key: cord-0883064-cuaaajrj authors: Tiwari, Devashish; Naidoo, Keshrie; Chatiwala, Naseem; Bartlo, Pamela L; Triola, Allison; Ong, Brandon; Gore, Shweta title: Exploratory Analysis of Physical Therapy Process of Care and Psychosocial Impact of the COVID-19 Pandemic on Physical Therapists date: 2021-03-05 journal: Phys Ther DOI: 10.1093/ptj/pzab088 sha: bdf06fab692e4cb11c78c26bda763c708286adcc doc_id: 883064 cord_uid: cuaaajrj OBJECTIVE: The purpose of this study was to investigate the physical therapy process of care, clinical practices, and the self-reported psychosocial impact of working during the 2020 pandemic on physical therapists and physical therapist assistants. METHODS: An electronic survey including both closed and open-ended questions was distributed to physical therapists employed in a range of health care settings across the United States. RESULTS: Physical therapy utilization and process of care varied across settings. Feasibility of performing an assessment was the main driver for selection of outcome measures. Interventions were mainly geared toward improving respiratory function and deconditioning. Prone patient positioning, now commonplace, was used infrequently by therapists in acute care prior to COVID-19. Similarly, outpatient and home care settings noted an increase in the use of respiratory driven interventions such as incentive spirometry and breathing exercises. Qualitative data analysis revealed both physical barriers (personal protective equipment [PPE]) and social barriers to care. Therapists noted challenges in discharge planning and patient/family education due to the impact of social isolation. They also noted difficulty maintaining productivity standards due to additional time spent in changing PPE and following safety measures. Participants dealt with rapid changes in their role, changing productivity standards, and needing to increase their knowledge in a short amount of time. CONCLUSION: Physical therapy utilization varied widely across settings. Despite some concern for personal health, respondents felt that the COVID-19 pandemic increased a sense of togetherness among team members and promoted greater appreciation for life and work. IMPACT: This exploration of the process of care and current clinical practices across settings provides important knowledge about the role of physical therapists and physical therapist assistants in the care of patients with COVID-19. Gaining an understanding of the psychosocial impact of the pandemic among therapists could assist in creating solutions to better support clinicians’ well-being. Syndrome. 1, [5] [6] [7] [8] [9] [10] [11] Physical impairments can have a long-lasting negative impact on function, mobility, and social participation. 1 There is consensus within the U.S. health care community regarding the importance of physical therapy for patients with severe respiratory symptoms of COVID-19. 12 Physical therapy intervention has been demonstrated to be safe, feasible, and beneficial for patients requiring mechanical ventilation to lessen the effects of intensive care unit (ICU) acquired weakness. [13] [14] [15] Similarly, in postacute settings, physical therapy could play an important role in overcoming the effects of deconditioning, improving cardiovascular and muscular endurance, muscle strength, and overall functional mobility and participation. International physical therapist experts jointly Physical therapists traditionally require use of a hands-on approach to facilitate movement necessitating close proximity to patients. Caring for patients with COVID-19 requires the need to constantly adapt practice including the frequent donning and doffing of personal protective equipment (PPE) and use of technology to educate family members. 16 Working under high stress conditions during this pandemic may place additional psychological burden on therapists and may impact their psychosocial health. 8, 17 Currently, there is no information about the psychological effects of this disease on physical therapists and physical therapist assistants. Although there are psychological effects on patients affected by COVID-19 and their caregivers, 18 the focus of this study was primarily on the psychosocial impact on therapists working during the COVID-19 pandemic. The main objectives of this study, therefore, were to (1) describe the process of care and preferred physical therapist practices for patients with COVID-19 across settings and (2) determine the self-reported psychosocial impact of working during the pandemic on clinicians. Institutional Review Board. Initial questions were drafted by members of the research team utilizing concepts specific to physical therapy process of care from previously published studies on different conditions 19, 20 and psychosocial effects of infectious conditions on health care workers. 8 Figure) . Selection of outcome measures was guided by feasibility of application (63%), best practice (44.5%), and knowledge of the test (42.5%) ( Fig. 1 ). In contrast to the acute care setting, deconditioning was noted to be the most prevalent impairment in rehabilitation and outpatient/home care settings. In rehabilitation settings, most commonly used outcome measures included Borg RPE (30%) followed by the Timed "Up and Go" Test (28%), Five Times Sit-to-Stand (26%), and dyspnea scales (22%). The Borg RPE (14.3%) continued to be the most commonly used in outpatient and home care settings followed by the Timed "Up and Go," the 2-and 6-Minute Walk Tests, and dyspnea scales (Fig. 1) . Within the acute care settings, general conditioning (72%), patient education (72%), and gait training and dyspnea relief (70% each) were the most utilized interventions (Fig. 2 ). Approximately Among those therapists who completed the survey, 18.6% (N = 78) had been tested for COVID- 19 . Of those 78 participants, 7 tested positive. Wearing a mask was reported to be the most inconvenient and restrictive precaution (34.3%), followed by restricted access to the facilities (15%), restricted meetings (12 %), and use of goggles (12%). Most therapists rated their health as good to excellent (77.4%) but reported some emotional stress related to COVID-19 (51.9%). Most therapists were slightly (22.9%) or somewhat (31.2%) concerned for their personal health but somewhat (25.2%) to very concerned (25%) for their family's health (Tab. 4). Increased sense of togetherness and cooperation (33.6%) and greater appreciation of life and work (38.1%) were also reported as a part of their experiences working during the pandemic. Four themes that emerged from the thematic analysis of open-ended survey responses included: barriers to care, the invisible threat, steep learning curve, and teamwork and collaboration. This study is one of the first to describe preliminary data on process of care, utilization of physical therapy including examination and intervention strategies, and the psychosocial impact of working during the pandemic. Although the referral to physical therapy in acute care settings generally remained high, the timeframe for initiation of therapy following admission was delayed. Recommendations for active therapy mobilization require that the patient is conscious (RASS ≥ -2). 27 It is possible that patient severity might have resulted in this delay with patients too heavily sedated, unconscious, or unstable for therapy. A high variation seen in COVID-19 caseload among therapists could 16 most likely be due to regional differences in incidence of COVID-19 and interhospital policies regarding use of physical therapy services and PPE conservation. Future studies comparing the utilization of rehabilitation services across geographical areas and health care systems and examining the reasons for delayed utilization of services are warranted. This study's participants also reported a much longer hospital stay for patients with COVID-19 (8-28 days) than previously seen for patients with other infectious diseases. 28 These results highlight that patient presentation with COVID-19 was more severe than other respiratory diseases requiring a longer stay. Longer length of stay could also be attributed to difficulties with discharge planning. At the time of this study, patiens were discharged to home rather than subacute rehabilitation facilities unless absolutely necessary. 29 Additionally, some patients may have favored discharge to home over rehabilitation. A longer hospital stay is associated with adverse physical, functional, and psychological consequences of immobility 30 Respiratory system impairments followed closely by deconditioning were the most commonly reported impairments in acute care. This was consistent with previous literature on COVID-19 when the pulmonary system was shown to be greatly impacted and a primary cause of mortality. 32 Intervention Therapists reported using interventions that they had not previously used in practice. Prone positioning was one such intervention that was infrequently used in acute care settings prior to the COVID-19 outbreak. Prone positioning was found to improve oxygenation status in these patients. 38 Given the involvement of physical therapists in proning patients with COVID-19, it is likely that they will continue to be an integral part of proning teams with patients who are difficult to wean in the ICU settings in future. Therapists in other settings reported using incentive spirometry and breathing exercises more frequently than they did prior to COVID-19. In contrast, interventions such as inspiratory muscle training were not frequently utilized despite Combining respiratory breathing exercises during balance intervention is one example of how the physical therapist can address multisystem impairments in their allotted therapy session time limit. This will be crucial given the difficulty with productivity standards and staffing models. likely due to limited availability of testing. 41 Therapists experienced emotional distress regarding their own health and their family's health. Given the possibility of chronic long-lasting physical effects from the disease based on previous reports on SARS 10 along with heightened emotional stress, follow-up with these therapists longitudinally would be crucial in assessing the long-term physical and psychological impacts from the disease. Participants described difficulty maintaining productivity standards due to increased time to don and doff PPE and follow infection control measures. The physical therapy profession has seen an increase in attention paid to productivity standards, billing units, and other time-sensitive job duties over the past decade. There has been an increase in burnout among therapists, often observed in the acute care setting. 42 When exercising clinical decision making in a regular acute care setting, a physical therapist is impacted by hospital equipment availability, insurance reimbursement, staff numbers, and lack of support staff. 43 It is safe to assume that these factors will be the same, if not worse, during the COVID-19 pandemic. Hospital equipment, PPE, and staff have all been at a premium since March 2020. The influence of these outside factors was seen in some of this study's results regarding difficulty maintaining productivity standards typically set for the therapists. It has also been shown that patients with cardiovascular or pulmonary complications tend to have lower rates of participation in acute care physical therapy. 44 Because most patients hospitalized with COVID-19 have some degree of pulmonary or cardiovascular involvement, it would be important to look even more closely at physical With regard to physical therapy staffing in acute care settings, there is no clear answer as to an ideal staffing ratio or productivity number. One study found that the physical therapist supply and need for therapy services in an area heavily influenced staffing ratios and the roles of therapists in those hospitals. 45 In hospitals dealing with high numbers of patients with COVID-19, this would also be the case. The role of the therapy services will be heavily influenced by the supply of therapists at that hospital. This could lead to a difference in utilization of physical therapy services and the interventions used by therapists in acute care settings. This was partly seen in the current study with regard to length and frequency of treatment sessions for patients with COVID-19 and to a lesser degree with regard to interventions performed by physical therapists with these patients. Typical supply and demand theory applies when considering the role of therapists in treating patients with COVID-19. Regardless of setting, the availability of therapists, equipment, and support and the demand (patient volume) will greatly impact therapy service utilization. The therapists in this study also reported facing challenges related to physical isolation. Participants described challenges with discharge planning and patent/family education, rapid changes in their roles, productivity standards, workflow, and the need to increase their knowledge rapidly. Supports within health care administration must be built to help overcome these challenges and bolster a sense of camaraderie. This study was not without limitations. First, despite 2 reminders sent to maximize participation, the response rate remained low. The ability of physical therapists to respond to the survey could have been limited due to the narrow time frame in which the survey was collected, given their extensive involvement in patient care and their emotional and physical stress. Also, because the survey was anonymous, the ability to reach out specifically to the nonrespondents was limited. There are no funders to report for this study. U N C O R R E C T E D M A N U S C R I P T 24 U N C O R R E C T E D M A N U S C R I P T U N C O R R E C T E D M A N U S C R I P T U N C O R R E C T E D M A N U S C R I P T 27U N C O R R E C T E D M A N U S C R I P T 29 Early reflection on the global impact of COVID19, and implications for physiotherapy World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19) COVID-19) Cases in the U Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention SARS: prognosis, outcome and sequelae Peripheral nerve disease in SARS: report of a case Disability Among Ebola Survivors and Their Close Contacts in Sierra Leone: A Retrospective Case-Controlled Cohort Study The experience of the 2003 SARS outbreak as a traumatic stress among frontline healthcare workers in Toronto: lessons learned Emerging infectious diseases Neuromusculoskeletal disorders following SARS: a case series Neuromuscular Disorders in Severe Acute Respiratory Syndrome Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations ICU-acquired weakness Physical Therapy Management and Patient Outcomes Following ICU-Acquired Weakness: A Case Series ICU-Acquired Weakness: A Rehabilitation Perspective of Diagnosis, Treatment, and Functional Management Impact of COVID-19 on Physical Therapist Practice in Portugal Psychosocial effects of SARS on hospital staff: survey of a large tertiary care institution Psychosocial impact of COVID-19 Clinical practice in line with evidence? A survey among primary care physiotherapists in western Sweden A survey of physical therapists' clinical practice patterns and adherence to clinical guidelines in the management of patients with whiplash associated disorders (WAD) Are We Asking the Right Questions? Using Cognitive Interviews to Improve Surveys in Education Research. Educational Evaluation and Policy Analysis The REDCap consortium: Building an international community of software platform partners Research electronic data capture (REDCap)-A metadata-driven methodology and workflow process for providing translational research informatics support Using thematic analysis in psychology Organizational research: Determining appropriate sample size in survey research. Information technology, learning, and performance journal Determining Sample Size. University of Florida Cooperative Extension Service, Institute of Food and Agriculture Sciences, EDIS Physiotherapy in the intensive care unit: an evidence-based, expert driven, practical statement and rehabilitation recommendations The Epidemiological and Clinical Characteristics of 81 Children with COVID-19 in a Pandemic Hospital in Turkey: an Observational Cohort Study Navigating Coronavirus Disease 2019 (Covid-19) in Physiatry: A CAN Report for Inpatient Rehabilitation Facilities Reducing iatrogenic risks: ICUacquired delirium and weakness--crossing the quality chasm Ten Hove R. The COVID-19 rehabilitation pandemic. Age and ageing The neuroinvasive potential of SARS-CoV2 may play a role in the respiratory failure of COVID-19 patients Consideration of prevention and management of long-term consequences of post-acute respiratory distress syndrome in patients with COVID-19 COVID-19 pandemic. What should PRM specialists do? A clinician's perspective The role of physical and rehabilitation medicine in the COVID-19 pandemic: the clinician's view. Annals of Physical and Rehabilitation Medicine Considerations for Postacute Rehabilitation for Survivors of COVID-19. JMIR public health and surveillance Recommendations for hospital-based physical therapists managing patients with COVID-19 Surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19) Inspiratory Muscle Rehabilitation in Critically Ill Adults. A Systematic Review and Meta-Analysis Time to Standardize Acute Care Rehab for Patients Poststroke, Say Researchers COVID-19) Testing Experiences of Physical Therapists Working in the Acute Hospital Setting: Systematic Review Cross-Sectional Examination of Patient and Therapist Factors Affecting Participation in Physical Therapy in Acute Care Hospital Settings Finding the "Right-Size" Physical Therapy Workforce: International Perspective Across 4 Countries The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.This article is adapted in part from a platform presentation made at the American Physical Therapy Association's Virtual Combined Sections Meeting, February 1-28, 2021.