Physiotherapy input and outcomes in patients hospitalised with COVID-19: A retrospective chart review

Introduction

Treating COVID-19 (SARS-CoV-2) infections has posed an enormous challenge to healthcare systems across the globe (Rothan & Byrareddy, 2020). While the number of recovered patients continues to increase, there are many unanswered questions regarding what recovery from COVID-19 infection entails, including the rehabilitation required to support the physical recovery of patients hospitalised with COVID-19 (Hosey & Needham, 2020; Sheehy, 2020).

Patients admitted to critical care with COVID-19 may require extensive rehabilitation in order to regain losses in muscle strength and physical function (Van Aerde et al., 2020; McWilliams et al., 2021). While it is known that critical care rehabilitation is safe and should be commenced as early as possible (Thomas et al., 2020), it is unknown if those hospitalised with COVID-19 infection recover in a predicted fashion and whether traditional mechanisms for rehabilitation meet the needs of this group (Bailey et al., 2007). Physical weakness may also occur in those admitted for ward-based care as a result of deconditioning caused by illness and inactivity during hospital admission (Townsend et al., 2020). As the effects of COVID-19 infection are more systemic than initially expected it is naive to assume a return to baseline function (pre-hospital admission mobility status) for all COVID-19 positive survivors (Arentz et al., 2020; Townsend et al., 2021). Physiotherapists have a role in providing exercise, mobilisation and rehabilitation interventions to survivors of critical illness associated with COVID-19 in order to enable a functional return to home (Jose & Dal Corso, 2016; Thomas et al., 2020). Recent work has identified functional status as a strong predictor for discharge destination for patients with COVID-19 (Roberts et al., 2021). However, further information is needed to identify the impact of COVID-19 on the rehabilitation needs of patients post critical care or those admitted for ward-based care. There is an absence of studies addressing predictors for discharge destination and describing rehabilitation selection criteria for patients with COVID-19 (Wang et al., 2020; Ceravolo et al., 2020). More information on use of rehabilitation services, as well as objective descriptors of functional recovery and patient rehabilitation needs on hospital discharge, may provide valuable insight into the supportive services required to support patient discharge.

The primary aim of this study was to profile the acute physiotherapy service provided to patients admitted with COVID-19. Secondary aims were to examine patients’ rehabilitation needs on hospital discharge and to examine the association between patient characteristics and likelihood of receiving a referral to physiotherapy, likelihood of returning to baseline mobility status and likelihood of discharge home.

Methods

A retrospective patient chart review was completed in September 2020 on all patients admitted to St James’s Hospital with a confirmed diagnosis of COVID-19 between 16th March and 14th May, 2020. Exclusion criteria included the charts of patients who contracted and were diagnosed with COVID-19 during the course of their inpatient stay. St James’s Hospital is the largest acute teaching hospital in Ireland and is partnered academically with Trinity College Dublin.

Data source

Data were obtained from the inpatient hospital databases: the electronic patient record (EPR) system for ward-based care, including rehabilitation, and ICU electronic patient record (the IntelliSpace Critical Care and Anaesthesia-ICCA, Phillips), allowing patients to be followed throughout their entire hospital stay.

Data collection

Each patient admitted with a positive SARS-CoV-2 RT-PCR was identified in the EPR and ICCA database. A standardised data collection tool was created for the collection of all data. Demographic information (including gender, age, medical history and ethnicity) and information regarding hospital stay (including admission to ICU or ward-based care, hospital length of stay) was collected for each patient by 2 members of the research team. Where differences between the 2 researchers’ results were encountered, the chart was re-examined by both observers and results were recorded after an agreement was reached.

The standard of care for physiotherapy input in the study centre was:

1. Early rehabilitation in ICU facilitated by a blanket referral to physiotherapy for every patient on the day of ICU admission.

2. Needs based referrals to physiotherapy by the medical teams of patients admitted for ward-based care.

All physiotherapy input was delivered in the context of a multi-disciplinary care model (where physicians, nurses, physiotherapists, clinical pharmacists, and other staff members provide critical care as a team). Information on the physiotherapy rehabilitation received by each patient was collected, including information on referral to physiotherapy (yes/no), referral to other members of the multidisciplinary team, the number of days to referral to physiotherapy and the number and duration of each physiotherapy session. A pre-admission functional mobility status and functional mobility status on hospital discharge was recorded for each patient from inpatient physiotherapy documentation. Pre-admission mobility status was determined from documentation of the patient’s subjective history on admission. For patients receiving ward-based care, time from physiotherapy referral until mobility away from bedside was collected. For patients admitted to ICU, information was collected on time from referral to physiotherapy until patients successfully achieved the following standardised functional milestones on the ICU mobility scale: independent sitting, independent transfers, independent mobility away from bedside and independent completion of stairs (Hodgson et al., 2014). Functional mobility status on hospital discharge was determined from the objective assessment of patient mobility prior to discharge. Discharge information recorded for all patients included discharge destination (transfer for further inpatient rehabilitation, home, home with community rehab, long-term care, death, remains inpatient in study centre) and referral to community-based physiotherapy on discharge (yes/no).

For patients admitted to ICU additional information was collected, including PaO2/FiO2 on admission, intubation (yes/no), tracheostomy (yes/no), ICU length of stay, the number of days on ventilation and any activity related desaturation during physiotherapy sessions.

Ethical consideration

The study was approved by the Tallaght St James’s Research Ethics Committee (reference number: 2020-06, list 23).

Statistical analysis

Data were analysed using SPSS (2013). Descriptive statistics, namely percentage, mean, and standard deviation, were used for quantitative variables.

We compared factors (for example, patient characteristics, referral to physiotherapy) and patient outcomes (return to baseline function, hospital discharge destination) using the t test for means of continuous variables and the χ2 test for categorical variables. Each factor was 1st tested individually, before all factors that showed an association in the univariate model (p <0.10) were added to a multivariable model (Mudge et al., 2012). We used multivariable logistic regression analysis [backward stepwise selection (likelihood ratio) (PIN <0.05, POUT >0.10)] to determine the association between different factors (for example, length of stay) and referral to physiotherapy (yes/no). The Hosmer-Lemeshow goodness-of-fit test, was used to assess model fit. ANOVA was used to assess any association between patient characteristics (for example, age) and outcomes (for example, discharge destination). p values of <0.05 were considered to be statistically significant.

Results

A retrospective chart review of 171 charts was performed. The clinical characteristics of patients are described in Table 1. Patients admitted to ICU were significantly younger than patients admitted for ward-based care (mean 61 v. 65 years, p = 0.045). In total 98 patients (57%) received a referral for physiotherapy during their inpatient stay. Of the 135 patients alive at the time of data analysis, a total of 19 (14%) patients had not returned to baseline function (pre-hospital admission mobility status). 57% of patients (n = 97) receiving physiotherapy input had input from a mean of 2 other members of the multi-disciplinary team (MDT) (IQR 0–4) (including clinical nutrition, speech and language therapy, occupational therapy and social work).

Table 1: Patient demographics.

LOS: length of stay; COPD: chronic obstructive pulmonary disease; LTC: long term care.

Physiotherapy service provided to patients admitted with COVID-19

Ward-based physiotherapy

A total of 130 patients received ward-based care only (Table 1). Patients admitted for ward-based care were referred to physiotherapy by their medical teams a mean of 3 days post hospital admission (SD 4.45). Amongst patients referred for physiotherapy, 72% of patients were documented as ‘off baseline mobility function’ upon initial assessment. Patients admitted for ward-based care mobilised away from the bedside on average 3 days after referral to physiotherapy (SD 6).

Physiotherapy in critical care

A total of 41 patients were admitted to ICU (Table 1), with 28 (68%) of these patients intubated. The mean PaO2/FiO2 on admission to ICU was 22.2 (SD 15.8). The mean duration of intubation was 13.2 days (SD 10.5, range 2–43 days), with 5 patients receiving a tracheostomy during their ICU stay. The mean ICU length of stay (ICU-LOS) was 15.8 days (SD 13.9, range 2–69 days). All patients were referred for physiotherapy during their critical care stay (range: 0–49 sessions). Patients began active rehabilitation sitting over the edge of the bed a mean of 9.9 days (range 2–38 days) after ICU admission and progressed to mobilise away from the bedside 12.96 days post ICU admission (range 1–33) (Figure 1). In total 20 (49%) participants experienced a documented oxygen desaturation during physical rehabilitation in ICU, the majority while transferring out of bed and mobilising (SpO2 90–95% n = 6, SpO2 85–90% n = 8, SpO2 80–85% n = 4, SpO2 75–80% n = 2).

A total of 38 (93%) patients had independent mobility before admission to ICU. Of the 35 patients who survived an ICU stay, 26 (71%) patients had returned to baseline mobility status on discharge home while 5 (14%) patients required increased aids/assistance with mobility when compared to baseline function. A further 4 patients (11%) were still receiving inpatient rehabilitation at the time of the chart review.

See Figure 1: Functional mobility milestones in ICU.

Rehabilitation needs on hospital discharge

Of the 100 patients discharged from ward-based care, 86 (87%) of patients returned to their documented baseline mobility status. A total of 38 (93%) patients had independent mobility before admission to ICU. Of the 35 patients who survived an ICU stay, 26 (74%) patients had returned to baseline mobility status on discharge home while 5 (14%) patients required increased aids/assistance with mobility when compared to baseline function. A further 4 patients (11%) were still receiving inpatient rehabilitation at the time of the chart review. The chart review identified that 13% (n = 17) of the 131 patients discharged home had a documented onward referral for further physiotherapy input in the community.

Factors associated with referral to physiotherapy

Male patients were significantly more likely to be referred to physiotherapy than females (p = 0.004). Patients with a cardiac history were also more likely to be referred to physiotherapy (p = 0.025) however no association was found between a cancer history, respiratory history (COPD and asthma), cognitive impairment (a documented diagnosis of dementia or Alzheimer’s disease) and likelihood of referral to physiotherapy. Patients were less likely to have independent mobility on hospital discharge if referred to physiotherapy (p = 0.038). Multivariate analysis demonstrated older patients and those with a longer length of stay were significant predictors of those more likely to be referred to physiotherapy (p <0.001) (Table 2).

Table 2: Multiple logistic regression model for factors associated with referral to physiotherapy.

Factors associated with return to baseline function

Cardiac history and history of cognitive impairment were significantly associated with a lower likelihood of return to baseline function on discharge home (p = 0.041 and p = 0.046 respectively). A cancer history (p = 0.113), respiratory history (p = 0.251), gender (p = 0.287), ethnicity (p = 0.988) and an admission to ICU (p = 0.572) had no association with return to baseline function. Results of the ANOVA analysis found both patient’s age and hospital length of stay were significantly associated with likelihood of return to baseline function (both p <0.001). In addition, receiving a higher number or longer physiotherapy sessions was not found to increase the likelihood of returning to baseline function (Table 3).

Table 3: Results of ANOVA analysis: Factors associated with return to baseline function.

Factors associated with discharge destination

A cardiac history and history of cognitive impairment were significantly associated with likelihood of discharge home (p = 0.001 and p = 0.013). There was no association between ICU admission and likelihood of discharge home (p = 0.439). No association was found between gender, cancer history, respiratory history and likelihood of discharge home. Results of ANOVA analysis found younger age, a shorter hospital length of stay, shorter ICU length of stay were all associated with an increased likelihood of discharge home (p <0.05) (Table 4). A lower number of physiotherapy sessions and lower total physiotherapy treatment time were also associated with increased likelihood of discharge home (p <0.05). Patients’ functional status on discharge home was also associated with hospital discharge destination, with those achieving independent mobility significantly more likely to be discharged home (both p <0.001).

Table 4: Results of ANOVA analysis: Factors associated with discharge home.

Discussion

Findings of this study indicate that a significant number of patients hospitalised with COVID-19 require physiotherapy input. Once physiotherapy commenced, a large proportion of patients progressed quickly through functional mobility classifications to become independently mobile on discharge. A sub-set of patients included in the chart review required extensive inpatient physical rehabilitation following a critical care stay.

The patients admitted to critical care were of a similar age to those in our centre pre-pandemic and the national average of patients admitted to critical care (Hodalova et al., 2020). However, there was a lower proportion of females in this COVID-19 critical care cohort (22%) when compared to previous work in our centre (45%) and gender distribution internationally (40%) (Dwyer et al., 2018). This is in keeping with previous reports of sex differences in both hospitalisation and ICU admission rates in those with COVID-19 (Gomez et al., 2021). Additionally, the length of stay of patients admitted to critical care was lower than those in previous studies (22 ± 13 v. 34 ± 24.4 days) however the mortality rates of our COVID-19 critical care population were higher than predicted national mortality rates for ICU (15% v. 7%) (Dwyer et al., 2018).

This study found 72% of patients were off baseline function when referred to physiotherapy, demonstrating the high number of patients hospitalised with COVID-19 infection who require inpatient physiotherapy input. However, a large proportion (86%) of these patients returned to baseline function on discharge from hospital, possibly highlighting the important role of rehabilitation services during the pandemic. The large number of surviving patients that returned to baseline function is in contrast to the results of recent studies in populations recovering with COVID-19 where patients are discharged from hospital with persistent functional and cognitive deficits (Barker-Davies et al., 2020; Roberts et al., 2021). However, there are several possible explanations for this. Firstly, the quality of care and continuity of physiotherapy services in the study setting was high. For example, blanket orders are in place for physiotherapy in the ICU and physiotherapy referral on the ward is consistent with high acknowledgment of the contribution of physiotherapy along the continuum of care. In addition, while patients returned to baseline function, they may still have been experiencing common post COVID-19 symptoms such as fatigue and dyspnoea (Mahase, 2020; Carfì et al., 2020). Although patients regained their capacity to move, they may not have regained their pre-COVID-19 exercise tolerance or subjectively felt fully recovered on discharge from hospital. Indeed, a high number of patients in this study had a transient decrease in oxygen saturation during physiotherapy. While this is a common adverse event in acute rehabilitation (<1% incidence of activity related adverse events) there was a higher incidence of activity related adverse events in this COVID-19 population (Bailey et al., 2007). These, in some cases profound desaturations, resolved with rest and appeared to have no long term effects for the patient in their recovery (Adler & Malone, 2012). In keeping with previous work, this study highlights the importance of understanding the functional limitations of patients with COVID-19 and providing rehabilitation care for hospitalised patients with COVID-19 (Wang et al., 2020). The provision of physiotherapy care continued within the evolving hospital and national guidance throughout the pandemic, with levels of physical rehabilitation provision higher than those reported in similar work (Roberts et al., 2021). This involved careful planning to manage infection control and reduce risk to patients and staff by working in small teams. Information collected in this evaluation has been incorporated into continuous physiotherapy COVID-19 education and advocacy initiatives with healthcare staff at ward level.

A number of patients in this study were referred to community physiotherapy for further rehabilitation input following their hospital admission, reflecting the current evidence regarding the post-hospital rehabilitation needs for patients with COVID-19 (Carfì et al., 2020; Mandal et al., 2021; Taquet et al., 2021). Specific follow up clinics for COVID-19 patients may provide a way to assess patient needs for further rehabilitation resources and services. From the results of this study these services may benefit from including physiotherapy. Patients were less likely to have independent mobility on hospital discharge if referred to physiotherapy, possibly reflecting the complexity of the patient cohort in need of physical rehabilitation.

This study has some limitations. The extensive data collection using electronic records for information specific to physiotherapy means there is a possibility of human error in relation to the recording of study data. Data was recorded from clinical notes that were not specifically documented for research purposes and during urgent care transitions, documentation was occasionally unclear and required interpretation, contributing to potential misclassification bias. It is unknown how well/fit the individuals in this study were pre- SARS-CoV-2 infection. The recording of patients functional status provides only broad classifications of functional mobility pre-admission and on hospital discharge. In addition, it is possible that those patients who remain unwell experience the highest burden of long-term effects of COVID-19 and continue to receive inpatient based care. Further longitudinal follow up is required to identify the long-term trajectory of the rehabilitation required by patients admitted to hospital with COVID-19.

This study examines physiotherapy input only; to have a complete picture of the rehabilitation needs for this patient group other professions such as speech and language therapy, dietetics, occupational therapy and so on, would be required, however, this was beyond the scope of this study. Additonally, ward based patients relied on referral from the medical team or nursing staff for a referral to physiotherapy. As a result, there may have been patients in this review that needed but did not receive physiotherapy. The strengths of this paper include information on patients admitted for both ICU and ward-based care, a cohort with longitudinal analysis and the MDT appproach to patient care. The review highlights that recovery to baseline mobility is probable following COVID-19 infection. It attempts to provide expected markers of progress for physiotherapists treating inpatients with COVID-19. No attempt was made to link the reported longer term effects of COVID-19 infection with the physiotherapy input recevied as an inpatient. The data that has been presented from this institution post covid clinic, including this patient cohort, highlights that fatigue and exercise intolerance remain an issue in the medium term (Townsend et al. 2021). It is unknown whether a potential intervention at hospital discharge such as education and advice on fatigue management, paced exercise and recovery trajectory are benefical in longer term recovery.

Conclusion

This study found a significant number of patients hospitalised with COVID-19 required physiotherapy input. Older patients and those with a longer length of hospital stay were more likely to be referred to physiotherapy. A large proportion of patients returned to pre-morbidity mobility status at the time of hospital discharge however a sub-set of patients included in this chart review required extensive inpatient physical rehabilitation following a critical care stay.

Key points

• A large number of patients hospitalised with COVID-19 were found to be off baseline mobility levels on initial physiotherapy assessment.

• The majority of patients with COVID-19 patients discharged from hospital had returned to their baseline mobility.

• Older patients with COVID-19 and those with a longer length of hospital stay were more likely to be referred to physiotherapy.

Acknowledgements

We would like to thank all patients involved as well as the healthcare providers who cared for these patients throughout their illness, in particular the physiotherapy department in St James’s Hospital.

Author contributions

GS and JD contributed to planning, conducting, design, data acquisition, analysis of data, and writing of the manuscript. NM, KOB, KC, BM, KN and GK contributed data acquisition and review of manuscript. LT, CB and IML contributed to planning, conduction, design, data acquisition and manuscript review.

Competing interests and funding support

• Funding: no funding.

• Conflict of interest: nothing to report.

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