic stability, medical plan of care, etc.

There is a large body of evidence regarding mobilizing patients who are critically ill, on MV, with acute respiratory distress syndrome (ARDS), sepsis, or other causes of respiratory failure.13,15,20–23 As a result of the COVID-19 pandemic, health care professionals have been challenged to adjust best practices. The authors used the literature referenced in this manuscript and our clinical expertise to extrapolate the recommendations and apply them to physical therapy management of critically ill patients with COVID-19. Using that information, in consultation with the intensivists and respiratory therapists (RT), the authors developed the nCDM algorithm, found in Figure 2, to establish a standard of PT practice and decision-making for patients with COVID-19 in the ICU. This evolved from the current clinical decision-making process, along with new information from published research and clinical experience gained during the pandemic.

Previous parameters for initiating PT intervention included a fraction of inspired oxygen (FiO2) <60%14 a positive end expiratory pressure (PEEP) <10 cmH2O14 a PaO2/FiO2 ratio (P/F ratio) >150, and a partial pressure of oxygen in arterial blood (PaO2) ≥ 80 mmHg.16 After consulting with the intensivist, the authors would occasionally proceed with PT intervention for patients whose PaO2 was as low as 60 mmHg. ARDS is classified by the severity of hypoxemia, indicated by the P/F ratio: mild (P/F ratio 201–300), moderate, (P/F ratio 101–200), and severe (P/F ratio ≤100).35 Per the hospital's ICU proning algorithm, a P/F ratio ≤150 is one of the criteria to indicate the need for a prone position. Because of the pathophysiology of COVID-19 and its effects on the lungs and other body systems,2–9 the above parameters evolved to include a higher FiO2 and PEEP, lower PaO2, and lower P/F ratio.

The clinical decision-making algorithm considers the patient's cognitive, hemodynamic, and respiratory stability to help guide mobilization of patients. Physical therapist intervention was initiated using the algorithm along with a response-dependent progression of mobility.36,37 Additional supplemental oxygen or ventilator support was given as needed, after consultation with the medical team (intensivists, RT, and nursing), and orders were received for target oxygen saturation (SpO2) levels to be maintained during activity for individual patients. The Richmond Agitation-Sedation Scale (RASS) was used to determine the patient's level of sedation and readiness to participate with physical therapy.38

The Activity Measure for Post-Acute Care “6 clicks” (AM-PAC) was assessed during all physical therapy encounters. The Perme ICU Mobility Score (Perme Score), Medical Research Council Sum Score (MRC-SS), and RASS were performed during all ICU physical therapy initial evaluations and re-evaluations. Because of frequent intubation and encephalopathy causing limited communication ability, the Barthel Index (BI) was included during this pandemic to provide an objective assessment of prior level of function.39 The BI measures activities of daily living and function. The score ranges from 0 to 100 with higher scores indicating more independence. Although it has not been validated as a tool to formally measure a patient's prior level of function, this pandemic has challenged clinicians to adjust their practice and become creative. The BI is simple to perform and easy to use with patients at the bedside or caregivers over the telephone. If the patient was unable to provide the information, the patient's emergency contact was called to provide information about the patient's prehospital functional level. The BI was found to be reliable and valid when obtained by interview over the telephone from caregivers.40 The AM-PAC assesses a patient's functional mobility beginning with bed mobility and ending in stair negotiation using a four-point scale ranging from 6 to 24. Jette et al have reported on the inter-rater reliability and validity of this measurement tool in the acute care setting.41,42 The Perme Score is used to objectively assess a patient's functional mobility in any ICU at a specific moment in time. It begins with assessing mental status and ends in the distance walked in 2 minutes. The score ranges from 0 to 32 and is derived from 15 items grouped into 7 categories. It has been shown to have high inter-rater reliability and validity.43 The MRC-SS uses a 6-point scale ranging from 0 to 60 to measure muscle strength. The ability to follow commands is initially assessed followed by measuring the strength of 3 muscle groups in all 4 limbs. The MRC-SS was shown to have good-to-excellent interobserver agreement and is most commonly used as a diagnostic tool for ICUAW (scores <48).44 The RASS is a structured assessment of sedation and agitation used for patients who are critically ill. It ranges from −5 (unarousable) to +4 (combative), with negative numbers correlating to degree of sedation and positive numbers correlating to degree of agitation. It was found to have high reliability and validity in adult ICU patients.38

Data were collected using an Excel spreadsheet, which included demographics, comorbidities, prior level of function, Sequential Organ Failure Assessment (SOFA) score on ICU admission, hospital and ICU admission and discharge dates, hospital discharge location, days on ventilator, use of prone position while chemically paralyzed, use of extracorporeal membrane oxygenation device (ECMO), physical therapy evaluation date, number of and average amount of time of physical therapy visits, number of missed physical therapy visits, FiO2 during each session, AM-PAC Score, and complications documented at hospital discharge. Complications were marked as present or not after review of the last physical therapy note and physician documentation in the medical record on the day of hospital discharge. They were grouped into 7 categories as: cardiovascular, pulmonary, musculoskeletal, neurological, delirium/cognitive impairment, venous thromboembolism, and no complications.

The following data were collected at the initial physical therapy evaluation: oxygen delivery method, PEEP, FiO2, heart rate, mean arterial pressure, SpO2, P/F ratio, BI, MRC-SS, AM-PAC, Perme Score, RASS. During all physical therapy sessions, the patient's highest level of mobility was recorded using a 5-point scale. A score of 1 indicates the patient performed bed level activity, 2: sitting side of bed, 3: standing at bedside, 4: ambulating up to five feet, and 5: ambulating more than 5 feet.

Data extracted from the electronic medical record were reviewed by 3 members of the research team to ensure accuracy and prevent any form of potential bias. Data were entered by subinvestigators into a password protected, secured computer. Descriptive results are presented as frequencies, percentages, medians, and interquartile ranges. Because the data did not meet assumptions of normality, nonparametric tests were used to compare groups (Wilcoxon signed-rank test) and to identify relationships between clinical variables (Spearman rho correlation). Effect sizes were estimated with Cohen's d for nonparametric analysis by dividing the Z value by the square root of the total sample size. Data were analyzed using IBM SPSS Statistics Software version 25 (Armonk, NY). A significance α level was set at <0.05.

RESULTS

Two hundred forty-seven patients with COVID-19 were admitted to ICU between March and May 2020. One hundred four patients received a physical therapy consult and 77 of these patients received ICU physical therapy services (Fig. 1). Their demographics are summarized in Table 1. Twenty-seven patients were deemed inappropriate for physical therapy services for the reasons identified in Figure 1. Of the patients who received ICU physical therapy services, the median SOFA Score on ICU admission was 7 (interquartile range [IQR] 5 to 7). Thirty-nine percent were proned while chemically paralyzed and receiving MV and 7.8% received ECMO support during their ICU admission. A median of 5 (IQR 3–11) days passed between ICU admission and the initial physical therapy evaluation.

TABLE 1 - Patient Characteristics (N = 77)
Age, median (IQR) 58 (46.5–70.5)
Sex—female, n (%) 36 (46.8)
BMI, median (IQR) 30.6 (26.5–36.3)
Race, n (%)
 White 44 (57.1)
 Black 27 (35.1)
 Asian 6 (7.8)
Ethnicity, n (%)
 White, Non-Hispanic 18 (23.4)
 White, Hispanic 26 (33.8)
 Black, Non-Hispanic 27 (35.1)
 Asian, Non-Hispanic 6 (7.7)
Hospital LOS—days, median (IQR) 18 (13–25)
ICU LOS—days, median (IQR) 13 (7–18.5)
Days on ventilator, median (IQR) 10 (5–17)
P/F Ratio on evaluation, median (IQR) 280 (203–403.8)
SOFA Score on ICU admission, median (IQR) 7 (5–7)
FiO2 on evaluation, median (IQR) 40 (35–50)
PEEP on evaluation, median (IQR) 8 (5–10)
Number of PT visits during admission, median (IQR) 6 (4–8)
Duration of PT visits during admission, min, median (IQR) 37.2 (32–42.8)
AM-PAC Score on evaluation, median (IQR) 8 (6–12)
Perme Score on evaluation, median (IQR) 10 (5–19)
Barthel Index, median (IQR) 100 (100–100)
Highest level of mobility on evaluation, median (IQR) 3.7 (2.7–4.4)
Proned, n (%) 30 (39)
ECMO, n (%) 6 (7.8)
AM-PAC, Activity Measure for Post-Acute Care “6 clicks”; BMI, body mass index; ECMO, Extracorporeal Membrane Oxygenation; FiO2, fraction of inspired oxygen; IQR, interquartile range; ICU, intensive care unit; LOS, length of stay; n, frequency; P/F ratio, PaO2/FiO2 ratio; PaO2, partial pressure of oxygen in arterial blood; PEEP, positive end expiratory pressure; PT, physical therapy; Perme Score, Perme ICU Mobility Score; SOFA, Sequential Organ Failure Assessment.

The median BI score to indicate the patient's prior level of function was 100 (IQR 100–100). During the initial physical therapy evaluation, the median AM-PAC score was 8 (IQR 6–12) and the median Perme score was 10 (IQR 5–19) (Table 1). As seen in Figure 3, 16.9% of patients stood at the bedside, 20.8% of patients ambulated ≤5 feet and 13.0% of patients ambulated >5 feet during the initial evaluation. There was a statistically significant improvement (Wilcoxon Z = −6.378, P < .001, ES = 0.51) between AM-PAC scores on the initial physical therapy evaluation and the last physical therapy note before ICU discharge (Fig. 4).

F3
Fig. 3.:
Highest Level of Mobility Obtained on Physical Therapy Evaluation.
F4
Fig. 4.:
Comparison of AM-PAC Scores on Initial Evaluation and ICU Discharge.

At the time of hospital discharge, 54 (70.1%) patients had multiple (2 or more) new complications present, 5 patients (6.5%) had only pulmonary complications, 2 patients (2.6%) had only musculoskeletal complications, 1 patient (1.3%) had only cognitive impairments, 1 patient (1.3%) had only neurological impairments, and 5 patients (6.5%) had no complications.

Patients on Mechanical Ventilation

Of the 77 patients who received ICU physical therapy services, 44 (57.1%) patients were receiving MV support via endotracheal tube on the initial physical therapy evaluation (Table 1). The median highest level of mobility for these patients during the initial physical therapy evaluation was 2 (IQR 2–3). Fifty-point six percent of these patients had a RASS Score of 0 and 22.8% had a score of −1 (Fig. 5). The highest level of mobility shows no relationship with the MV settings of PEEP (rs = −.057, P = .712) and FiO2 (rs = −.256, P = .094). There was a statistically significant improvement between AM-PAC scores on the initial physical therapy evaluation and the last physical therapy note before ICU discharge (Wilcoxon Z = −4.765, P < .001, ES = 0.50) (Fig. 4).

F5
Fig. 5.:
Highest Level of Mobility Performed by RASS on Physical Therapy Evaluation.

Patients With Values Outside Previously Established Parameters

There were 26 patients who were outside our previously established parameters for initiating PT intervention and continuing mobility during physical therapy sessions (Table 2). Seven (26.9%) patients' P/F ratio was <150 on the initial physical therapy evaluation. There were 9 (34.6%) patients with an FiO2 > 60% and 16 (61.5%) patients with a PEEP ≥10 cmH2O on the initial physical therapy evaluation. The median highest level of mobility during the initial physical therapy evaluation was 2 (IQR 2–3.3) and 38.5% of these patients were able to stand or ambulate. There was a statistically significant improvement between AM-PAC scores on the initial physical therapy evaluation and the last physical therapy note before ICU discharge (Wilcoxon Z = −3.802, P < .001, ES = 0.52) (Fig. 4). Of these patients who were outside the previously established parameters, 8 patients were discharged to home, 5 patients were discharged to an inpatient rehab facility, 4 patients were discharged to a skilled nursing facility, 5 patients were discharged to a long-term acute care facility, 2 patients were discharged to an affiliated system hospital, and 2 patients were discharged to hospice or expired.

TABLE 2 - Patients With Values Outside Previously Established Parameters (N = 26)
Patient Number FiO2 (on PT Evaluation) PEEP (on PT Evaluation) P/F Ratio (on PT Evaluation) Highest Level of Mobility (on PT Evaluation) AM-PAC Score (on PT Evaluation) Perme Score (on PT Evaluation) DC Location
3 45 10a 206 3 9 16 LTAC
14 45 14a 200 2 8 12 IRF
15 40 10a 222.5 2 6 2 ASH
18 40 12a 321.5 4 12 16 Home
33 35 10a 271.4 2 6 2 IRF
34 40 14a 248 3 6 10 SNF
36 30 12a 483.3 2 6 5 Home
37 50 10a 210 2 6 3 SNF
44 40 10a 190 2 6 5 IRF
45 100a 5 473.3 2 6 6 LTAC
49 44 N/A 123a 1 7 4 SNF
52 40 10a 280 2 6 6 Home
55 40 10a 235 2 6 8 LTAC
57 80a N/A 148a 5 20 24 Home
61 60 12a 101.7a 2 6 7 Hospice
62 90a N/A N/A 2 8 9 IRF
64 60 11a 153.3 2 6 4 LTAC
65 95a N/A N/A 5 18 27 Home
67 50 15a 156 2 7 6 Home
68 40 12a 427.5 2 6 4 Expired
69 90a N/A 68.8a 4 12 16 LTAC
71 40 10a 412.5 3 9 8 ASH
73 100a N/A 113.6a 4 17 29 Home
74 93a N/A 82.8a 1 7 7 SNF
75 80a N/A 218.2 3 7 11 IRF
77 100a N/A 98.6a 4 22 29 Home
aValues that were outside previously established parameters for initiating physical therapy intervention.
AM-PAC, Activity Measure for Post-Acute Care “6 clicks”; ASH, Affiliated System Hospital; DC, discharge; FiO2, fraction of inspired oxygen; IRF, inpatient rehabilitation facility; LTAC, Long-Term Acute Care Hospital; N/A, not applicable; P/F Ratio, PaO2/FiO2 Ratio; PaO2, partial pressure of oxygen in arterial blood; PEEP, positive end expiratory pressure; Perme, Perme ICU Mobility Score; SNF, skilled nursing facility.

DISCUSSION

The aim of this study was to describe our PT practice for patients with critical illness because of COVID-19 at a tertiary hospital and to describe an nCDM algorithm and its use in enhancing clinical practice for patients with COVID-19 in the ICU. Our data shows that the authors were able to obtain positive effects on functional measures in patients that were seen despite high respiratory support, various levels of sedation, and fluctuating hemodynamic status.

Early mobilization of patients in the ICU has been shown to be safe and feasible.22,23,45–47 Although physical therapy was consulted early for patients in ICU with COVID-19, there was a median of 5 days between ICU admission and the initial physical therapy evaluation because of high ventilator settings, prolonged sedation, neuromuscular blocking agents, and/or prone positioning. McWilliams et al reported a mean time to mobilization of 14 days for patients with COVID-19 in the ICU.48

In 2014, an expert consensus outlined recommendations for the mobilization of patients who are mechanically ventilated.14 Chung and Mueller13 presented a summary of factors that might limit safe mobilization of patients with ARDS and MV. There is evidence to support mobility for patients with a higher FiO2 and PEEP,17,22 although this differs from articles by Hodgson and Adler recommending for the FiO2 to be ≤60% and PEEP ≤10.14,49 During this pandemic, the clinical decision-making algorithm evolved from current practice using the literature referenced in this manuscript and clinical experiences to identify patients ready to participate in PT intervention. Because COVID-19 primarily affects the respiratory system, the authors decided to focus more on parameters that indicate the function of the respiratory system; therefore, parameters including PaO2, FiO2, PEEP and P/F ratio were adapted to this specific patient population. The respiratory rate parameters used in the clinical decision-making algorithm were similar to the recommendations of 5 to 40 breaths per minute by Cameron et al.15

Physical therapy sessions and ambulation were limited to inside the room, as per infection control recommendations. Single-patient use gait belts were provided and strengthening exercises were adapted to using only disposable resistance bands and items available inside the patient rooms. Exercise platforms, standing frames, and gait training devices were not used with this population because of infection control recommendations.

The median BI score indicates most of the 77 patients were “independent of assistance from others” in baseline functional mobility.39 On ICU admission, the median SOFA score for these patients indicated a hospital mortality rate of approximately 21.5%.50 The median highest level of mobility during the initial physical therapy evaluation signifies that, despite the effects of COVID-19 and illness requiring ICU admission, a majority of our patients were able to progress past bed exercises and sitting to standing at the bedside. One-third of our patients, some while mechanically ventilated, were able to ambulate in the room. During their ICU stay, the patients were able to continue participating with physical therapy resulting in a statistically significant improvement between AM-PAC scores on the initial physical therapy evaluation and ICU discharge.

Twenty-six of these patients were outside the previously established parameters for initiating PT intervention and continuing mobility during physical therapy sessions. Our data shows that during the initial physical therapy evaluation, this critically ill patient population was able to progress past bed exercises and passive mobility, with more than one-third of these patients standing or ambulating. Between the initial physical therapy evaluation and ICU discharge, there was a statistically significant improvement in AM-PAC scores. Without this novel algorithm, these patients may not have received PT intervention while in the ICU or intervention may have been delayed based on our previous guidelines. In addition, as the number of patient admissions increased with subsequent surges, this algorithm was used as a teaching tool for other PTs who did not primarily work in the ICU. This improved the consistency of clinical decision-making across all PTs working with this patient population in the ICU.

Forty-four patients were on MV during the initial physical therapy evaluation. Per the ICU Liberation ABCDEF Bundle, sedation was limited to what was necessary to prevent delirium and agitation, reduce use of restraints, and allow patients to participate with mobility, interact with staff, etc.19 A majority of patients with a RASS of 0 were able to ambulate up to 5 feet during the initial physical therapy evaluation. However, for patients whose sedation was titrated for a RASS of −1, the highest level of mobility reached during the initial physical therapy evaluation was sitting side of bed. As reported earlier, there was no relationship found between the patient's highest level of mobility and MV settings (PEEP and FiO2) during their physical therapy sessions. This indicates that even patients with COVID-19 on MV with a high FiO2 and PEEP may have the potential to stand and/or ambulate during physical therapy sessions. There was also an improvement seen in AM-PAC scores between the initial physical therapy evaluation and ICU discharge suggesting these patients on MV may be able to improve their functional mobility while in the ICU.

Regardless of their medical status, the patients who received ICU physical therapy services improved their functional mobility while in the ICU. This is evident when looking at the statistically significant improvement in AM-PAC scores between the initial physical therapy evaluation and the last physical therapy note before ICU discharge. This was important as most of our patients were discharged home. In our geographical area, early in the pandemic, there was a lack of postacute care facilities that accepted patients with a positive COVID-19 test. A number of our patients would have benefited from continued rehabilitation, but were discharged home with no home health physical and occupational therapy. This was different than normal practice for posthospital care and presented a unique challenge for these patients and their families. As illustrated in our results, a majority of our patients had 2 or more new complications at the time of hospital discharge, primarily pulmonary and cardiovascular. This is in line with the recent literature published on the adverse effects of COVID-19 along with current literature on the complications of critical illness, including delirium, ICUAW, and PICS.51–53

Strengths

First, this study is one of the first to describe PT practice for critically ill patients in ICU with COVID-19, with and without MV. Second, therapy sessions were progressed to a maximal level of mobility within physiological tolerance allowing for various types of intervention (eg, resistance exercise, standing, gait, etc). Third, the clinical decision-making algorithm provides a step-by-step process that may translate to other patient diagnoses and ICU settings.

Limitations

First, this is a single-center, retrospective study performed at an academic institution with a small sample size and only included the adult patient population during the first pandemic surge in this area. Hence, the generalizability of our study results may be limited. Second, patients were limited to activity inside the room which may have limited the results of our data. Third, although the authors did observe improvements in AM-PAC scores between the initial physical therapy evaluation and ICU discharge, the authors are unable to conclusively state that physical therapy was the only reason for the patients' improvement in functional mobility. Fourth, at the beginning of this pandemic, discharge options were limited for patients hospitalized with COVID-19, so the data for discharge locations may be skewed. Fifth, because of the methodological limitations of retrospective chart review, the inferences drawn from this study should be taken with caution. Finally, the authors did not collect any data about the safety and feasibility of using this clinical decision-making algorithm.

Clinical Relevance

This study has shown that PT practice can be modified to meet the needs of patients in the ICU with critical illness due to COVID-19 using this nCDM algorithm. Without this algorithm, PT intervention may have been delayed or not received by patients who were outside the previously established parameters for mobility. With subsequent surges, this algorithm, along with one-on-one mentoring, was incorporated into daily practice by PTs who were less experienced in the ICU setting. Consequently, this allowed for more consistent clinical decision-making for patients with COVID-19 in the ICU throughout this pandemic. Patients who have similar respiratory impairments (eg, ARDS due to other causes) may also benefit from determining appropriate timing for intervention using this algorithm, but further research is needed.

Future Studies

Future studies should see if these results are reproducible at other facilities and with a larger sample size. In this study, the authors observed improved AM-PAC scores between the initial physical therapy evaluation and the last physical therapy note before ICU discharge; however, future studies are needed to observe long-term outcomes for this patient population. Also, further research needs to be done on the safety and feasibility of using this clinical decision-making algorithm for patients with COVID-19 or other similar respiratory impairments (eg, ARDS due to other causes).

CONCLUSION

Physical therapist intervention is an integral component of a patient's course for recovery during and after critical illness due to COVID-19. The authors have described the development and use of an nCDM algorithm to improve our PT clinical practice for patients with COVID-19 in the ICU. This algorithm allowed us to provide PT intervention for patients who may not have been seen or for whom intervention may have been delayed based on our previous guidelines. This algorithm can assist clinicians with identifying patients who are appropriate for PT intervention and determining an appropriate time to intervene to maximize the benefits of early mobility in patients with COVID-19 in the ICU.

Acknowledgments

The authors would like to thank Cathy Currier-Buckingham, Dennis Fails, Judy Ragsdale, Alyssa Ramirez, Emelin Martinez, Aydin Dursunov.

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Keywords:

early mobility; decision-making; algorithm

2022 Academy of Cardiovascular and Pulmonary Physical Therapy