key: cord-0785633-gr7oa9up authors: Karri, Jay; Seymour, Michelle L.; Verduzco-Gutierrez, Monica; Jayaram, Prathap title: Point of care procedures in physiatry: Practice considerations during the Covid-19 pandemic date: 2020-05-08 journal: Am J Phys Med Rehabil DOI: 10.1097/phm.0000000000001463 sha: 60ebb78e1b701c190cc1db751034ee9321af04d6 doc_id: 785633 cord_uid: gr7oa9up Coronavirus Disease 2019 (Covid-19) is an active pandemic that has required rapid conversion of practice patterns to mitigate disease spread. Although recommendations have been released for physicians to postpone elective procedures, the utility of common physiatry procedures and their infectious risk profile have yet to be clearly delineated. In this article, we describe an update on existing national recommendations and outline considerations as practitioners and institutions strive to meet the needs of patients with disabilities. appropriately using personal protective equipment (PPE) can reduce viral transmission and potentially reduce Covid-19 related deaths 4, 5, 10, 11 . The CDC and CMS recently released recommendations that all elective and non-essential medical, surgical, and dental procedures be deferred in an attempt to optimize use of healthcare equipment and resources amidst the Covid-19 pandemic 4, 5 . The overarching aims for the current national recommendations are four-fold: (1) to preserve personal protective equipment (PPE), inpatient beds, and ventilators; (2) to ensure that the healthcare workforce is available to care for patients most in need; (3) to encourage patients to remain home as much as possible to limit exposure; and (4) to provide a framework for triaging non-essential surgeries and procedures. As an illustration of this framework, CMS provides examples of common elective procedures with division into tiers and recommendations for scheduling based on associated patient and procedural risks 5 . However, these tiered procedural recommendations largely focus on invasive and/or surgical procedures and make scant reference to minimally-invasive and noninvasive procedures, which comprise the vast majority of general physiatry procedures in which earlier intervention can optimize recovery and reduce cost-burden. Beyond these recommendations, both the CDC and CMS agree that decisions about proceeding with non-essential surgeries and procedures will be made at the local level by the clinician, patient, hospital, and state and local health departments 4, 5 . Physiatry based procedures are unique in that their overall goals are to allow for functional independence; this is particularly important in such times as we try to reduce the functional decline in our vulnerable patient A C C E P T E D population 10, 12 . Most physiatry procedures are performed on an outpatient basis and so do not directly impact the availability of valuable hospital resources needed to care for inpatients. Use of PPE is an important consideration and varies based on procedural and patient risk factors, which will be discussed further below. While most physiatry procedures are considered elective, this designation does not suggest that they are unnecessary, but rather are not time-sensitive in nature. Given the current status of national recommendations -practitioners have a level of autonomy in deciding which patients may be appropriate candidates for a non-emergent or non-life sustaining procedures 4,5 . Therefore, blanket protocols to terminate all ambulatory could introduce barriers for persons with disabilities for whom timely physiatric care can be vital to their health and function 10 10 . Additionally, telemedicine may provide a unique opportunity to stratify procedural urgency and identify appropriate procedural candidates. Common point of care physiatry procedures include, but are not limited to 14 :  pain and musculoskeletal procedures such as joint, peripheral nerve, epidural injections, and trigger point injections  spasticity procedures such as chemodenervation and neurolysis  electrodiagnostic procedures such as nerve conduction (NCS) and electromyography (EMG) studies The elective nature and time sensitivity of these procedures has understandably come into question. While no clearly delineated recommendations from governmental health agencies or major medical societies exist, considering the urgency and indication of each procedure on a case-by-case basis is instrumental. As previously mentioned, the use of telemedicine services in the Covid-19 pandemic, as extensively endorsed by the CDC, CMS, AMA, and WHO, may help to stratify procedural urgency in patients pending elective procedures 5,6,10,13 . We would like to more fully consider the elective and functionally driven nature of physiatry procedures, as well as their time sensitivity. There exist purely elective procedures in chronic conditions that can be rescheduled without meaningful functional impairment or patient risk. While elective physiatry procedures may not carry life-sustaining benefits, they can provide meaningful improvements in pain ( 16 . Much uncertainty exists with time insensitive, "functionally driven" procedures that may optimize functional recovery or capacity in certain patients ( 24 . Therefore, careful consideration of patients' immune status is imperative prior to peripheral corticosteroid administration. An additional concern is that if these procedures are deferred, worsening impairments will increase dependence on caregivers and increase the vulnerability of disabled patients during the staffing limitations and social distancing associated with the pandemic 11, 13 . Therefore, physiatrists may consider performing functionally driven procedures in appropriate patient candidates who are deemed to have discrete functional goals. Appropriate patient and procedure specific infectious prevention measures should be undertaken. There are also time-sensitive physiatry procedures for which procedural benefits may include a reduction in mortality, morbidity, or immediate disease burden [25] [26] [27] . Such procedures should continue to be performed given their importance in providing timely diagnostic and therapeutic benefit ( 29 . In these cases, practitioners must wear appropriate PPE as allocated by their institution 12, 30 . Despite implementation of recommended preventative measures, the risk of Covid-19 exposure or infection is likely increased with certain patients and procedures ( Table 2) 11, 13 . In higher risk cases, proper prophylactic considerations must be taken so as to meaningfully minimize the risk of spread among the patient, physician, and supportive personnel 11, 13, 30, 31 . Such considerations are especially necessary in persons with disability as they are often at a higher risk for diseaserelated morbidity and mortality 11, 13 . Additionally, careful consideration is warranted for procedures where multiple direct patient encounters are necessary. Such scenarios which include diagnostic nerve blocks to be followed by neuroablative procedures i.e. phenol neurolysis, radiofrequency ablation, etc. or series of viscosupplementation understandably confer increased patient and practitioner risk given recurrent interactions. Given that meaningful or durable analgesic or functional benefit in such instances may only be fully achieved after completion of these procedural protocols, practitioners should carefully weigh the potential benefit of these procedures against the amplified risks posed to patients and physicians with recurrent encounters. Recently, the American Society of Interventional Pain Physicians has released risk stratification guidelines to help characterize patients at increased risk of COVID associated morbidity 34 . While not substantiated, such resources can be instrumental in helping identify and exclude procedural candidates. The uncertainty of Covid-19 associated disease burden has led to rapidly changing clinical practices and recommendations. The intent of our commentary is to provide an update on existing national recommendations and outline considerations as practitioners and institutions strive to make wise decisions at the local and individual level for physiatric practices. Given global and national disparities in healthcare resources, rehabilitation care models, and Covid-19 prevalence and healthcare burden, these decisions are inherently complex and individualized. While the CDC and CMS recommend for elective procedures to be rescheduled in order to preserve healthcare resources and personnel, these recommendations do not account for the spectrum of physiatry procedures and the uniquely vulnerable population we serve. A more nuanced approach that takes procedure and patient specific risks into account will facilitate a more individualized approach to balancing the competing concerns of preserving PPE, protecting both medical staff and patients from Covid-19 exposure and infection, and continuing to provide high-quality care for conditions that substantially impact quality of life and function. EMG leads and machine ultrasound probes and machine procedure suite surfaces following CDC recommended cleaning and disinfection protocols is vital in maintaining sanitary equipment and surfaces 31 How will country-based mitigation measures influence the course of the COVID-19 epidemic COVID-19-new insights on a rapidly changing epidemic Covid-19-Navigating the Uncharted CDC Recommendation: Postpone Non-Urgent Dental Procedures, Surgeries, and Visits Centers for Medicare & Medicaid Services. CMS Releases Recommendations on Adult Elective Surgeries, Non-Essential Medical, Surgical, and Dental Procedures During COVID-19 Response People are still getting tummy tucks and cataract surgeries -and health-care workers fear it puts all at risk for coronavirus. The Washington Post People are still getting tummy tucks and cataract surgeries -and health-care workers fear it puts all at risk for coronavirus. 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