Presentation Slides

5/24/2020

COVID-19: Implications for Physical and Occupational Therapy in the Acute Care Setting- Putting Evidence into Clinical Practice Ashley Bella-Klepps, PT, DPT Jenna Schmid, PT, DPT Whitney Kortuem, OTR/L

Objectives

● Discuss considerations on creating institutional standard of care documents for an interdisciplinary team ● Describe the pathophysiology of COVID-19, including the cardiac and neurologic effects ● Describe common lab values and medical management of patients diagnosed with COVID-19 ● Discuss operational aspects of managing patients diagnosed with COVID-19 based on best available evidence

Patient Perspective

Whitney’s close encounter with coronavirus

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Mayo Clinic Hospital - Arizona

268 beds, 21 operating rooms, and ED1

● Units: ○ ICU, Intermediate, Transplant, Orthopedic/Urology, Inpatient Rehab, General Medical/Surgery, Hematology/Oncology, Neurology/Neurosurgery, Cardiology/Cardiothoracic Surgery

Daily Interdisciplinary Collaboration

● Therapy Teams ● Therapy Technicians ● Recreational Therapy ● PT/OT screening process ● Rounding on medical floors/units ● ICU huddle with multidisciplinary team ● Coordinate with dialysis, RT and RN

Mayo Clinic’s Primary Value2

“The best interest of the patient is the only interest to be considered”

- Dr. William J. Mayo

The needs of the patient come first.

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Creating and Disseminating the Guideline

The Process

The Purpose

The Procedure

The Process-SBAR

Situation: No current guidelines for management of patients diagnosed with COVID-19

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The Process-SBAR

Background: Hospital Incident Command charged us to increase overall bed availability by 25% by April 10th 50% by April 24th for anticipated influx Expected surge of cases in mid to end of April

The Process-SBAR Assessment: Physical and occupational therapists were not equipped with the knowledge or experience to safely evaluate and treat patients diagnosed with COVID-19

The Process-SBAR Recommendation: Decision tree and guidelines to promote clinical decision making • Evaluation • Treatment

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The Process-Timeline Mon. 3/30 Tues. 3/31 Weds. 4/1 Thurs. 4/2 Fri. 4/3 Received first Evaluated Started Collaboration orders first patient Decision Tree with Watched with COVID- Critical webinar 19 Care

Mon. 4/6 Tues. 4/7 Weds. 4/8 Thurs. 4/9 Fri. 4/10 Reviewed Finalized Started InTouch Decision guidelines Health Trees PPE technology champion

Mon. 4/13 Tues. 4/14 Weds. 4/15 Thurs. 4/16 Fri. 4/17 Finalized guidelines

The Purpose

Consolidation of information

Education of staff

Advocate for our patients and professions

The Procedure

Sun. 3/29 Mon. 3/30 Tues. 3/31 Weds. 4/1 Thurs. 4/2 Fri. 4/3 Sat. 4/4 Received First patient Started first orders with Decision COVID-19 Tree

Sun. 4/5 Mon. 4/6 Tues. 4/7 Weds. 4/8 Thurs. 4/9 Fri. 4/10 Sat. 4/11 Reviewed Finalized Started InTouch Decision guidelines technology Trees PPE champion

Sun. 4/12 Mon. 4/13 Tues. 4/14 Weds. 4/15 Thurs. 4/16 Fri. 4/17 Sat. 4/18 Respiratory Finalized In-service guidelines

Sun. 4/19 Mon. 4/20 Tues. 4/21 Weds. 4/22 Thurs. 4/23 Fri. 4/24 Sat. 4/25 Staff Staff Staff Staff education education education education

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Mayo Clinic Arizona COVID-19 Guideline

Guideline

● Evolving! ○ Symptoms ○ Pathophysiology ○ Impairments ○ Lab trends, imaging, and medical management ○ PPE ○ Role of physical and occupational therapy

Guideline Disclaimer 3 ● COVID-19 highly contagious respiratory illness spread through droplets and physical contact ● Prudent that clinicians limit contact with infected individuals to essential rehabilitative interventions ● Close communication to ensure the right care is provided to the right patient at the right time ● Evidence informed care pathway: guide decision making, not replace individualized decision making

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COVID-19 Symptoms 4,5

● Mild symptoms: Dry cough, fever, shortness of breath, chills, muscle pain, sore throat, loss of sense of smell & taste ● Warning signs: Difficulty breathing, persistent chest pressure/pain, confusion, cyanosis

COVID 19: Pathophysiology 5,6,7,8

https://www.azuravesta.com/covid-19-pandemic

Cardiac Impairments 5,9 ● History of cardiovascular disease ○ Increased risk of more severe complications ● Heart failure ○ Systemic inflammatory response to the infection, high lung pressures from lung damage, or myocarditis ○ Direct viral infection in the heart: SARS-CoV-2 can bind with the ACE 2 receptors ● Arrhythmias: infection or side effects from medications

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Cardiac Impairments 5

● Medical intervention for cardiac issues may be warranted ○ Await for decrease in troponins, hemodynamic stability ● Troponin rise, elevated BNP, p-BNP + ARDS ○ Heart dysfunction ○ Diagnosed COVID-19→ critically ill, increased risk of mortality ■ ? hold therapy

Neurological Impairments 10,11,12,13 ● Elderly patients, history of cardiovascular risk factors ○ Higher risk for new cerebrovascular disease ● Direct central nervous system (CNS) injury is rare ● High rates of altered mental status

Neurological Impairments 10,11,12,13

● Mechanisms of insult ○ Direct infection, Hypoxic, immune injury ○ SARS-CoV-2 binding to ACE 2 receptors ● Direct insult: anosmia, headache, encephalitis and myelitis ● Stroke, seizure, altered mental status, delirium, neuromuscular disorders, and critical illness polyneuropathy and myopathy ● Assessment & recognition of effects

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Common Labs Values and Trends

• Increase, indicating • Recognize trends in lab more severe illness: values that may indicate • *CRP14 worsening disease • *Ferritin 15 • *LFTs 16 • *LDH17 • *D-dimer 18 • *IL-619

Imaging Chest X-Ray5, 20 Chest CT21

Kuo M, NG M, Lee E. 2020. https://pubs.rsna.org/doi/pdf/10.1148/ryct.2020200034

Common Medications

22 ● Azithromycin: antibiotic 23, 24 ● Hydroxychloroquine: antimalarial 25 ● Lenzilumab “Len”: humanized monoclonal antibody 26 ● Tocilizumab “Toci”: interleukin-6 blocker 27 ● Zinc: essential mineral 28 ● Convalescent Plasma

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Medical Management 5,29

● Supplemental O2 ○ Nasal cannula ○ High-Flow Nasal cannula ○ NIPPV ○ Mechanical Ventilation ● Prone Positioning ● VV ECMO

Putting It All Together Clinical Decision Making Tool

Decision Tree-FLOOR

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Decision Tree-ICU

InTouch Health Technology

Virtual Care Platform30 Each therapist with a personal login Desktop at nurses’ stations and therapy department iPads Purpose-minimize exposure and use of PPE; coordinate care with RN

PPE

Appropriate donning/doffing of PPE is crucial for preventing infection transmission5 Appointed staff member to be a PPE champion -consistent updates with RN educator -advocate for PT and OT -available for one-on-one training

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Therapeutic Interventions Caution

Patients diagnosed with COVID-19 have impaired recovery ability5 Monitor closely patient’s activity tolerance and how much supplemental O2 the patient requires Requires clinical judgment (disease process)

Educational Handouts

● Functional mobility and activities ○ Progression of activity ○ Exercise Handouts

Educational Handouts (cont.)

● Strategies to decrease delirium31 ○ Reorientation ○ Sensory Improvements ○ Environmental Modifications ○ Normalize Routine ○ Engage in Leisure Activities ○ Promote Proper Sleep/Wake Cycles

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Institution Specific Operations

Original Workflow and Current Updates

COVID-19 Unit Processes

● COVID-19 units: ICU, Intermediate, Medical ● Check point with a nurse prior to entering ● Resource nurses to assist with PPE ● RN/RTs proning patients

Workflow

● Rule-outs ● Specific teams/therapists identified each week ○ ICU and Medical team ○ Adjust size of team accordingly ● Schedule for end of day

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Workflow (cont.)

Staff that should avoid exposure: ● Pregnant ● Significant chronic respiratory illness ● Immunosuppressed ● Older (eg. >60) ● Chronic health conditions ● Immunodeficiencies

Challenges and Changes

● Furloughs/reduced FTE’s ○ Increase in caseload, more assist from RNs, step outside our teams more ● Managing patients with the virus ● Social distancing ○ Rounds cancelled

Lessons Learned & Next Steps

● Teamwork ● Communication: staff encouraged to note trends, post questions ● Disseminating new information ○ White board ○ Departmental emails ○ Update standard of care as necessary

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APTA Scope of Practice

“Over the course of the physical therapist’s career, scope of practice evolves based on considerations including, but not limited to, societal needs;... advancements in knowledge, research, clinical skills, and technology; and the evolving health delivery system…. The professional scope of practice includes contributions to public health services aimed at improving population health and the human experience.” (APTA, 2017)

THANK YOU!

To access this guide go to:

https://www.acutept.org/page/COVID19

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References

1. Mayo Clinic Hospital, Phoenix, Arizona. Mayo Clinic. https://www.mayoclinic.org/patient-visitor-guide/arizona/campus-buildings-maps/mayo-clinic-hospital. Updated November 20, 2019. Accessed May 18, 2020. 2. Viggiano TR, Pawlina W, Lindor KD, Olsen KD, and Cortese, DA. Putting the Needs of the Patient First: Mayo Clinic’s Core Value, Institutional Culture, and Professionalism Covenant. Academic Medicine. 2007; 82 (11) 1089 -1093. 3. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. How to Protect Yourself and Others. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html. Updated April 13, 2020. Accessed April 14, 2020. 4. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Coronavirus Disease 2019: Symptoms. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. Updated May 13, 2020. Accessed May 15, 2020. 5. Campbell, A., Engel, H., Hillegass, E., Perme, C., Ramsey, S. COVID-19: Clinical Best Practices in Physical Therapy Management [Webinar]. March 28 2020. Retrieved from https://register.gotowebinar.com/recording/7342833725268746509. Accessed April 6, 2020. 6. Cascella M, Rajnick M, Cuomo A, Dulebohn S, Di Napoli R. Features, evaluation and treatment of coronavirus (COVID-19). In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020. https://www.ncbi.nlm.nih.gov/books/NBK554776/ #_NBK554776_pubdet. Accessed April 9, 2020. 7. Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak [published online ahead of print February 26, 2020]. J Autoimmun. 2020; 109. DOI: 10.1016/j.jaut.2020.102433 8. Hasudungan, A. COVID-10 (SARS Coronavirus 2): Timeline, pathophysiology (ARDS), coronavirus life cycle, treatment [video]. YouTube. https://www.youtube.com/watch?v=DD_wdvwN9rg. Published April 6, 2020. Accessed April 9, 2020. 9. Weiss, C. How does COVID-19 affect the heart? Mayo Clinic. https://newsnetwork.mayoclinic.org/discussion/how-does-covid-19-affect-the-heart/. Published April 3, 2020. Accessed May 11, 2020. 10. Kumble S, Lopker M, Verma A. Physical Therapy Considerations of Neurologic Presentations in COVID-19 [Webinar]. April 25, 2020. Retrieved from https://register.gotowebinar.com/recording/recordingView?webinarKey=998243714740537359®istrantEmail=bellaklepps.ashley%40mayo.edu. Accessed April 28, 2020. 11. McEntire C, Misra A, O’Hare M, Srikanth P, Williams E, Yau W. COVID-19 Protocols: Neurology. Brigham and Women’s Health. https://covidprotocols.org/protocols/11-neurology/?highlight=rehab. Updated April 24, 2020. Accessed May 3, 2020.

References (cont.)

12. 12. Cervantes A, Greer D. COVID-19 Neurology Protocols. Boston Medical Center. https://covidneurology.org/1-introduction. Accessed May 3, 2020. 13. Wu Y, Xu X, Chen Z, et al. Nervous system involvement after infection with COVID-19 and other coronaviruses [published online ahead of print March 30, 2020]. J Brain Behav Immun. 2020. doi: 10.1016/j.bbi.2020.03.031. 14. Test ID: CRP C-Reactive Protein (CRP), Serum. Mayo Clinic Laboratories. https://www.mayocliniclabs.com/test-catalog/Clinical+and+Interpretive/9731. Accessed April 9, 2020. 15. Mayo Clinic Staff. Ferritin Test. Mayo Clinic. https://www.mayoclinic.org/testsprocedures/ferritin-test/about/pac-20384928. Updated November 28, 2019. Accessed April 9, 2020. 16. Mayo Clinic Staff. Liver function tests. Mayo Clinic. https://www.mayoclinic.org/tests-procedures/liver-function-tests/about/ pac-20394595. Updated June 13, 2019. Accessed April 9, 2020. 17. What Is a Lactate Dehydrogenase (LDH) Test? WebMD. https://www.webmd.com/a-to-z-guides/lactic-acid-dehydrogenase-test#1. Accessed May, 10, 2020 18. What does a D-Dimer test do? WebMD. https://www.webmd.com/dvt/qa/what-does-a-ddimer-test-do. Updated November 18, 2018. Accessed April 10, 2020. 19. Test ID: IL 6 (Interleukin 6, Plasma). Mayo Clinic Laboratories. https://www.mayocliniclabs.com/test-catalog/Clinical+and+Interpretive/63020. Accessed April 10, 2020. 20. Wong H, Lam H, Fong A, et al. Frequency and distribution of chest radiographic findings in COVID-19 positive patients[published online ahead of print March 27, 2020]. Radiology. 2020. doi: 10.1148/radiol.2020201160. 21. Salehi S, Abedi A, Balakrishnan S, Gholamrezanezhad A. Coronavirus disease 2019 (COVID-19): a systematic review of imaging findings in 919 patients [published online ahead of print February 29, 2020] . Amer Jour of Roentgenology. 2020; 215. Doi: 10.2214/ AJR.20.23034. 22. Azithromycin. Medline Plus. https://medlineplus.gov/druginfo/meds/a697037.html. Updated March 16, 2020. Accessed April 13, 2020. 23. Hydroxychloroquine. Medline Plus. https://medlineplus.gov/druginfo/meds/a601240.html Updated March 16, 2020. Accessed April 13, 2020.

References (Cont.)

24. Mercuro NJ, Yen CF, Shim DJ, et al. Risk of QT interval prolongation associated with use of hydroxychloroquine with or without concomitant Azithromycin among hospitalized patients testing positive for coronavirus disease 2019 (COVID19). JAMA Cardiology (2020), doi:10.1001/jamacardio.2020.1834 25. FDA approves emergency IND use of humanigen's lenzilumab for compassionate use in COVID-19 patients. Bloomberg. https://www.bloomberg.com/press- releases/2020-04-02/fda-approves-emergency-ind-use-of-humanigen-s- lenzilumabfor-compassionate- use-in-covid-19-patients. Updated April 2, 2020. Accessed April 14, 2020. 26. Tocilizumab (actemra). American College of Rheumatology. https://www.rheumatology.org/I-Am-A/PatientCaregiver/Treatments/Tocilizumab-Actemra. Updated March 2019. Accessed April 13, 2020. 27. Zinc. National institutes of Health: Office of Dietary Supplements. https://ods.od.nih.gov/factsheets/ZincHealthProfessional/. Updated March 2, 2020. Accessed April 13, 2020. 28. Duan K, Liu B, Li C, et al. Effectiveness of convalescent plasma therapy in severe COVID-19 patients. PNAS. 2020;117(17):9490-9496 29. Alhazzani W, Moller MH, Arabi YM, et al. Surviving sepsis campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Society of Critical Care Medicine. https://sccm.org/getattachment/ Disaster/SSC- COVID19-Critical-Care-Guidelines.pdf?lang=en-US. Accessed April 13, 2020. 30. InTouch Health. https://intouchhealth.com/ Accessed May 20, 2020 31. Delirium Tool Box. Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center. https://uploads- ssl.webflow.com/5b0849daec50243a0a1e5e0c/5e7b98c0de1ee43dd63b0244_CIBS-Delirium-Toolbox-Rack-Card.pdf. Accessed April 13, 2020. 32. American Physical Therapy Association. Physical therapists scope of practice. https://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Practice/PTScopeOfPracticeCombined.pdf. Accessed May 15, 2020