Characteristics and therapy needs of COVID-19 survivors during an enhanced therapy service provision between critical care and discharge: A service evaluation

Introduction

In the United Kingdom the first COVID-19 case was observed on the 31st of January 2020. The ensuing COVID-19 pandemic reached its peak in early April 2020 and required a rapid response from the National Health Service (NHS). This included the expansion of critical care services and the redeployment of multiple staff groups to increase capacity. At our institution in East London in the United Kingdom (The Royal London Hospital, Barts Health NHS Trust), critical care capacity was increased from the 44 beds to almost 90 beds during the first wave of the pandemic. This translated into an increased number of patients requiring a step-down bed on an acute ward following their critical care admission.

Critical care admissions are associated with multiple short- and long-term impairments in both physical and non-physical domains (Needham et al. 2012; Thomas et al. 2019). For example, muscle weakness acquired during the critical care period (ICUAW) can take several months to improve and has a major impact on quality of life (Kress & Hall 2014).

Early work suggests high acuity and prolonged ventilation in patients admitted to ICU with COVID-19. Rehabilitation has been shown possible, however there can be delays to patients starting therapy due to the severity of the illness (McWilliams et al. 2021). We aim to build on this work completed in Birmingham to further understand the rehabilitation needs of COVID-19 survivors.

We proposed to describe the therapy needs of COVID-19 survivors between critical care and acute hospital discharge during enhanced service provision. In addition, we proposed to capture the therapy interventions delivered to our COVID-19 critical care survivors, to determine the type, incidence and frequency of interventions. This will contribute to our understanding of the recovery and rehabilitation needs to support future inpatient and community workforce planning and skill development.

Method

Setting

The Royal London Hospital (Barts Health NHS Trust) is a major teaching organisation and operates over four discreet sites (The Royal London Hospital, Whipps Cross University Hospital, Newham University Hospital, and St Bartholomew’s Hospital) providing local and specialist tertiary care services.

We collected data retrospectively for patients transferred from our adult critical care units to the acute inpatient wards at the Royal London Hospital following an admission with COVID-19 related illness, over a nine-week period (30th March and 31st May 2020). Patients were handed over by the critical care therapy team daily. We excluded patients who were discharged by therapists in critical care, those who were repatriated within 24 hours, and those who were transferred to wards outside our service remit (Figure 1).

See Figure 1: Cohort inclusion and exclusion.

We provided a new seven-day service during the data collection period due to the redeployment of staff from community and outpatient teams. This resulted in a 12% increase in occupational therapist’s (three additional members of staff) and a 93% increase in physiotherapists (14 additional members of staff). The resultant therapist to patient ratio on a Wednesday to Saturday shift was 1:9 for physiotherapists and 1:8 for occupational therapists. While the Sunday to Wednesday shift resulted in a 1:7 patient to therapist ratio for physiotherapists and 1:9 for occupational therapists.

This workforce delivered a service to all acute inpatients irrespective of COVID-19 status guided by a standard operating procedure which included a tool for the prioritisation of services for patients with urgent needs. Consequently, all patients on the therapy case-load received an intervention frequency and intensity according to their perceived need, rather than diagnosis. All redeployed therapy staff completed an induction covering personal protective equipment (PPE), manual handling, national early warning scores (NEWS), braces and orthotics, respiratory competencies, proning, prioritisation, discharge planning, note writing and transdisciplinary working.

Experienced acute inpatient ward occupational therapists and physiotherapists designed the data collection tool (apriori) which included 21 coded therapy interventions as our primary outcome measure. Our secondary outcomes were the critical care background and demographics. Table 1 shows the data we collected.

Table 1: A summary of the data collected (including the primary outcome which was the 21 coded therapy intervention that made up the data collection tool).

Data was extracted from the electronic patient record and entered onto a password protected excel spreadsheet, anonymised and stored locally in compliance with General Data Protection Regulation (GDPR 2018). Only three therapists accessed this spreadsheet throughout the course of the evaluation. Prior to data extraction and analysis, the spreadsheets were scrutinised for consistency of format and coding, and corrections were made as required. Data was subsequently collated via coding and tabbed spreadsheets to extract descriptive information regarding number and frequency of contacts, including which specific interventions were most used.

Ethical approval and patient consent were not required as the project was deemed a service evaluation by the clinical effectiveness unit at The Royal London Hospital. There was no deviation from usual care for any patient, therefore consent was not required. The service evaluation was registered within Barts Health NHS trust according to local policy (registration number 11171).

Results

Therapy interventions

The cohort received a total of 170 therapy sessions over the nine-week period representing a mean of 4.85 (±5) sessions per patient. There was a large range (1–22 sessions) of therapy sessions delivered to patients. All patients were assessed within 48 hours of being transferred from critical care to the wards (Table 2).

Table 2: Mean ± standard deviation (SD) for descriptive data; CPAx: The Chelsea critical care physical assessment tool, (Corner et al. 2012) is a measurement tool used to assess physical function in the ICU.

Initially the most common therapy interventions included mobility, sitting on the edge of the bed, sitting in a chair and discharge planning. During the last four weeks there was an increased frequency of most interventions with peaks in exercise training and mobility practice.

Multidisciplinary interventions delivered at the bed space were highest during the middle of the data collection period and exercise training interventions peaked towards the end of the data collection. Mobility interventions including mobilising with and without oxygen peaked in the fourth and fifth week. Therapy interventions to improve performance in activities of daily living increased from the third week of data collection. More patients were requiring respiratory interventions towards the later part of the evaluation by the physiotherapists including oxygen titration, breathing exercises, self proning, positioning and suctioning. There was a steady increase in the frequency of reorientation and behavioural management interventions which peaked in the seventh week while discharge planning interventions were weighted in the latter half of the period. Figure 2 demonstrates these temporal changes in combined intervention categories across the time.

See Figure 2: Temporal change in combined intervention categories.

The mean time from critical care step down to hospital discharge was 9.74 ± 9.4 days (Table 1). At hospital discharge, 57% of the cohort had returned to complete independence; 17% were independent but required a walking aid; 14% needed the assistance of one person to mobilise and the remaining 12% needed the assistance of two. 29% remained deconditioned as documented by treating therapists and 17% were experiencing fatigue which was also documented on community rehabilitation referrals by therapists. 9% were desaturating when mobilising and an equal percentage had ongoing confusion. 85% were discharged to their own home and 8.5% required a package of care to do so. 6% were repatriated for in-patient rehabilitation and 9% remained in the hospital at the end of the data collection period. 34% were referred for community therapy support at hospital discharge. Only 26% did not require a referral to community services. The mean CPAx score at hospital discharge had improved to 41.3 (±5.4 points) representing a mean improvement of 9.7 (±8.7) points. Although it is currently difficult to generalise these findings to other critical care survivors due to the unpredictability of COVID-19, this would be a clinically meaningful change based on the work of Corner et al. (2015).

Demographics

Thirty-five patients experiencing a COVID-19 related admission were included in the evaluation (71% male: 29% female), with a mean age of 53 years (±13.7 years; Table 2). 55% of the sample identified as Black, Asian or Minority Ethnic (BAME), 30% identified as White/White-Other and 15% were not stated. The mean length of hospital admission was 23 days (±16.3days). There were 25 separate comorbidities represented within the sample and demonstrated in Figure 3. Hypertension, type 2 diabetes, end stage renal failure and high body mass index occurred with the greatest frequency. Many patients presented with three co-morbidities (40%), followed by 4 comorbidities (20%) and 2 comorbidities (14%), however four patients (11%) had no previous past medical history prior to contracting COVID-19 (Figure 3).

See Figure 3: Frequency of co-morbidities within the sample.

BMI = body mass index; T2DM = type 2 diabetes mellitus; OSA = obstructive sleep apnoea; HTN = hypertension; COPD = chronic obstructive respiratory disease; PE = pulmonary embolism; ESRF = end stage renal failure; TIA = transient ischaemic attack; ILD = interstitial lung disease; IHD = ischaemic heart disease; GORD = gastro oesophageal reflux disorder; HIV = human immunodeficiency virus; TB = tuberculosis.

Critical care background

The cohort had a mean intubation time of 13.6 (±6.4) days. 51% of the samples (18 patients) were delirious in the post critical care period. Patients were identified as being delirious by the treating medical teams. 71% of the sample required oxygen therapy post critical care ranging from a range of interfaces including nasal cannula, venturi masks, humidified oxygen and nasal high flow oxygen. Three patients required tracheostomies to help wean from ventilation in critical care, these patients were all weaned off their tracheostomies on the wards. The mean Chelsea Critical care physical assessment (CPAX) score was 30 ± 11.3 points immediately following critical care discharge. This will be patient specific however indicates improvements in respiratory function, mobility, transfers and grip strength. (Table 1).

Discussion

This analysis further strengthens the work completed by McWilliams et al. (2021) in looking into the therapy needs of COVID-19 survivors post critical care step down. This analysis is unique since it was completed during the first peak of the COVID-19 pandemic in the United Kingdom during a period of enhanced staffing. In 2018, the National Institute for Health and Care Excellence (NICE) produced Guideline 94: Enhanced inpatient access to physiotherapy and occupational therapy which recommended extended access to physiotherapy and occupational therapy for people admitted to hospital with a medical emergency. In reaching this recommendation, randomised control trials were identified that compared the benefits of enhanced therapy access (across seven days) to standard access (across five days) in stroke patients (English et al. 2015) and older people (Said et al. 2012; Said et al. 2018 ). These trials suggest additional therapy provision increases the frequency and intensity of therapy delivery, but there are rare accounts or descriptions of the inpatient therapy service or the staff to patient ratio’s which enable these outcomes to be achieved.

Irrespective of our increase in service provision, we were able to identify COVID-19 related impairments that needed to be addressed by therapists at different time points during their recovery.

A high number of patients required oxygen therapy and other respiratory interventions persisting into the latter half of the evaluation. 14% of the cohort experienced significant desaturation events with minimal active movement, limiting the intensity of mobility interventions which could be delivered safely. Future staff training in oxygen delivery devices, weaning and titrating oxygen, mobilising with oxygen, general respiratory and pacing techniques may support staff (especially occupational therapists and therapy support workers as appropriate) to manage these impairments more effectively.

The reports of deconditioning (29%) and severe fatigue (17%) were high however we noticed there was no standardised measure being used to assess these impairments. It could be proposed that these numbers may not actually be a true reflection of the patients who were experiencing these symptoms due to lack of screening tools being used by the team. A meta-analysis of 15 studies including 47,910 patients by Lopez-Leon et al. (2021) found the most common symptom of COVID-19 survivors was fatigue with 58% of these patients experiencing this to some extent.

All these impairments may have the potential to limit the overall intensity and frequency of therapy interventions during the inpatient period and therefore we need an accurate screening tool/assessment and management plan for these specific impairments.

One of the main limitations to our service delivery was the number, range and skill mix of re-deployed therapists who required team induction. Although our team induction covered a range of diagnoses and clinical areas, our initial training focus was on patient safety and essential information to prevent harm given the number of inexperienced staff responsible for intervention delivery (some redeployed team members had not delivered acute ward therapy in over 10 years). Subsequent training was delivered as the pandemic progressed and common clinical presentations were emerging to guide the training content. It is possible that the incidence and frequency of intervention delivery was affected by staff confidence, exposure and expertise. In hindsight, an in-service training schedule that incorporated patient safety and intervention competency, for the commonly expected impairments may have influenced our outcomes however this was a real challenge at the time due to case-load numbers.

We also recognise that the PPE provision and infection prevention restrictions presented a unique challenge during the pandemic. For example, stair and kitchen assessments and other off ward activities which would usually inform ongoing interventions, assist in assessing cognition in a functional way and support discharge planning were ceased. We completed bed side stair assessment if required or set patients a single level to optimise their safety on discharge. The role of the ward therapist changed significantly, with more therapists completing basic care interventions to support nursing activity, especially in COVID-19 designated areas where full PPE was required. Ward culture shifted during the pandemic as patients were nursed predominantly in their beds, due both to the severity of the virus and the risks associated with patients sitting out or mobilising in unobserved clinical areas. These issues may have affected the intensity of therapy services being delivered.

Lastly, we recognise that decisions relating to therapy intervention during the data collection period were based on individual therapist assessment and reasoning alone. Impairments following a COVID-19 related critical care admission were a novel presentation. Therapists may have had difficulty determining the intensity and frequency of rehabilitation sessions in the absence of a clear critical care step down pathway and experience in treating COVID-19 survivors. The absence of measures predicting rehabilitation needs may have left therapists unable to fully appreciate the complexity of these patients and the intensity of rehabilitation they required. Consequently, the assessment and intervention the sample received may have been influenced by staff capacity rather than known (or measured) rehabilitation needs. Understanding the rehabilitation and recovery needs of the post critical care population in future quality activities may help to inform staffing ratios and the recommended intensity of therapy services. We need to be able to objectively identify rehabilitation/recovery needs, provide a therapy service that is sufficient to meet this need, while still focussing on patient flow and safe patient discharge.

Conclusion

This is the first service evaluation looking into the therapy needs of COVID-19 survivors in detail following their critical care admission. We were able to describe in detail the type, incidence and frequency of therapy interventions delivered during the first peak of the pandemic. It has enabled the team to gain a greater understanding of the impact of COVID-19 from an impairment level and helped us to address gaps in knowledge regarding interdisciplinary management of delirium, oxygen desaturations during routine therapy and fatigue management. This analysis has also demonstrated the resilience and responsiveness of the inpatient therapy team and what can be achieved over short period of time. Future work will explore the establishment of a pathway for patients who are transferred from critical care to the acute wards at The Royal London Hospital to ensure patients receive a comprehensive assessment to help establish their individual rehabilitation complexity and therapy needs.

Acknowledgements

The teams of staff within the rehab and discharge team who delivered a seven-day therapy service to patients discharged from critical care onto the wards at the Royal London Hospital during the COVID-19 pandemic 2020.

Clark, B., Whitall, J., Kwakkel, G., Mehrholz, J., Ewings, S., & Burridge, J. (2017). Time spent in rehabilitation and effect on measures of activity after stroke. The Cochrane Database of Systematic Reviews, 2017(3), CD012612. https://doi.org/10.1002/14651858.CD012612.

Corner, E. J., Hichens, L. V., Attrill, K. M., Vizcaychipi, M. P., Brett, S. J., & Handy, J. M. (2015). The responsiveness of the Chelsea critical care physical assessment tool in measuring functional recovery in the burns critical care population: An observational study. Burns: Journal of the International Society for Burn Injuries, 41(2), 241–247. https://doi.org/10.1016/j.burns.2014.12.002.

Corner, E. J., Wood, H., Englebretsen, C., Thomas, A., Grant, R. L., Nikoletou, D., & Soni, N. (2013). The Chelsea critical care physical assessment tool (CPAx): validation of an innovative new tool to measure physical morbidity in the general adult critical care population; an observational proof-of-concept pilot study. Physiotherapy, 99(1), 33–41. https://doi.org/10.1016/j.physio.2012.01.003.

English, C., Bernhardt, J., Crotty, M., Esterman, A., Segal, L., & Hillier, S. (2015). Circuit class therapy or seven-day week therapy for increasing rehabilitation intensity of therapy after stroke (CIRCIT): A randomised controlled trial. International Journal of Stroke, 10(4), 594–602. https://doi.org/10.1111/ijs.12470.

Intensive Care Society. (2019). Guidelines for the provision of intensive care services (2nd ed.). https://www.rcslt.org/-/media/docs/clinical-guidance/critical-care-gpics-v2.pdf.

Kress, J. P., & Hall, J. B. (2014). ICU-acquired weakness and recovery from critical illness. The New England Journal of Medicine, 370(17), 1626–1635. https://doi.org/10.1056/NEJMra1209390.

Lopez-Leon, S., Wegman-Ostrosky, T., Perelman, C., Sepulveda, R., Rebolledo, P. A., Cuapio, A., & Villapol, S. (2021). More than 50 long-term effects of COVID-19: A systematic review and meta-analysis. Scientific Reports, 11(1), 16144. https://doi.org/10.1038/s41598-021-95565-8.

McWilliams, D., Weblin, J., Hodson, J., Veenith, T., Whitehouse, T., & Snelson, C. (2021). Rehabilitation levels in patients with COVID-19 admitted to intensive care requiring invasive ventilation. An observational study. Annals of the American Thoracic Society, 18(1), 122–129. https://doi.org/10.1513/AnnalsATS.202005-560OC.

National Institute for Health Care and Excellence. (2018). NICE guideline 94. Chapter 31: Enhanced inpatient access to physiotherapy and occupational therapy. Emergency and acute medical care in over 16s: service delivery and organisation. https://www.nice.org.uk/guidance/ng94/evidence/31.enhanced-inpatient-access-to-physiotherapy-and-occupational-therapy-pdf-172397464670.

Needham, D. M., Davidson, J., Cohen, H., Hopkins, R. O., Weinert, C., Wunsch, H., Zawistowski, C., Bemis-Dougherty, A., Berney, S. C., Bienvenu, O. J., Brady, S. L., Brodsky, M. B., Denehy, L., Elliott, D., Flatley, C., Harabin, A. L., Jones, C., Louis, D., Meltzer, W., Muldoon, S. R., & Harvey, M. A. (2012). Improving long-term outcomes after discharge from intensive care unit: Report from a stakeholders’ conference. Critical Care Medicine, 40(2), 502–509. https://doi.org/10.1097/CCM.0b013e318232da75.

Peiris, C. L., Shields, N., Brusco, N. K., Watts, J. J., & Taylor, N. F. (2018). Additional physical therapy services reduce length of stay and improve health outcomes in people with acute and subacute conditions: An updated systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation, 99(11), 2299–2312. https://doi.org/10.1016/j.apmr.2018.03.005.

Peiris, C. L., Taylor, N. F., & Shields, N. (2011). Extra physical therapy reduces patient length of stay and improves functional outcomes and quality of life in people with acute or subacute conditions: A systematic review. Archives of Physical Medicine and Rehabilitation, 92(9), 1490–1500. https://doi.org/10.1016/j.apmr.2011.04.005.

Said, C. M., Morris, M. E., Woodward, M., Churilov, L., & Bernhardt, J. (2012). Enhancing physical activity in older adults receiving hospital based rehabilitation: A phase II feasibility study. BMC Geriatrics, 12, 26. https://doi.org/10.1186/1471-2318-12-26.

Said, C. M., Morris, M. E., McGinley, J. L., Szoeke, C., Workman, B., Liew, D., Hill, K. D., Woodward, M., Wittwer, J. E., Churilov, L., Danoudis, M., & Bernhardt, J. (2018). Additional structured physical activity does not improve walking in older people (>60 years) undergoing inpatient rehabilitation: A randomised trial. Journal of Physiotherapy, 64(4), 237–244. https://doi.org/10.1016/j.jphys.2018.08.006.

Sarkies, M. N., White, J., Henderson, K., Haas, R., Bowles, J., & Evidence Translation in Allied Health (EviTAH) Group (2018). Additional weekend allied health services reduce length of stay in subacute rehabilitation wards but their effectiveness and cost-effectiveness are unclear in acute general medical and surgical hospital wards: A systematic review. Journal of Physiotherapy, 64(3), 142–158. https://doi.org/10.1016/j.jphys.2018.05.004.

Sheehy, L. M. (2020). Considerations for postacute rehabilitation for survivors of COVID-19. JMIR Public Health and Surveillance, 6(2), e19462. https://doi.org/10.2196/19462.

Spruit, M. A., Holland, A. E., Singh, S. J., Troosters, T., Balbi, B., Berny, S., Brooks, D., Burtin, C., Clini, E., Franssen, F. M. E., Glöckl, R., Goldstein, R., van ‘t Hul, A., Janssen, D., Kho, M., Langer, D., Maddocks, M., Marques, A., Paneroni, M., & Vitaca, M. (2020). Report of an ad-hoc international task force to develop an expert-based opinion on early and short-term rehabilitative interventions (after the acute hospital setting) in COVID-19 survivors. https://ers.app.box.com/s/npzkvigtl4w3pb0vbsth4y0fxe7ae9z9.

Thomas, S., Mehrholz, J., Bodechtel, U., & Elsner, B. (2019). Effect of physiotherapy on regaining independent walking in patients with intensive-care-unit-acquired muscle weakness: A cohort study. Journal of Rehabilitation Medicine, 51(10), 797–804. https://doi.org/10.2340/16501977-2606.

Wade, D. T. (2020). Rehabilitation after COVID-19: An evidence-based approach. Clinical Medicine, 20(4), 359–365. https://doi.org/10.7861/clinmed.2020-0353.