key: cord-353196-pbjrgyj2
authors: Keeney, Tamra
title: Physical Therapy in the COVID-19 Pandemic: Forging a Paradigm Shift for Rehabilitation in Acute Care
date: 2020-05-26
journal: Phys Ther
DOI: 10.1093/ptj/pzaa097
sha: 
doc_id: 353196
cord_uid: pbjrgyj2

nan

The emergence of SARS-CoV-2, the coronavirus that causes COVID-19, and its rapid transmission around the globe have confronted health care systems with unprecedented challenges and necessitated swift changes in the provision of health care across all settings. As the United States exceeds 1 million confirmed cases, it has become abundantly clear that patients hospitalized with moderate to severe illness will require significant rehabilitation at hospital discharge. This expected surge in rehabilitation needs has sparked national-level conversations around the importance of physical therapy for COVID-19 survivors in home and communitybased settings 1-3 as well as in postacute care facilities. 4 However, these discussions primarily focus on the designation of COVID-19-specific postacute care facilities to offload hospital capacity and delivery of high intensity home-based services to avoid the need for facility-based postacute care and rehospitalization.

Although delivery of rehabilitation in these settings is unquestionably a key component of COVID-19 care, the multifaceted contribution of rehabilitation in the acute care setting remains largely overlooked. This lack of focus on acute care rehabilitation is due, at least in part, to the

perceived role of inpatient physical therapists as discharge consultants. Discharge planning is an important component of physical therapist practice in hospitals, yet the role of rehabilitation is often myopically constrained to facilitation of efficient discharge planning. In recent years, pressure to decrease hospital length of stay and increase "through-put"-the rate at which patients are moved in and out of the system-has contributed to a culture in many acute care environments whereby physical therapy functions primarily as a consultation service for discharge recommendations. In this culture, physical therapists work rapidly to prioritize large caseloads of patients, often seeing patients late in their hospital stays and making decisions about postacute care based on a single visit. Although some hospitals have adequate rehabilitation staffing to provide services beyond discharge consultation and mobility recommendations, many lack the financial infrastructure needed to employ adequate staff to meet patient needs. In these cases, rehabilitative care becomes fragmented and increasingly difficult to deliver, particularly among the patients in those less abundantly funded areas of the hospital who need it the mostmedically complex older adults admitted to general medicine units.

The ongoing surge of patients with COVID-19 within our health systems has presented enormous challenges in discharge planning, both for patients with and without the disease. Even prior to the pandemic, discharge planning was a disjointed, complex task 5 that often lacked the evidence needed to systematically identify patient care needs and match them to the optimal postacute care setting for recovery. 6, 7 This is due to both the limited amount of time acute care physical therapists often have with each patient, as well as the paucity of research supporting appropriate discharge location selection. Now, as COVID-19 ravages many long-term care and rehabilitation centers, patients are increasingly denied acceptance to these facilities and decisions Increased rehabilitation staffing in acute care ensures rehabilitative care is consistently delivered to patients with skilled therapy needs and may result in faster functional gains during hospitalization. 16 Such gains can potentially deter the need for institution-based postacute care, particularly for certain patient subgroups. 17 Optimal rehabilitation staffing can also benefit patients with functional limitations and disability who are otherwise unable to utilize these services following hospitalization due to limited access or inadequate insurance coverage.

Increased staffing levels further allows for better longitudinal evaluation of functional recovery throughout a patient's hospitalization, thereby ensuring the most appropriate discharge recommendation as well.

Rehabilitation departments simultaneously need to partner with researchers to systematically collect data and evaluate outcomes in these patients, thereby further emphasizing the value of our services within our health systems. Unfortunately, researchers are not commonly embedded within rehabilitation departments, however these relationships are feasible and beneficial. As an example, research partnerships at Cleveland Clinic and Johns Hopkins have explored the potential of functional assessments to predict discharge disposition among hospitalized patients. [18] [19] [20] Despite these growing areas of research in acute care, considerable work remains to generate the evidence needed to optimize physical therapy delivery in the inpatient setting. We need to improve our ability to quantify patients' multidimensional care needs and identify actionable targets that may be achieved during hospitalization with appropriate allocation of skilled therapy services. It is also essential that we better predict patients' potential for recovery in a given postacute care setting and use this evidence to promote shared decision making with our patients, their families, and our interdisciplinary care partners.

The COVID-19 pandemic is a crucible for health care systems across the country. Although rehabilitation utilization in hospitals varies enormously based on institution size, financial resources, and geographic location, it is clear that even in settings where acute care physical therapy is well staffed and well-funded, expansion of our roles is essential. Acute care physical therapists have long provided skilled evaluation and treatment in frenetic and fast-paced environments to patients struggling with serious illness. However, it is only by reacting to these new and difficult circumstances with growth and self-advocacy that we can forge a future characterized by intensive skilled rehabilitation services in the inpatient setting, simultaneously benefiting our health care systems and the patient populations we serve. 

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