Remote rehabilitation for patients with COVID-19.

OBJECTIVE: To describe the effectiveness and risk management of remote rehabilitation for coronavirus disease (COVID-19) patients. DESIGN: Single-centre, retrospective, observational study. PATIENTS: COVID-19 patients undergoing rehabilitation (24 April to 24 May 2020). METHODS: All COVID-19 inpatients undergoing rehabilitation in the general ward were assessed. Data were collected on age, sex, physical ability, rehabilitation modality (remote/direct), need for intubation or extracorporeal membrane oxygenation, degree of pneumonia, oxygen therapy from the start of rehabilitation, D-dimer and C-reactive protein levels, and rehabilitation-related complications. Activities of daily living were measured using the Barthel Index. RESULTS: Out of a total of 43 patients, 14 were initially provided with remote rehabilitation and 29 with direct rehabilitation. Four patients were switched from direct to remote rehabilitation during the study, thus at the end of the study there were 18 in the remote rehabilitation group and 25 in the direct rehabilitation group. Patients in remote rehabilitation were significantly younger than those in direct rehabilitation. Of 12 patients who required intubation, 3 were given remote rehabilitation. One extracorporeal membrane oxygenation survivor underwent direct rehabilitation. All patients on remote rehabilitation were discharged home or to a hotel. Twelve out of 29 patients were transferred to a rehabilitation hospital due to delayed recovery of activities of daily living. No serious adverse events occurred. CONCLUSION: Effective and safe remote rehabilitation was performed in 41.9% of COVID-19 patients in this study, which resulted in improved rehabilitation in COVID-19 zones.

The impact of the COVID-19 pandemic on cardiology services.

OBJECTIVE: The COVID-19 pandemic resulted in prioritisation of National Health Service (NHS) resources to cope with the surge in infected patients. However, there have been no studies in the UK looking at the effect of the COVID-19 work pattern on the provision of cardiology services. We aimed to assess the impact of the pandemic on cardiology services and clinical activity. METHODS: We analysed key performance indicators in cardiology services in a single centre in the UK in the periods prior to and during lockdown to assess reduction or changes in service provision. RESULTS: There has been a greater than 50% drop in the number of patients presenting to cardiology and those diagnosed with myocardial infarction. All areas of cardiology service provision sustained significant reductions, which included outpatient clinics, investigations, procedures and cardiology community services such as heart failure and cardiac rehabilitation. CONCLUSIONS: As ischaemic heart disease continues to be the leading cause of death nationally and globally, cardiology services need to prepare for a significant increase in workload in the recovery phase and develop new pathways to urgently help those adversely affected by the changes in service provision.

Development of an integrated rehabilitation pathway for individuals recovering from COVID-19 in the community.

OBJECTIVE: COVID-19 is a multisystem illness that has considerable long-term physical, psychological, cognitive, social and vocational sequelae in survivors. Given the scale of this burden and lockdown measures in most countries, there is a need for an integrated rehabilitation pathway using a tele-medicine approach to screen and manage these sequelae in a systematic and efficient way. METHODS: A multidisciplinary team of professionals in the UK developed a comprehensive pragmatic telephone screening tool, the COVID-19 Yorkshire Rehabilitation Screen (C19-YRS), and an integrated rehabilitation pathway, which spans the acute hospital trust, community trust and primary care service within the National Health Service (NHS) service model. RESULTS: The C19-YRS telephone screening tool, developed previously, was used to screen symptoms and grade their severity. Referral criteria thresholds were applied to the output of C19-YRS to inform the decision-making process in the rehabilitation pathway. A dedicated multidisciplinary COVID-19 rehabilitation team is the core troubleshooting forum for managing complex cases with needs spanning multiple domains of the health condition. CONCLUSION: The authors recommend that health services dealing with the COVID-19 pandemic adopt a comprehensive telephone screening system and an integrated rehabilitation pathway to manage the large number of survivors in a timely and effective manner and to enable the provision of targeted interventions.

Changes to Rehabilitation Service Delivery and the Associated Physician Perspectives During the COVID-19 Pandemic: A Mixed-Methods Needs Assessment Study.

This project aimed to determine the impact of and needs from physician members of the Canadian Association of Physical Medicine & Rehabilitation during the early response to the COVID-19 global pandemic. The purpose of this project was to develop a framework for addressing the pandemic tailored to the needs of Canadian physiatrists. A convergent mixed-methods design was used for this needs assessment quality project. A total of 136 responses were obtained with an overall response rate of 34%. Three major themes were identified relating to the impact of COVID-19 on physicians: (1) changes to direct patient care, (2) changes to nonclinical aspects of physician's practices, and (3) impacts on personal and family well-being. Three requests for Canadian Association of Physical Medicine & Rehabilitation support during the pandemic were as follows: (1) collaborative sharing of information and resources, (2) advocacy for both patients and providers, and (3) avenues for social connection and wellness. This project provided insight into the impact of COVID-19 and current needs of Canadian Association of Physical Medicine & Rehabilitation physicians. The results were used to develop a solutions framework including guidance on use of virtual care and holding education webinars on high-yield topics. Next steps include a follow-up survey on change in preparedness and member satisfaction with the Canadian Association of Physical Medicine & Rehabilitation response.

A Proposal for Multidisciplinary Tele-Rehabilitation in the Assessment and Rehabilitation of COVID-19 Survivors.

A global pandemic of a new highly contagious disease called COVID-19 resulting from coronavirus (severe acute respiratory syndrome (SARS)-Cov-2) infection was declared in February 2020. Though primarily transmitted through the respiratory system, other organ systems in the body can be affected. Twenty percent of those affected require hospitalization with mechanical ventilation in severe cases. About half of the disease survivors have residual functional deficits that require multidisciplinary specialist rehabilitation. The workforce to deliver the required rehabilitation input is beyond the capacity of existing community services. Strict medical follow-up guidelines to monitor these patients mandate scheduled reviews within 12 weeks post discharge. Due to the restricted timeframe for these events to occur, existing care pathway are unlikely to be able to meet the demand. An innovative integrated post-discharge care pathway to facilitate follow up by acute medical teams (respiratory and intensive care) and a specialist multidisciplinary rehabilitation team is hereby proposed. Such a pathway will enable the monitoring and provision of comprehensive medical assessments and multidisciplinary rehabilitation. This paper proposes that a model of tele-rehabilitation is integrated within the pathway by using digital communication technology to offer quick remote assessment and efficient therapy delivery to these patients. Tele-rehabilitation offers a quick and effective option to respond to the specialist rehabilitation needs of COVID-19 survivors following hospital discharge.

Rehabilitation needs of the first cohort of post-acute COVID-19 patients in Hubei, China.

BACKGROUND: Corona Virus Disease-2019 (COVID-19) is an acute respiratory infectious disease. Despite being clinically cured, some patients still find it difficult to return to their normal life and work due to the varying degree of dysfunctions that they have, as part of the disease's aftereffect. Through this study, we aim to learn more about the dysfunctions and rehabilitation needs of COVID-19 patients. METHODS: In this survey, the basic information, dysfunctions, and rehabilitation needs of the hospitalized COVID-19 patients, who were selected by convenience sampling in Hubei Provincial Hospital of Integrated Traditional Chinese and Western Medicine, were obtained using a self-designed questionnaire. The research was conducted from February 29, 2020 to March 2, 2020. RESULTS: A total of 280 patients were finally included, who were mainly over 51 years of age (64.2%). The main physical dysfunctions that the patients had were sleep disorders (63.6%), decreased activity endurance (61.4%), and respiratory dysfunction (57.9%), while the main psychological dysfunctions included anxiety (62.1%) and fear (50.0%). Rehabilitation that mainly requested by the patients included exercise guidance, dietary instruction, traditional Chinese medicine therapy, physical therapy, and Chinese traditional health exercises. CONCLUSIONS: The demand for rehabilitation is high among COVID-19 patients, which requires the quick establishment of a comprehensive and individualized rehabilitation program, to be fulfilled.

COVID-19 et réanimation cardiorespiratoire (RCR) en contexte hors-hospitalier / COVID-19 and cardiopulmonary resuscitation (CPR) in out-of-hospital context

CONTEXTE: Le présent document ainsi que les constats qu'il énonce ont été rédigés en réponse à une interpellation du ministère de la Santé et des Services sociaux dans le contexte de l'urgence sanitaire liée à la maladie à coronavirus (COVID-19) au Québec. L'objectif est de réaliser une recension sommaire des données publiées et de mobiliser les savoirs clés afin d'informer les décideurs publics et les professionnels de la santé et des services sociaux. Vu la nature rapide de cette réponse, les constats ou les positions qui en découlent ne reposent pas sur un repérage exhaustif des données publiées, une évaluation de la qualité méthodologique des études avec une méthode systématique ou sur un processus de consultation élaboré. Dans les circonstances d'une telle urgence de santé publique, l'INESSS reste à l'affût de toutes nouvelles données susceptibles de lui faire modifier cette réponse rapide. POSITIONS DE L'INESSS À CE JOUR 14 mai 2020 En se basant sur la documentation scientifique disponible au moment de sa rédaction et sur les consultations menées, et malgré l'incertitude existante dans cette documentation et dans la démarche utilisée, et compte tenu que : Dans le contexte de la COVID, les meilleures pratiques de réanimation cardiorespiratoire (RCR) doivent tenir compte de certains principes importants : éviter la propagation du virus, protéger la santé du premier intervenant tout en assurant les meilleures chances de survie pour la victime. La transmission communautaire est le principal moyen de transmission du SARSCov-2 au Québec. La RCR est considérée comme une intervention pouvant générer des aérosols, mais lorsqu'évaluée par composante, les manœuvres de ventilation et d'intubation seraient les plus à risques de produire des aérosols. Les compressions thoraciques et la défibrillation présentent un risque incertain et seraient davantage considérés comme pouvant produire des gouttelettes. La protection des intervenants et des travailleurs de la santé est la priorité en temps de pandémie. Les sociétés savantes et les experts consultés jugent que les manœuvres de réanimation devraient être réalisées, même en temps de pandémie, avec les équipements appropriés et en fonction des expertises des intervenants. PRÉSENTATION DE LA DEMANDE: Au cours des deux dernières décennies, le taux de survie après un arrêt cardiaque survenant tant en milieu hospitalier qu'en milieu communautaire (ou hors-hospitalier) a connu une amélioration constante. Ce succès repose sur l'initiation rapide d'interventions éprouvées, telles que les compressions thoraciques de bonne qualité et la défibrillation [Edelson DP, 2020]. Toutefois, la pandémie actuelle de COVID-19 soulèvent d'importants défis pour les pratiques et les processus établis en matière de manœuvres de réanimation cardiorespiratoire (RCR) lors de la prise en charge hors des hôpitaux. Si l'objectif de la prise en charge rapide est de minimiser la mortalité et la morbidité de tous les individus, le contexte de pandémie nécessite d'éviter la propagation du virus et de protéger la santé de la personne qui effectue les manœuvres de réanimation. La transmission communautaire est maintenant le principal moyen de transmission du virus de COVID-19. La crainte de contagion pourrait, en contexte communautaire ou hors-hospitalier, nuire aux bonnes pratiques de réanimation auprès d'un individu présentant des signes d'arrêt cardiaque. En effet, en ce temps de pandémie, les premiers intervenants doivent à la fois considérer les besoins immédiats des victimes et leur propre sécurité. C'est dans ce contexte que le MSSS a produit un protocole de réanimation simplifié de la COVID-19 pour tous les milieux de soins prenant en charge des usagers hors des hôpitaux (version du 9 avril 2020). Le protocole vise à uniformiser la réanimation cardiorespiratoire dans le contexte pandémique dans tous les milieux de soins prenant en charge des usagers hors des hôpitaux de soins aigus. Cela inclut les centres d'hébergement et de soins de longue durée, les cliniques externes, les résidences privées pour aînés, les cliniques désignées d'évaluation, les unités de psychiatrie et tout autre milieu de soins. MÉTHODOLOGIE: Questions d'évaluations : 1. Quels sont les risques de contamination à la COVID-19 selon les manœuvres de RCR effectuées par un premier intervenant? 2. Quelles sont les manœuvres de RCR à privilégier en contexte hors-hospitalier ainsi que la protection nécessaire pour les effectuer? CONCLUSION: Le processus de recension de la littérature et de consultation sur les risques de transmission de la COVID-19 et les meilleures pratiques de réanimation en situation d'ACR ont mis en évidence la pertinence de décomposer le processus de RCR en ses différentes composantes et de revoir les recommandations émises par le MSSS en fonction de cette distinction. Il ressort que les manoeuvres de compressions thoraciques et de défibrillation semblent comporter un risque moindre que les composantes liées à la ventilation et devraient donc être prodiguées sans délai, une fois l'équipement de protection adéquat revêtu, et ce sans que le statut de la personne en ACR soit connu (i.e. si infectée ou non à la COVID-19). Différentes recommandations sont soumises au MSSS pour soutenir la révision du protocole émis le 9 avril. Pour faciliter les ajustements souhaités par le MSSS, une proposition provisoire de révision de leur protocole.

COVID-19 and cardiopulmonary resuscitation (CPR) in the out-ofhospital settings

BACKGROUND: This document and the findings it contains were prepared in response to an inquiry from the Department of Health and Social Services in the context of the health emergency related to coronavirus disease (COVID-19) in Quebec. The objective is to carry out a summary review of the published data and to mobilize key knowledge in order to inform public decision-makers and health and social services professionals. Given the rapid nature of this response, the conclusions or positions that stem from it are not based on an exhaustive identification of the published data, an evaluation of the methodological quality of the studies with a systematic method or on an elaborate consultation process. In the circumstances of such a public health emergency, the INESSS remains on the lookout for any new data likely to make it modify this rapid response. INESSS POSITIONS TO DATE May 14, 2020 Based on the scientific documentation available at the time of writing and on the consultations carried out, and despite the uncertainty existing in this documentation and in the approach used, and taking into account that: In the context of COVID, best cardiopulmonary resuscitation (CPR) practices must take into account certain important principles: avoid the spread of the virus, protect the health of the first responder while ensuring the best chances of survival for the victim. Community transmission is the main means of transmission of SARSCov-2 in Quebec. CPR is considered an aerosol-generating intervention, but when assessed by component, ventilation and intubation maneuvers would be most at risk of producing aerosols. Chest compressions and defibrillation pose an uncertain risk and would be considered more likely to produce droplets. The protection of health care workers and workers is the priority during a pandemic. The learned societies and experts consulted believe that resuscitation maneuvers should be carried out, even in a pandemic, with the appropriate equipment and according to the expertise of the responders. SUBMISSION OF APPLICATION: Over the past two decades, the rate of survival from cardiac arrest in both hospital and community (or non-hospital) settings has improved steadily. This success relies on the rapid initiation of proven interventions, such as good quality chest compressions and defibrillation [Edelson DP, 2020]. However, the current COVID-19 pandemic poses significant challenges to established practices and processes for cardiopulmonary resuscitation (CPR) maneuvers when taken out of hospital. If the goal of rapid management is to minimize the mortality and morbidity of all individuals, the pandemic context requires preventing the spread of the virus and protecting the health of the person performing the resuscitation operations. Community transmission is now the primary means of transmission of the COVID-19 virus. The fear of contagion could, in a community or out-of-hospital context, undermine good resuscitation practices for an individual with signs of cardiac arrest. Indeed, in this pandemic time, first responders must both consider the immediate needs of the victims and their own safety. It is in this context that the MSSS produced a simplified resuscitation protocol for COVID-19 for all healthcare settings taking care of users outside hospitals (version of April 9, 2020). The protocol aims to standardize cardiopulmonary resuscitation in the pandemic context in all care settings taking care of users outside acute care hospitals. This includes residential and long-term care centers, outpatient clinics, private seniors' residences, designated assessment clinics, psychiatric units and any other care setting. METHODOLOGY: Evaluation questions: 1. What are the risks of contamination with COVID-19 according to CPR maneuvers performed by a first responder? 2. What CPR maneuvers should be favored in a non-hospital context and the protection necessary to carry them out? CONCLUSION: The literature review and consultation process on the risks of transmission of COVID-19 and the best resuscitation practices in RCT situations have highlighted the relevance of breaking down the CPR process into its different components and to review the recommendations issued by the MSSS based on this distinction. It appears that the maneuvers of chest compressions and defibrillation seem to involve a lower risk than the components related to ventilation and should therefore be given without delay, once the adequate protective equipment is put on, and this without the status of the person in ACR is known (ie whether or not infected with COVID-19). Various recommendations are submitted to the MSSS to support the revision of the protocol issued on April 9. To facilitate the adjustments desired by the MSSS, a provisional proposal to revise their protocol.

[Rehabilitation during the lockdown]. / Rehabilitación en época de confinamiento.

The health system is facing a global pandemic due to coronavirus disease 2019. Emergency plans often fail to consider specific rehabilitation issues, whether inpatient or outpatient, although the World Health Organization advises the inclusion of rehabilitation professionals as soon as possible. The contingency plans of rehabilitation services must be carried out in coordination with the other healthcare areas. This review was prepared with the current available evidence on coronavirus disease 2019 and was based on the experience of a specific environment, to plan the continuity of rehabilitation care for all patients and to help rehabilitation teams in this period of lockdown and uncertain lifting of restrictions.

Clinical tools for cardiorespiratory assessment and rehabilitation: A primary care perspective.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected millions of people worldwide. It mainly affects the respiratory system, seen as pneumonia or acute respiratory distress syndrome. Cardiovascular manifestations have been observed in some patients. Hence, cardiorespiratory assessment is an important component of diagnosis, management and follow-up of this disease. Primary care is the first point of contact with the healthcare system for most patients. Therefore, methods for assessment and rehabilitation should be feasible in a primary care setting. This commentary aims to provide a primary care perspective on existing clinical tools for cardiorespiratory assessment and rehabilitation.

COVID-19 rehabilitation units are twice as expensive as regular rehabilitation units.

OBJECTIVE: The COVID-19 pandemic has caused significant motor, cognitive, psychological, neurological and cardiological disabilities in many infected patients. Functional rehabilitation of infectious COVID-19 patients has been implemented in the acute care wards and in appropriate, ad hoc, multidisciplinary COVID-19 rehabilitation units. However, because COVID-19 rehabilitation units are a clinical novelty, clinical and organizational benchmarks are not yet available. The aim of this study is to describe the organizational needs and operational costs of such a unit, by comparing its activity, organization, and costs with 2 other functional rehabilitation units, in San Raffaele Hospital, Milan, Italy. METHODS: The 2-month activity of the COVID-19 Rehabilitation Unit at San Raffaele Hospital, Milan, Italy, which was created in response to the emergency need for rehabilitation of COVID-19 patients, was compared with the previous year's activity of the Cardiac Rehabilitation and Motor Rehabilitation Units of the same institute. RESULTS: The COVID-19 Rehabilitation Unit had the same number of care beds as the other units, but required twice the amount of staff and instrumental equipment, leading to a deficit in costs. DISCUSSION: The COVID-19 Rehabilitation Unit was twice as expensive as the 2 other units studied. World health systems are organizing to respond to the pandemic by expanding capacity in acute intensive care and sub-intensive care units. This study shows that COVID-19 rehabilitation units must be organized and equiped according to the clinical and rehabilitative needs of patients, following specific measures to prevent the spread of infection amongs patients and workers.

The War on COVID-19 Pandemic: Role of Rehabilitation Professionals and Hospitals.

The global outbreak of coronavirus disease 2019 has created an unprecedented challenge to the society. Currently, the United States stands as the most affected country, and the entire healthcare system is affected, from emergency department, intensive care unit, postacute care, outpatient, to home care. Considering the debility, neurological, pulmonary, neuromuscular, and cognitive complications, rehabilitation professionals can play an important role in the recovery process for individuals with coronavirus disease 2019. Clinicians across the nation's rehabilitation system have already begun working to initiate intensive care unit-based rehabilitation care and develop programs, settings, and specialized care to meet the short- and long-term needs of these individuals. We describe the anticipated rehabilitation demands and the strategies to meet the needs of this population. The complications from coronavirus disease 2019 can be reduced by (1) delivering interdisciplinary rehabilitation that is initiated early and continued throughout the acute hospital stay, (2) providing patient/family education for self-care after discharge from inpatient rehabilitation at either acute or subacute settings, and (3) continuing rehabilitation care in the outpatient setting and at home through ongoing therapy either in-person or via telehealth.

Rehabilitation Response in Pandemics.

The World Health Organization declared a pandemic due to the serious health risk posed by coronavirus disease (COVID-19). The number of infected cases is on the rise globally with escalating human, economic, and societal costs. Survivors of COVID-19 may experience a range of clinical, functional, and psychological impairments, resulting in disabilities. Many are amenable to rehabilitation intervention. The current focus of COVID-19 management is on public health measures and acute management. As patients transfer to subacute care or discharged to the community, rehabilitation services need to have a number of organizational and operational models in place to provide safe and effective care for patients and health professionals.There is need for global action by professional organizations in developing a structured rehabilitation approach for international response to disasters, including pandemics. This report proposes development of a "Rehabilitation Response Plan" to enable the International Society of Physical and Rehabilitation Medicine, to provide crucial leadership and governance role in liaison and coordination with the World Health Organization (and other stakeholders), to provide rehabilitation input during current and future pandemics. The key considerations include following categories: governance, coordination, communication, evaluation, and care continuum. These will strengthen rehabilitation, assist in the effective delivery of services, and provide advocacy and an international coordinated perspective.

Systematic rapid living review on rehabilitation needs due to COVID-19: update as of April 30th, 2020.

INTRODUCTION: This paper adds to the series of systematic rapid living reviews, started in April 2020, to provide the rehabilitation community with updates on the latest scientific literature on rehabilitation needs due to COVID-19 pandemic. The aim of this paper is to present the results of a systematic scientific literature search performed on papers published from April 1st to April 30th, 2020. EVIDENCE ACQUISITION: A systematic search was performed on PubMed, Embase, Scopus, CINAHL, PEDro, Web of Science and the main international guideline databases for articles published (including Epub), in English, from April 1st to April 30th, 2020. Papers were included if they reported on one of the following: 1) prevalence and features of the emerging disability after COVID-19; 2) rehabilitation strategies applied for COVID-19 patients, regardless of setting or stage; 3) information about rehabilitation services after COVID-19; 4) impact on diseases of rehabilitative interest; 5) complications of rehabilitative interest. EVIDENCE SYNTHESIS: Out of 445 articles retrieved for the time frame, 50 were finally included for qualitative analysis. They consist of seven guidelines, one scoping review, one randomized controlled trial, four descriptive studies (qualitative), one case series, one case report, and 35 expert opinions. CONCLUSIONS: This systematic rapid living review showed an increasing evidence on rehabilitation needs due to COVID-19 outbreak during April 2020. The main novelties include: 1) the first appearance of epidemiological data on the likely high incidence of neurological complications/disabling sequelae in patients hospitalized for COVID-19; 2) rapid guidelines on the management of chronically disabled patients in the COVID-19 era; 3) advices to provide COVID-19 patients with early respiratory rehabilitation in the acute phase, and with telemonitoring and telerehabilitation in the post-acute phase. Although the overall quality of studies has increased, prospective cohort studies on disability course in COVID-19 pandemic and experimental studies on the effects of rehabilitation are still warranted.