key: cord-0792528-5vyteoxz
authors: Gaspari, Clara H; Assumpção, Iana; Freire, Renata; Silva, Ariane; Santiso, Cintia; Jaccoud, Anna Carolina
title: The First 60 Days: Physical Therapy in a Neurosurgical Center Converted Into a COVID-19 Center in Brazil
date: 2020-09-17
journal: Phys Ther
DOI: 10.1093/ptj/pzaa175
sha: 0cf90b3d88fe665d9f1f40fd8164de16643146b5
doc_id: 792528
cord_uid: 5vyteoxz

OBJECTIVE: The purpose of this case report was to describe the role of physical therapists in a neurosurgical center that was converted into a COVID-19 center for critically ill patients. METHODS (CASE DESCRIPTION): On March 16, 2020, the state government of Rio de Janeiro, Brazil, determined that a neurosurgical center with 44 ICU beds equipped with mechanical ventilators should immediately transfer all patients with neurological conditions to other institutions and prepare for patients who were critically ill with COVID-19. The staff, including physical therapists, were trained to handle patients with COVID-19, many of whom were developing acute respiratory distress syndrome (ARDS) with complex and multifactorial ventilatory support needs. Adjustments were made to the physical therapy routine and protocols. Following the stabilization of patients’ respiratory condition, physical therapist interventions focused on restoring physical function. RESULTS: A total of 116 confirmed COVID-19 cases were treated from March 17 to May 17, 2020. Sixty percent were men (70) and 40% were women (46), with a median age of 59 years. Eighty-nine percent (103) underwent mechanical ventilation during hospitalization, of which 11% (11) were successfully extubated. Thirty percent (31) of patients underwent tracheostomy, and 26% of those (8) were successfully decannulated. Of the total patients, 57 patients died (mortality rate of 49%), 4 (3%) were transferred to another institution, 23 (20%) were discharged home, and 32 (28%) continued to be hospitalized. CONCLUSION: Physical therapists in the ICU can facilitate care for critical events such as intubation, patient positioning, ventilatory adjustments, extubation, and functional training. IMPACT: The coronavirus pandemic has highlighted the importance of physical therapists, specifically in the care of patients who are critically ill with COVID-19. The availability and expertise of physical therapists in the ICU are important for managing critical events such as intubation, patient positioning, ventilatory adjustments, extubation, and functional training.

Objective. The purpose of this case report was to describe the role of physical therapists in a neurosurgical center that was converted into a COVID-19 center for critically ill patients.

On , the state government of Rio de Janeiro, Brazil, determined that a neurosurgical center with 44 ICU beds equipped with mechanical ventilators should immediately transfer all patients with neurological conditions to other institutions and prepare for patients who were critically ill with COVID-19. The staff, including physical therapists, were trained to handle patients with COVID-19, many of whom were developing acute respiratory distress syndrome (ARDS) with complex and multifactorial ventilatory support needs. Adjustments were made to the physical therapy routine and protocols. Following the stabilization of patients' respiratory condition, physical therapist interventions focused on restoring physical function.

A total of 116 confirmed COVID-19 cases were treated from March 17 to May 17, 2020. Sixty percent were men (70) and 40% were women (46), with a median age of 59 years. Eighty-nine percent (103) underwent mechanical ventilation during hospitalization, of which 11% (11) were successfully extubated. Thirty percent (31) of patients underwent tracheostomy, and 26% of those (8) were successfully decannulated. Of the total patients, 57 patients died (mortality rate of 49%), 4 (3%) were transferred to another institution, 23 (20%) were discharged home, and 32 (28%) continued to be hospitalized.

Physical therapists in the ICU can facilitate care for critical events such as intubation, patient positioning, ventilatory adjustments, extubation, and functional training.

The coronavirus pandemic has highlighted the importance of physical therapists, specifically in the care of patients who are critically ill with COVID-19. The availability and expertise of physical therapists in the ICU are important for managing critical events such as intubation, patient positioning, ventilatory adjustments, extubation, and functional training. therapists, until then proficient in treating patients after neurological surgery, started to handle patients critically ill with COVID-19, many of whom were developing acute respiratory distress syndrome (ARDS) with complex and multifactorial ventilatory support needs.

The department, originally staffed with 37 physical therapists, was increased by an additional 18 hires to meet the influx of patients requiring constant mechanical ventilation adjustments and complex care. Reports of increased contamination among health care workers abroad 17, 18 were also contemplated for possible future sick leave.

Other disciplines also quickly adapted to the new demands. Anesthesiologists, who normally assisted in neurosurgeries, became part of the team of intensivists caring for patients

with COVID-19. Their expertise in difficult intubations and other invasive procedures were of immense benefit. Outside physicians joined the inhouse intensivist staff, and neurointensive care pediatricians began caring for adult patients. Adaptability became the greatest challenge for each member of every team.

On March 17, the first patient with COVID-19 arrived, 1 day after receiving the state guidelines to convert. All 44 beds were occupied in the succeeding weeks and have since been fully occupied with patients with COVID-19.

As the staff began receiving specific PPE (protective glasses, N95/PPF2 masks, rubbersoled shoes, face shields, and impermeable gowns), the infectious disease (ID) control team created training protocols on the proper use of each PPE. Knowing that most health care professional contamination occurs during the doffing of PPE, special care was given to the proper sequence of doffing and discarding each item. 19 The training sessions were led by the ID physician and nurses, who ensured that every professional correctly demonstrated the donning/doffing sequencing. All staff practiced 2 to 3 times in group sessions that lasted 30 to 40 minutes.

Another cause for concern was the continuous reports of worldwide PPE unavailability and the ongoing perception that IECPN could also run short of such crucial equipment. As suppliers struggled to provide the items and keep up with the hospital's demands, the infection control team implemented extended-use and limited-reuse guidelines to prevent PPE shortage during times of peak demand. The N95/PFF2 masks, which were discarded following each use

prior to the COVID-19 outbreak, had to be reused for 30 consecutive days. The once disposable impermeable gowns were now used for extended periods (2 gowns per 12-hour shift).

As of mid-June, 8 of the 55 physical therapists (15%) at IECPN have tested positive for SARS-CoV-2. All of these infected professionals also worked extra shifts at different institutions.

From the early months of the pandemic, articles in medical journals suggested that the prone position, widely used since the 1990s to increase oxygenation in patients with ARDS, 20 could be effective for appropriately selected patients with COVID-19. 21, 22 This information led to a hospital-wide effort, led by the physical therapy department, to develop and implement a protocol for prone positioning in patients who are mechanically ventilated. Although the procedure was uncommon in our pre-coronavirus routine for neurosurgical patients, we provided training in proning to all health care professionals handling patients with COVID-19.

The "bed sheet envelope-technique" 23 was adopted based on the experience of senior physical therapists and in conjunction with colleagues from other hospitals in Rio de Janeiro.

Essentially, this technique uses 2 bedsheets to wrap the patient and allows the patient to be swaddled for a 3-point turn to be performed in sequential movements: first, the patient is moved to the side of the bed opposite of the mechanical ventilator; next, the patient is placed in sidelying, and then turned to the prone position. 23 . It is a high-risk procedure because accidental extubation can lead to the patient's death 24 and environment contamination. 25 Relying on their expertise in airway management,

anesthesiologists were designated to be stationed at the headboard to reintubate promptly if needed. Rigorous team synchronization and effective communication were essential. Each nurse, nurse's aide, physician, and physical therapist was trained at least once for the specific sequence of events by performing a simulation of the maneuver using one of the staff members as a mock patient. This preparation led to increased staff confidence for the arrival of the first patient. As of June, no adverse event has been registered in over 72 proning maneuvers.

The regular monthly journal clubs and weekly inservice discussions related to our usual neurosurgical patient population were temporarily suspended. New physical therapy protocols were developed or adjusted, according to the current patients' clinical needs.

The weaning protocol was adapted to the new patient profile and consisted of a 3-step assessment:

(1) Evaluation of the patient's readiness to undergo the spontaneous breathing trial (SBT) checklist: resolution of the cause that led to intubation, absence of fever, partial pressure of arterial oxygen/fraction of inspired oxygen (PaO 2 /FiO 2 ) ≥200 mm Hg, positive end-expiratory pressure (PEEP) ≤8 cm H 2 0, pressure support (PS) <10 cm H 2 0, and FiO 2 <40%.

(2) If approved on all items, the patient would undergo the SBT in a closed system with PS of 5cm H 2 0 and PEEP of 0 cm H 2 0 for 60 minutes.

(3) If approved on step 2, the patient's ability to protect the airway was assessed prior to artificial airway removal: the patient was asked to follow 4 simple commands, and coughing was assessed using closed-system tracheal aspiration. The institutional extubation protocol was also adjusted to include the use of an acrylic box and the administration of intravenous lidocaine (by the medical team or nursing) to decrease coughing, 2 techniques meant to reduce droplet spread during the procedure. 25, 26 A specific protocol for the application and management of noninvasive ventilation took into account the high transmissibility of the virus and ways to minimize staff contamination during this procedure. 27 Specific measures included using double-limb breathing circuit, full face masks, high-efficiency particulate air (HEPA) filter, and, when available, an isolation room. 27 Following the stabilization of the patient's respiratory condition, the physical therapist interventions focused on restoring physical function. When the patient lacked trunk control, physical therapists regularly used the tilt-table, and, prior to discharge, all patients sat at the edge of the bed, stood, and walked during the physical therapy session. 

There are no funders to report.

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.

i ure : "Bed sheet en elope technique": i e tea e bers wrap the patient using 2 bed sheets (one under and one over the patient) leaving the head/neck exposed. The edges are tightly rolled to maintain the patient swaddled during the maneuver. The team member at the headboard commands each step and protects the artificial airway. 

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