key: cord-0684701-pqil86ij authors: Greenwood, Jonathan; Fragala-Pinkham, Maria; Dakhlian, Megan Geno; Brennan, Ellen; Ploski, Christine; Correia, Annette title: A Pediatric Hospital Physical Therapy and Occupational Therapy Department’s Response to COVID-19: An Administrative Case Report date: 2021-06-25 journal: Phys Ther DOI: 10.1093/ptj/pzab164 sha: 7686c025a4d6bc58b0e261827bd09b453fc5ba4d doc_id: 684701 cord_uid: pqil86ij OBJECTIVE: The purpose of this case report is to describe the challenges that COVID-19 presented for therapists in a pediatric hospital and the response to these challenges. METHODS (CASE DESCRIPTION): The case report setting is a physical therapy and occupational therapy department (department) of an academic pediatric medical center that provides a range of health care services for children and youth. Challenges that COVID-19 presented to the Department included: (1) managing safety concerns for patients, their families, and staff; (2) continuing to provide high-quality therapy services within state mandated restrictions; (3) triaging patients; and (4) keeping clinicians employed and working productively. RESULTS: The Department therapists responded to these challenges by: (1) increasing communication huddles, (2) developing procedures for staffing and triaging of patients, (3) developing procedures for telehealth therapy services, and (4) designing a remote work program for all department employees. The number of patients and staff on site were reduced by initiating telehealth services, triaging patients, and developing a remote work plan. Communication huddles, department meetings, and supervision meetings were converted to virtual meetings. Staffing rates, patient-care productivity, and department project work were maintained. CONCLUSION: In response to COVID-19, the department developed new protocols provided information about the protocols, which might be helpful for other pediatric hospitals or outpatient settings when planning for future pandemics or other issues that challenge the ability to provide usual care. Increasing the frequency of verbal and written communication on operational topics is recommended. Primary sources of information from national organizations (eg, the American Physical Therapy Association and the American Occupational Therapy Association) can assist with determining the scope of practice and code of conduct during a pandemic. IMPACT: COVID-19 posed challenges to operations and delivery of patient care. Although this case report is specific to COVID-19, principles applied and lessons learned from this experience can be applied to other emergency situations. Impact. COVID-19 posed challenges to operations and delivery of patient care. Although this case report is specific to COVID-19, principles applied and lessons learned from this experience can be applied to other emergency situations. During the COVID-19 pandemic, the Centers for Disease Control and Prevention (CDC) issued recommendations about limiting large gatherings, implementing social distancing, and increasing disinfection procedures. 1 March 2020, the Governor of Massachusetts declared a state of emergency and ordered all non-urgent services to close their physical workplaces, limiting on site face-to-face (F2F) services. Later, the Governor issued a multiple phase reopening plan that started May 18 th with Phase 1, allowing hospitals to conduct some non-urgent procedures or care that were previously deferred and in need of attention. 2 Phase 2 started on June 6 th and allowed health care providers to incrementally resume in-person, non-urgent services while complying with health and safety standards. Phase 3, initiated July 6, allowed group treatment programs and day programs to provide in-person services while still monitoring patient volume and complying with safety standards. 2 These state mandates forced physical therapists and other healthcare professionals to make changes in how they provided healthcare services. Therapists had to quickly develop new protocols to maintain the safety of patients, their families, and staff while still providing high quality care. The purpose of this administrative case report is to describe the challenges that COVID-19 presented for a Physical Therapy and Occupational Therapy Department in a pediatric hospital and the response to these challenges. Although our experiences are specific to Massachusetts, they are applicable to most states in the USA. Other hospital systems, outpatient centers, and private practices experienced the same challenges related to statewide mandates. It is our hope that the experiences outlined in this case report may provide guidance to others in the event that a similar crisis should take place in the future. Specific challenges addressed in this case report include: 1) maintaining safety for patients, their families, and staff; 2) continuing to provide high quality inpatient and outpatient services; 3) triaging inpatients and outpatients; and 4) keeping clinicians employed and working productively. I P T 7 mission was to promote patient, family, and staff safety by preventing the spread of COVID-19 while still providing patients with high quality care. U N C O R R E C T E D M A N U S C R Huddles are usually brief team meetings that promote communication and identify problems from being overlooked and can lead to improved quality of patient care and patient safety. 3, 4 Our staff were familiar with the concepts of huddles prior to the COVID-19 pandemic since they routinely participated in huddles as part of the high reliability culture within the different service areas of the Department and the hospital. At the start of the pandemic, we added one daily morning huddle for Department leadership that included the director, managers, and local supervisors. All huddles were conducted on a password protected virtual platform to promote social distancing and to include therapists working at the satellites or remotely. Huddles followed a specific agenda, starting with a safety or success story. Next, new hospital or Department policies and procedures were announced, reviewed, or discussed. Finally, supervisors from each service area reported on the following physical therapy or occupational therapy data: Number of F2F visits, telehealth visits, patients with COVID-19 receiving therapy, outpatients with tracheostomies and potentially needing aerosol generating procedures, outpatients with behavioral challenges, and staff on unscheduled time off for potential COVID-19 reasons. Plans were established and meeting minutes were recorded and saved on a password protected shared network drive so that staff could refer back to information. A second huddle was added at midday for all staff at a frequency of five times per week to announce, review, or discuss new hospital or Department policies and procedures. Meetings started with a safety or success story, followed by any operational updates. Staff were encouraged to ask questions and provide feedback on daily operations. Questions were promptly addressed or escalated in order to provide a quick response for safety or operations. During Phase 2, staff huddles were decreased to three times per week and eventually to one time per week. Changes in policies and procedures were also communicated through emails to staff. Documents about general operations, patient scheduling, and telehealth procedures were placed in a folder on a password protected shared network drive that all staff could access. As part of the increase in communication, staff were asked for feedback on policies and procedures. From this feedback, "listening rounds" were initiated, whereby the director and managers followed staff during part of their day to experience the challenges and to listen directly to staff. Initial planning for inpatient services during the pandemic included implementation of different staffing patterns to address inpatient care needs as the hospital census dropped due to the stopping of elective surgeries and procedures. As we prepared for potential uncertainty, several other factors were considered as we determined inpatient staffing needs: 1) potential surge in patient census due to patients hospitalized with COVID-19 and pediatric patients from neighboring hospitals admitted so they could increase their bed availability for adults, 2) potential decrease in available inpatient staff due to illness or other restrictions, 3) utilization and availability of PPE, and 4) treatment of patients with COVID-19. To address a potential surge in inpatient census and potential decrease in staffing, we created a plan to utilize outpatient staff who previously worked in inpatient settings and had rate for children is much lower than for adults, however, children have been hospitalized in the ICU with COVID-19. 7 Although the rate of severe respiratory problems in children is much lower, some children have a severe response called Pediatric Multisystem Inflammatory Syndrome (PMIS). 8, 9 Clinical presentation consists of typical or atypical Kawasaki Disease, refractory vasodilatory shock similar to Toxic Shock syndrome or a combination of these. 8, 9 Initially, we relied on information shared in hospital-wide meetings from the BCH medical team about PMIS. More recently, information about PMIS has become available on the NIH website 8 and in peer-reviewed journals. 9, 10 Some children with PMIS have acute physical therapy needs; however, at this time we do not know the long-term effects of PMIS on mobility and if these individuals will require physical therapy intervention in the future. We implemented three major changes during the pandemic: 1) decreased the number of patients seen F2F, 2) decreased the number of therapists working in the Department at one time, and 3) initiated telehealth therapy services using an audio and video based HIPAA compliant platform. We revised our outpatient scheduling triage policy to accomplish these changes. For existing patients, we prioritized Urgent or High Priority patients for F2F visits (Tab. 1). Appointments for outpatients who had an established plan of care and were not classified as Urgent or High Priority were cancelled at the start of the pandemic. All new referrals were reviewed to determine priority level and if they required a F2F visit to initiate a plan of care. Next, a plan for telehealth was developed to supplement F2F visits. Telehealth services have been defined as "healthcare service, support and information provided remotely via digital communication and devices". 11 Barriers to adopting telehealth services outside of the COVID-19 pandemic include lack of licensure uniformity and portability and reimbursement policies. 12 continues to evaluate the process. We recognize that maintaining safe patient volume and staffing patterns will be a dynamic process during the continuation of this pandemic. Recently, staff have been seeing outpatients after orthopedic surgery or injury who also contracted COVID-19 while recovering from these conditions. Therapists have reached out for guidance on return to physical activity/competitive sports and potential cardiac complications following COVID-19 infections. A task force of therapists have reviewed evidence on this topic and put together guidelines for therapists on screening patients returning to physical activity and sport following COVID-19 infections. Overall, our experience with conducting telehealth visits has been successful. As part of a Department quality improvement project, we surveyed therapists via online survey software, two months of initiating telehealth visits. Approximately 94% of physical therapists reported that they were satisfied with their ability to conduct telehealth visits. They reported that they were most successful conducting telehealth visits for patients with orthopedic, chronic pain, developmental delay and neurological conditions and least successful with patients diagnosed with autism. They also reported that they accomplished 75% or more of their telehealth session goals with patients who were middle school age or older. When working with infants or children under 3 years of age, therapists reported that they accomplished 50% or more of their session goals; whereas for 3 to 5-year-old patients, therapists accomplished 25% or more of their session goals. During huddles and staff meetings, therapists reported that it is "helpful to see patients doing exercises in their home setting and to provide recommendations on how to use their specific setting to improve the carryover of home exercise programs". For example, therapists have made recommendations for using the railing on the stairs for balance support during a standing activity or adjusting the seat and handlebar height to promote knee extension and upright trunk posture during stationary bike pedaling for a child with cerebral palsy. Another type of telehealth visit that we found to be very successful is durable medical equipment deliveries. During telehealth visits, therapists can provide feedback to equipment vendors, patients, and family members about adjustments, positioning, or use of equipment in the home. Telehealth visits are also helpful when determining which toilet or bath/shower equipment works best in the child's bathroom. For these reasons, telehealth visits would also be useful beyond the pandemic. Therapists requested assistance for providing telehealth visits to established patients from ten other states. Seven of these states allowed temporary licenses for therapists and over 40 patients outside the state of MA have received telehealth visits from therapists in our Department. In January 2021, the state passed a law that will make telehealth services permanently available by requiring insurance carriers and the state's Medicaid program to cover telehealth services in any case where the service would be covered in-person and telehealth is appropriate. This law will take effect 90-days after the state declares the current pandemic state of emergency over and will provide a plan for the state to transition between the current emergency regulations and the delivery of care post-pandemic. However at this time it is unclear if physical therapists in MA are included in "health care providers" that can provide telehealth services. Overall, this administrative case report describes a physical and occupational therapy department's challenges and responses during a state of emergency due to the COVID-19 pandemic. The response included the development of new protocols for a physical and occupational therapy department in a large pediatric hospital. We have provided information about our protocols, which may be helpful for other hospitals or outpatient settings during this pandemic or for planning for future issues that challenge our ability to provide usual care. Recommendations: In order to maintain optimal patient care and safety during this pandemic and in similar emergency situations, several themes and lessons have been learned. 1. The development of specific written policies and procedures will help to guide therapists in safe and effective practice. For situational changes (e.g. changes in state and federal mandates due to the pandemic), policies and procedures should be routinely reviewed and updated to keep up with changes. A written record of the process allows for reference and guidance for management and employees. 2. Routine re-evaluation of processes and staff feedback should be conducted and responded to with explanations to maintain high compliance and quality care. 3. Leadership should remain committed to this being a dynamic process and willing to change as the emergency situation changes (ie, PPE availability, staffing needs). Every emergency situation will pose challenges to operations and delivery of clinical care and require additional support for patients, employees and the organization. Use these lessons to provide safety first and work together with hospital administration early in the emergency process. Communicate often and listen to those closest to the emergency situation (ie, patients, caregivers and staff delivering patient care). Preventing Getting Sick Commonwealth of MA. Reopening Health and Human Services in Massachusetts Team Huddles: A winning strategy for safety Ohio Children's Hospitals' Solutions for Patient Safety: A Framework for Pediatric Patient Safety Improvement Development of guidelines for determining frequency of therapy services in a pediatric medical setting Italian Physical Therapists' Response to the Novel COVID-19 Emergency.Phys Ther. pzaa060 Centers for Disease Control and Prevention. Information for Pediatric Healthcare Providers Updated Centers for Disease Control and Prevention. Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with Coronavirus Disease Pediatric Inflammatory syndrome temporally related to COVID-19 Multisystem Inflammatory Syndrome in U.S. children and adolescents World Confederation for Physical Therapy and International Network of Physiotherapy Regulatory Authorities. The report of the WCPT/INPRA Digital Physical Therapy COVID-19 and the advancement of digital physical therapist practice and telehealth. Phys Ther. pzaa079 Funding: There are no funders to report. The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.