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 ©2017 MFMER | slide-1 1 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 ©2017 MFMER | slide-2 2 Patient Perspective Whitney’s close encounter with coronavirus ©2017 MFMER | slide-3 3 1 5/24/2020 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 ©2017 MFMER | slide-4 4 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 ©2017 MFMER | slide-5 5 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. ©2017 MFMER | slide-6 6 2 5/24/2020 Creating and Disseminating the Guideline ©2017 MFMER | slide-7 7 Creating and Disseminating the Guideline The Process The Purpose The Procedure ©2017 MFMER | slide-8 8 The Process-SBAR Situation: No current guidelines for management of patients diagnosed with COVID-19 ©2017 MFMER | slide-9 9 3 5/24/2020 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 ©2017 MFMER | slide-10 10 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 ©2017 MFMER | slide-11 11 The Process-SBAR Recommendation: Decision tree and guidelines to promote clinical decision making • Evaluation • Treatment ©2017 MFMER | slide-12 12 4 5/24/2020 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 ©2017 MFMER | slide-13 13 The Purpose Consolidation of information Education of staff Advocate for our patients and professions ©2017 MFMER | slide-14 14 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 ©2017 MFMER | slide-15 15 5 5/24/2020 Mayo Clinic Arizona COVID-19 Guideline ©2017 MFMER | slide-16 16 Guideline ● Evolving! ○ Symptoms ○ Pathophysiology ○ Impairments ○ Lab trends, imaging, and medical management ○ PPE ○ Role of physical and occupational therapy ©2017 MFMER | slide-17 17 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 ©2017 MFMER | slide-18 18 6 5/24/2020 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 ©2017 MFMER | slide-19 19 COVID 19: Pathophysiology 5,6,7,8 https://www.azuravesta.com/covid-19-pandemic ©2017 MFMER | slide-20 20 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 ©2017 MFMER | slide-21 21 7 5/24/2020 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 ©2017 MFMER | slide-22 22 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 ©2017 MFMER | slide-23 23 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 ©2017 MFMER | slide-24 24 8 5/24/2020 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 ©2017 MFMER | slide-25 25 Imaging Chest X-Ray5, 20 Chest CT21 Kuo M, NG M, Lee E. 2020. https://pubs.rsna.org/doi/pdf/10.1148/ryct.2020200034 ©2017 MFMER | slide-26 26 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 ©2017 MFMER | slide-27 27 9 5/24/2020 Medical Management 5,29 ● Supplemental O2 ○ Nasal cannula ○ High-Flow Nasal cannula ○ NIPPV ○ Mechanical Ventilation ● Prone Positioning ● VV ECMO ©2017 MFMER | slide-28 28 Putting It All Together Clinical Decision Making Tool ©2017 MFMER | slide-29 29 Decision Tree-FLOOR ©2017 MFMER | slide-30 30 10 5/24/2020 Decision Tree-ICU ©2017 MFMER | slide-31 31 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 ©2017 MFMER | slide-32 32 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 ©2017 MFMER | slide-33 33 11 5/24/2020 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) ©2017 MFMER | slide-34 34 Educational Handouts ● Functional mobility and activities ○ Progression of activity ○ Exercise Handouts ©2017 MFMER | slide-35 35 Educational Handouts (cont.) ● Strategies to decrease delirium31 ○ Reorientation ○ Sensory Improvements ○ Environmental Modifications ○ Normalize Routine ○ Engage in Leisure Activities ○ Promote Proper Sleep/Wake Cycles ©2017 MFMER | slide-36 36 12 5/24/2020 Institution Specific Operations Original Workflow and Current Updates ©2017 MFMER | slide-37 37 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 ©2017 MFMER | slide-38 38 Workflow ● Rule-outs ● Specific teams/therapists identified each week ○ ICU and Medical team ○ Adjust size of team accordingly ● Schedule for end of day ©2017 MFMER | slide-39 39 13 5/24/2020 Workflow (cont.) Staff that should avoid exposure: ● Pregnant ● Significant chronic respiratory illness ● Immunosuppressed ● Older (eg. >60) ● Chronic health conditions ● Immunodeficiencies ©2017 MFMER | slide-40 40 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 ©2017 MFMER | slide-41 41 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 ©2017 MFMER | slide-42 42 14 5/24/2020 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,