key: cord-328487-glwslgjy authors: Iannaccone, Sandro; Castellazzi, Paola; Tettamanti, Andrea; Houdayer, Elise; Brugliera, Luigia; de Blasio, Francesco; Cimino, Paolo; Ripa, Marco; Meloni, Carlo; Alemanno, Federica; Scarpellini, Paolo title: ROLE OF REHABILITATION DEPARTMENT FOR ADULT COVID-19 PATIENTS: THE EXPERIENCE OF THE SAN RAFFAELE HOSPITAL OF MILAN date: 2020-06-04 journal: Arch Phys Med Rehabil DOI: 10.1016/j.apmr.2020.05.015 sha: doc_id: 328487 cord_uid: glwslgjy Abstract The rapid evolution of the health emergency linked to the spread of SARS-CoV-2 requires specifications for the rehabilitative management of COVID-19 patients. The symptomatic evolution of COVID-19 patients is characterized by two phases: an acute phase in which respiratory symptoms prevail, and a post-acute phase in which patients can show symptoms related to prolonged immobilization, to previous and current respiratory dysfunctions as well as cognitive and emotional disorders. There is thus the need for specialized rehabilitative care for these patients. This communication reports the experience of the San Raffaele Hospital of Milan (Italy) and recommends the set-up of specialized clinical pathways for the rehabilitation of COVID-19 patients. In this hospital, between February 1st and March 2nd 2020, about 50 patients were admitted every day with COVID-19 symptoms. In those days, about 400 acute care beds were created (Intensive Care/Infectious Diseases). In the following 30 days, from March 2nd to mid-April, despite the presence of 60 daily arrivals to the ER, the organization of patient flow between different wards was modified and several different units were created based on a more accurate integration of patients’ needs. According to this new organization, patients were admitted first to acute care COVID-19 units, and then to COVID-19 rehabilitation units, post-COVID-19 rehabilitation units and/or quarantine/observation units. After hospital discharge, telemedicine was used to follow-up with patients at home. Such clinical pathways should each involve dedicated multidisciplinary teams composed of pulmonologists, physiatrists, neurologists, cardiologists, physiotherapists, neuropsychologists, occupational therapists, speech therapists and nutritionists. The rapid evolution of the health emergency linked to the spread of SARS-CoV-2 requires 2 specifications for the rehabilitative management of COVID-19 patients. The symptomatic evolution 3 of COVID-19 patients is characterized by two phases: an acute phase in which respiratory 4 symptoms prevail, and a post-acute phase in which patients can show symptoms related to 5 prolonged immobilization, to previous and current respiratory dysfunctions as well as cognitive 6 and emotional disorders. There is thus the need for specialized rehabilitative care for these 7 patients. This communication reports the experience of the San Raffaele Hospital of Milan (Italy) 8 and recommends the set-up of specialized clinical pathways for the rehabilitation of COVID-19 9 patients. In this hospital, between February 1 st and March 2 nd 2020, about 50 patients were 10 admitted every day with COVID-19 symptoms. In those days, about 400 acute care beds were 11 created (Intensive Care/Infectious Diseases). In the following 30 days, from March 2 nd to mid-April, 12 despite the presence of 60 daily arrivals to the ER, the organization of patient flow between 13 different wards was modified and several different units were created based on a more accurate 14 integration of patients' needs. According to this new organization, patients were admitted first to 15 acute care COVID-19 units, and then to The rapid, exponential, diffusion of the SARS-CoV-2 virus has dramatically shaken the functional 1 organization of public and private health facilities in Italy. The San Raffaele Hospital of Milan 2 (Lombardy, Italy) admitted more than 400 COVID-19 patients in one month (typically, during the 3 month of February, about 300 patients are admitted in the whole San Raffaele Hospital). 4 After this first phase, the clinical care of patients was reorganized to provide, on one hand, better 5 treatment for acute patients, and, on the other hand, to better meet the rehabilitation needs of 6 post-COVID-19 patients to optimize home discharge. This report describes the experience of the 7 Rehabilitation and Functional Recovery Department of the San Raffaele Hospital (Milan, Italy) and 8 aims to identify barriers to the functional recovery of COVID-19 patients and to provide 9 suggestions for the set-up of a specialized clinical standard procedure flow for the rehabilitation of 10 these patients. for COVID-19 patients. Various wards were merged, and no specialized rehabilitation care was 7 provided. Patients were hospitalized for about 2 weeks, after which they were usually home-8 discharged in order to meet the need for new patient admissions. Based on our experience, about 9 20-25% of discharged patients were discharged for home confinement with SARS-CoV-2 positive 10 swabs. Indeed, based on our experience, it usually takes from 2 to 4 weeks from symptoms onset 11 to obtain negative swabs. 12 Thus, the mean duration of hospitalization in the San Raffaele Acute COVID-19 Unit in phase 1 was 13 15 days, after which patients were discharged home. 14 After one month, the following criticisms emerged: (1) telemedicine/telerehabilitation (see Figure 2 ). The new objectives of phase 2 were to discharge 11 only patients with negative swabs and maximal functional autonomy, and to limit infections 12 among patients and healthcare workers inside the hospital. 13 All these different wards provided specialized rehabilitation to patients according to their clinical 14 status. Respiratory, motor, and cognitive rehabilitation treatments were designed based on the 15 literature according to patients' symptoms and functional impairments. A multidisciplinary team 16 of specialists dedicated to each unit evaluated and monitored patient conditions throughout the 17 rehabilitation process. The teams were composed of pulmonologists, physiatrists, neurologists, 18 cardiologists, physiotherapists, occupational therapists, speech therapists and neuropsychologists. 19 For each patient, personalized care must always be applied 2 , especially for patients with 20 severe/critical illness, advanced age, obesity, multiple underlying diseases and organ 21 complications. For each individual patient, a personalized rehabilitative project (addressing cardio-22 respiratory, neuromotor and cognitive impairments) must be designed. The following instrumental examinations were performed at the patient's bedside: X-ray, 1 echocardiogram, lung ultrasound, aorta ultrasound, fibroscopy for patients with dysphagia and 2 electromyogram. Thus, the patient did not have to be moved to perform these exams. 3 (Figure 2 about here: Rehabilitation paths for COVID-19 and POST COVID-19 patients in phase 2.) 4 For patients hospitalized with COVID-19, the purpose of rehabilitation in both the acute and post-5 critical phases was to improve respiratory dynamics, counteract musculoskeletal deconditioning 6 and immobilization, reduce the onset of complications, recover the cognitive and emotional status 7 in patients with hypoxic damage, reduce disability and improve the quality of life in anticipation of 8 the patient's discharge. During hospitalization, the electrolyte balance (frequent hypernatremia) 9 and cardiac load (ProBNP, cardiac, lungs and aorta ultrasounds) must be monitored. Central 10 nervous system involvement has also been reported, even in non-hypoxemic patients, with 11 dysgeusia, hyposmia and altered mental state or neuropsychological manifestations. Symptoms 12 related to neuromuscular pathology and cranial nerve involvement (ageusia and anophthalmia, 13 isolated paralysis of the VII cranial nerve) were also observed 3 . Acquisition of clinical data is in progress. We started to gather follow-up data at one month post-1 discharge. Although these data have not been published yet, the establishment of a specialized 2 multidisciplinary rehabilitation standard procedure flow for COVID-19 and post-COVID-19 patients 3 was intended to discharge patients with negative swabs and improve patient functional status. 4 The final goal is to discharge patients only after functional rehabilitation meets the objectives of 5 each personal rehabilitative plan. All patients were discharged with negative swabs and FIM and 6 ADL showing minimal areas of dependence. Moreover, so far, none of the dedicated healthcare 7 workers has been contaminated after the establishment of the specialized rehabilitation standard 8 procedure flow, potentially related to improved compliance with correct PPE use. Contamination 9 of hospital staff is monitored through mandatory body temperature measurements at hospital 10 entry/exit. 11 Overall, rehabilitation care needs to be integrated in the clinical care of COVID-19 patients. 12 In the case of the San Raffaele Hospital, the procedures and timing were formulated based on the 13 experience gained in the field. The drastic and unexpected flow of patients in the first 30 days led 14 to an emergency organization. The experience gained subsequently led us to recommend the 15 establishment of different units that followed the course of the disease with a more rational use of 16 Rehabilitation healthcare professionals. This type of organization of the second phase, according 17 to our experience, was the most suitable for managing such a situation in a large hospital that has 18 a continuous daily flow of 50-60 COVID-19 patients to the ER. hospital discharge. Further reports are thus needed to fully assert such functional improvements. 5 We are also currently improving our telemedicine system by simplifying the remote follow-up of 6 patients with the development of an App that will be provided to patients in May. This App 7 contains cognitive and motor rehabilitative exercises that can benefit patient recovery at low 8 costs. Recovery from intensive care Personalised pulmonary rehabilitation in COPD Rehabilitation of COVID-19 patients The spontaneous breathing pattern and work of breathing of patients with 17 acute respiratory distress syndrome and acute lung injury Prone positioning in severe acute respiratory distress syndrome Respiratory Parameters in Patients With COVID-19 After Using Noninvasive 21 Ventilation in the Prone Position Outside the Intensive Care Unit A randomised controlled trial of the effectiveness of an exercise training 1 program in patients recovering from severe acute respiratory syndrome Exercise rehabilitation following intensive care unit discharge for recovery 4 from critical illness Mini-mental state'. A practical method for 7 grading the cognitive state of patients for the clinician MoCA: a brief screening tool 9 for mild cognitive impairment Use of functional independence measure in rehabilitation of inpatients 12 with respiratory failure A short physical performance battery assessing lower extremity 14 function: association with self-reported disability and prediction of mortality and nursing home 15 admission Development of a Barthel Index based on dyspnea for patients with 17 respiratory diseases Improving the sensitivity of the Barthel Index for stroke 19 rehabilitation Clinical and 21 laboratory measures of postural balance in an elderly population Psychophysical bases of perceived exertion An investigation of the validity of six measures 3 of physical function in people awaiting joint replacement surgery of the hip or knee ATS 6 statement: guidelines for the six-minute walk test Nutritional management of COVID-19 patients in a rehabilitation unit The role of tele-medicine in patients with respiratory diseases Telerehabilitation and recovery of motor function: a systematic review 13 and meta-analysis Telehealth 15 in Physical Medicine and Rehabilitation: A Narrative Review Patient clinically recovered from Covid-19-CoV-2: a patient who, after presenting with clinical manifestations (fever, rhinitis, cough, sore throat, possibly dyspnea and, in severe cases, pneumonia with respiratory failure) associated with the virologically documented infection by SARS-CoV-2, becomes asymptomatic due to the resolution of the clinical symptomatology (apyrexia, improvement of respiratory symptoms until no need for ventilatory support, improved lung imaging). The clinically healed subject may still test positive for the SARS-CoV-2 test.Recovered patient: a patient who recovers from the symptoms of Covid-19 infection and who is negative in two consecutive SARS-Cov-2 testing swabs, carried out 24 hours apart.Definition of "FIM that shows areas of dependence": a score on the FIM scale that shows areas of dependence of the subject (score less than or equal to 5) in particular in the motor functions, such as to impact on the overall autonomy of the patient. 24 The main use of the FIM consists in the analysis of average scores on patient populations for the control of efficacy and efficiency of hospitalization rehabilitation programs.