key: cord-0943291-3rh7jwka authors: Turcinovic, Michael; Singson, Rufino; Harrigan, Matthew; Ardito, Suzanne; Ilyas, Anum; Sinvani, Liron; Hajizadeh, Negin; Burns, Edith title: Physical Therapy for Hospitalized COVID-19 Patients in Isolation: Feasibility and pilot implementation of telehealth for delivering individualized therapy date: 2021-02-18 journal: Arch Rehabil Res Clin Transl DOI: 10.1016/j.arrct.2021.100113 sha: 127fa1be84c828d6d8b6ed26d5e1dd4c760210b8 doc_id: 943291 cord_uid: 3rh7jwka Objective To optimize the ability of hospitalized patients isolated due to COVID-19 to participate in physical therapy. Design This was a prospective, quality improvement trial of the feasibility and acceptability of a “hybrid” in-person and telerehabilitation platform to deliver physical therapy to hospitalized adults. Setting Inpatient wards of a tertiary care, multi-specialty academic medical center in the greater New York City metropolitan area. Participants A convenience sample of 39 COVID-19+ adults, mean age 57.3 years, 69% male, all previously community dwelling agreed to participate in a combination of in-person and telerehabilitation sessions (TR). Intervention Initial in-person evaluation by physical therapist followed by twice daily PT sessions, one in-person and one via a telehealth platform meeting Health Insurance Portability and Accountability Act (HIPAA) confidentiality requirements. The communication platform was downloaded to each participant's personal smart device to establish audiovisual contact with the Physical Therapist. Measures The 6-clicks Activity Measure for Post-Acute Care (AM-PAC) was used to score self-reported functional status pre-morbidly by, and by the therapist at baseline and discharge. Results Functional status measured by AM-PAC 6-clicks demonstrated improvement from admission to discharge. Barriers to participation were identified and strategies are planned to facilitate use of the platform in future. Conclusions A consistent and structured protocol for engaging patient participation in PT delivered via a telehealth platform was successfully developed. A process was put in place to allow for further development, recruitment and testing in a randomized trial. New York City and the greater metropolitan area rapidly became one of the nation's first COVID-19 pandemic epicenters in the spring of 2020. [1] [2] One of the largest health systems in the state became the "epicenter of the epicenter," caring for over 13,000 patients with COVID-19 between March-May 2020. Standard hospital protocol required that COVID-19 patients be placed on strict contact and airborne isolation. 3 This translated to social isolation, with room doors closed and limited interaction with hospital staff. In-room visits were kept to essential tasks and it was encouraged that duration of each visit be reduced in order to conserve critically needed personal protective equipment and limit virus exposure. This resulted in a significant decrease in case load for the physical therapy team and marked decrease in the duration of contact between therapists and the isolated COVID-19+ patients they served on the wards. Telerehabilitation, the delivery of PT and other rehabilitation services via a natural interface (e.g. computer, tablet, smartphone) connecting patients and therapists, has been successfully used in the community, clinic and home settings. Randomized controlled trials of Telerehabilitation (TR) have demonstrated success in populations such as advanced-stage cancers, cerebrovascular accidents (CVAs), and orthopedic conditions. In the community, home-based TR vs. in-clinic therapy in people with osteoarthritis and CVAs demonstrated improvement in function .4,5 In patients with advanced cancer, TR has also demonstrated health cost savings and decreased hospitalizations. 6 A home-based TR program for veterans living in rural areas showed improvement in functional status, patient satisfaction, and quality of life. 7 We found only one report on use of TR in the hospital setting, for patients with advanced cancer, which demonstrated improved function and decreased LOS. 8 In an effort to provide more effective physical therapy (PT) during the first surge of COVID-19 hospitalizations, and based upon these encouraging reports, the Departments of Medicine and Physical Therapy initiated a TR feasibility and pilot study. [9] [10] [11] The overall goal was to optimize frequency of inpatient PT for isolated patients, prevent hospital-acquired debility (HAD), and minimize length of stay. First-time evaluations by a PT were conducted in person, and the quality improvement initiative described to those with access to their own smart device (e.g. phone or tablet). Potential barriers and challenges to participation were explored for all, and those who agreed were then oriented to the tele-PT process (described below). Ethical Considerations: This quality improvement, feasibility initiative received a determination of "Not Research" from the Institutional Review Board. All participants were fully informed of the purpose of the project, process to be followed, and gave verbal consent to participate. Role of the Funding Source: Tablet devices utilized by the physical therapy team consisted of iPads a acquired through a philanthropic gift. The funders played no role in the design, conduct or reporting of this study. Context: Screening and Recruiting of Patients: A convenience sample of hospitalized patients were screened and recruited using inclusion criteria of: age > 18 years; confirmed COVID-19 diagnosis; smart device at bedside and ability of patient to use independently; able to follow verbal commands of therapist; and ability to actively perform exercises in bed or chair. Potential participants were identified in several ways. PT staff reviewed patient census on medical wards daily (see Figure 1 ) between April 1, 2020 -June 1, 2020. Participants were also identified during in-person initial PT evaluations where a formal consult was requested. Finally, physical therapists participating in unit huddles and interdisciplinary rounds used these opportunities to identify those meeting inclusion criteria. Once identified, a dedicated telehealth physical therapist vetted each potential participant via phone or in person to ascertain interest and ability to participate in the project. If interested in participating, the patient needed to own a smart device with video capability and be able to independently operate the device when on the telehealth call. This QI project used a hybrid approach to delivery of PT, with a combination of in-person and TR visits. Standard of practice for in-patient PT may vary significantly between facilities. Our frequency of follow-up PT sessions can vary from 3 to as many as 7 in-person sessions per week depending on diagnosis and patient need. All sessions take place within the patient room and the activities performed are aligned with patient ability. For example, a post-stroke patient unable to move extremities may receive active, active-assisted, or passive range-of-motion exercises of the affected limbs depending on muscle strength. Patients admitted for different medical conditions may participate in functional-based sessions: activities performed at the bedside may include movement in bed, transferring from sit to stand, ambulating, or stair climbing in order to maximize functional capacity and endurance. Although this is the standard approach, many hospitalized patients do not receive the full complement of PT sessions. Patients may be taken off the floor or detained in a testing location (e.g. radiology) at the time of a planned PT session. Alternately, a patient may decline to participate if feeling too tired. Due to isolation precautions imposed by the pandemic, all sessions reported here were conducted in patient rooms (in-person and TR). All PT sessions were conducted with the patient physically in their hospital room; inperson sessions were conducted with patient and therapist in the hospital room, wearing the required PPE. Inperson evaluations and sessions were individualized to each patient's functional baseline, focusing on ADLs, bed mobility, transfers and ambulation. Physical therapists took into consideration the mode of oxygen delivery and possible need for home oxygen at time of discharge. Tentative plans for safe and appropriate discharge measures were formulated after the initial evaluation. TR sessions were conducted with the therapist located in the office of the PT department, via the audio-video "natural interface" created by the link between the patient's smart device and the therapist's iPad. The TR sessions focused upon and reinforced therapeutic exercises in supine, sitting and/ or standing positions (depending on the patient's functional ability determined from the in-person sessions). Exercises focused on deep breathing, balance and strengthening and were tailored to patient's current abilities. SpO2 levels were monitored remotely to ensure maintenance of appropriate oxygenation during exertion. The telehealth software used was Avizia b downloaded onto an iPad controlled by the therapist. The patient had to download the complementary AmWell Touchpoint app c on their smart device and open the app once the PT started the remote session. PT staff were available for the initial installation of the app onto the patient's smart device if needed. Measures: Baseline and Follow-Up Assessments. Baseline assessment included pre-morbid function, social history, and assessment of living environment/situation. Total number of in-person PT and tele-PT sessions was recorded along with dates of each visit, and any barriers or issues to participation at each time-point. Function was captured utilizing the 6-clicks Activity Measure for Post-Acute Care (AM-PAC) inpatient basic mobility form. 12 The AM-PAC is a therapist-scored standardized assessment of basic mobility and daily activity measure rating an individual's functional status on six items: turning over in bed, sitting down/standing up from a chair with arms, moving from lying on back in bed to sitting on the edge, moving between bed and chair, walking in the room, climbing 3-5 steps with a railing. Each item is scored on a 4-point scale, the first 3 items based on how much difficulty the patient has, the last 3 items on how much assistance is needed from another-unable, a lot, a little, none. A total AM-PAC score was calculated for pre-morbid function (based on self-report), and admission function for all participants. While the goal was to obtain a final AM-PAC score at discharge, this was not possible for all participants (e.g. patient discharged prior to therapist knowledge, patient expired, etc.). Statistical Analysis: Descriptive statistics and analysis of variance were run using SPSS d ANOVA were used to compare change in AM-PAC scores from pre-illness baseline, admission, and discharge. Participants, PT Sessions and Functional Performance: 48 patients were invited to join the program and 39 accepted. Approximately half of those enrolled were men; demographic information for all approached is shown in Table 1 . Average age of enrolled participants was 57.3 years (range 31-87) and average age of those who declined was 70.6 years (range 56-86). Of 39 individuals who initially agreed to participate 32 ultimately completed at least one tele-PT session; seven withdrew due to a variety of reasons, including technical difficulties, fine motor difficulty, unavailability when the therapist visited, preference for only in-person sessions, and discharge or expiration. Results and numbers of participants at each timepoint are reported in Table 2 . Average number of total PT sessions (in-person + TR) per participant was 5.25 + 3.6 (range 2-16); average number of in-person sessions was 2.5 + 1.7, and average number of TR sessions was 2.75 + 2.1. Average number of daily sessions was 1.9 + 0.41 (based on the total number of days each patient was seen by PT). Self-reported premorbid function based on AM-PAC showed a highly functional group with a score of 23.9 out of 24 maximum possible ( Table 2) . Mean AM-PAC function on admission was almost 5 points lower than selfreported baseline, 18.5 + 5.1 vs 23.9 + 0.5 (range 8-24 vs. 21-24). For the 19 participants for whom a discharge AM-PAC measure was available, there was significant improvement compared to admission, mean 2.5 points (range 1-10), but still less than pre-morbid function, repeated measures ANOVA quadratic effect F=13.2, p=.002 (Table 2, Figure 2 ). Final AM-PAC measures were missing on 13 participants who were discharged prior to a final PT session. These 13 participants were not significantly different in demographic characteristics (e.g. age, gender, data not shown), self-reported pre-illness AM-PAC function (24.0 + 0 vs. 23.85 + 0.5, student's t=0.97 , p= 0.34) and admission AM-PAC (18.72 + 4.4 Vs. 18.55 + 5.49, student's t = 0.106 , p=0.92). This brief QI report describes the process for implementation and demonstrates the feasibility of delivering PT via a telehealth platform to individuals hospitalized and isolated due to COVID-19. Over 80% of the potentially eligible patients identified by a physical therapist out of a convenience sample agreed to participate; 67% of the total eventually engaged in tele-PT sessions. Participants had an average of two PT sessions per day and demonstrated improvement in function from admission to discharge. Noting barriers to participation will help guide the team in planning for further trials, e.g. more easily manipulated devices (iPads or tablets) that can be sterilized and utilized by successive participants who lack their own smart devices. Use of "in-house," encrypted devices will also address concerns around security of health information. Additional strategies to assist those with impaired fine-motor skills include tablets with larger surface areas and application of textured acetate covers that improve touch sensitivity. Other barriers that occur across the spectrum of health care in this country, such as English language proficiency and health literacy, pose more difficult challenges and will require additional resources. Limitations: Because this was a feasibility pilot we did not control for demographic variables such as gender and age. The sample size was small, and data capture was incomplete; demographic information was limited to age and gender, there was not a standardized protocol for attempting to capture missing data points and we were unable to contact participants post-discharge. We were also limited in determining severity of illness which could significantly affect the ability to participate in PT. Future trials of this approach will take these variables into account and inform Intention to Treat design. Additional patient-centered outcome measures such as the Borg Perceived Exertion Scale 13 will be needed to demonstrate improved effectiveness of this hybrid approach to conducting PT vs. standard, in-person only PT. This pilot quality improvement project has demonstrated the feasibility of conducting PT a hybrid combination of in-person and virtual sessions for hospitalized patients isolated with COVID-19. The team will continue to utilize this approach and is developing plans for a pragmatic trial. This hybrid model may also have broader applicability in hospitalized and homebound populations. Improvements for future studies would include providing each participant with a smart device during their hospital stay and easing use for those with limited fine motor skills. Participants regularly commented that they greatly appreciated the value of the extra PT session each day and the effort of the therapist in providing the service. Severe outcomes among patients with coronavirus disease (COVID-19) -United States Preliminary Estimate of Excess Mortality During the COVID-19 Outbreak Coronavirus disease 2019 (COVID-19): Infection control in health care and home settings Efficacy of telerehabilitation compared with office-based physical therapy in patients with knee osteoarthritis: A randomized clinical trial Efficacy of Home-Based Telerehabilitation vs In-Clinic Therapy for Adults After Stroke: A Randomized Clinical Trial Epub ahead of print Cost-effectiveness of the Collaborative Care to Preserve Performance in Cancer (COPE) trial tele-rehabilitation interventions for patients with advanced cancers Effects of physical therapy delivery via home video telerehabilitation on functional and health-related quality of life outcomes Effect of Collaborative Telerehabilitation on Functional Impairment and Pain Among Patients With Advanced-Stage Cancer: A Randomized Clinical Trial Rethinking Hospital-Associated Deconditioning: Proposed Paradigm Shift Association of impaired functional status at hospital discharge and subsequent rehospitalization Rehabilitation for hospital-associated deconditioning The Six-Clicks Mobility Measure: A Useful Tool for Predicting Discharge Disposition Psychophysical bases of perceived exertion The authors thank Mr. Greg Galdi and Custom Computer Specialists for their generous support, Mr. Kenneth McMillan for support and encouragement, and Ms. Jennifer Itty for assistance with proof-reading, formatting and submitting the manuscript. The authors are supported by NIH UG3AG060626 from the (EB); NIA R21 AG061307 (EB); NIA T35 AG029793-11 (EB); NIA/NINR 5R21NR018500-02 (LS)