key: cord-0900910-6hec20lu authors: Wittmeier, Kristy; Parsons, Joanne; Webber, Sandra; Askin, Nicole; Salonga, Adrian title: Operational Considerations for Physical Therapy During COVID-19: A Rapid Review date: 2020-09-04 journal: Phys Ther DOI: 10.1093/ptj/pzaa156 sha: 1c0ee05c0a3b3b6e5a751dfd9bdfcadb58657edd doc_id: 900910 cord_uid: 6hec20lu OBJECTIVE: Physical therapists play an important role in responding to pandemic and physical disaster situations. Existing literature can provide guidance to health care leadership teams to appropriately and safely leverage physical therapy resources and skill sets during the COVID-19 pandemic. The purpose of this study was to provide a review of the pandemic and physical disaster management literature to summarize physical therapy–specific operational considerations to assist hospital-based leadership teams in planning and response efforts during the COVID-19 pandemic. METHODS: A rapid review was conducted over a 4-week time frame (April–May 2020). The review team included 3 physical therapist clinician researchers, a health librarian, and a member of the physical therapy leadership team. The initial search strategy identified 303 articles, 80 of which were retained for full-text screening. Twenty articles were included in the review. RESULTS: Five main categories of operational considerations for physical therapy during the COVID-19 pandemic were identified: (1) organizational actions, (2) staffing considerations, (3) physical therapist roles, (4) physical resources, and (5) other considerations. Additional relevant information from physical therapists’ experiences in physical disaster situations was also summarized. CONCLUSION: The evidence presented within this review can be used to inform facility-based and regional planning efforts during the current COVID-19 pandemic and in general preparedness planning. IMPACT: Physical therapists have an important role to play in response efforts related to major events that impact health and wellness, including the COVID-19 pandemic. Evidence-informed facility-based and regional planning during the current COVID-19 pandemic will help physical therapists enhance their role in treating patients in physical therapy and rehabilitation settings. including rehabilitation, has quickly adapted to prepare for their major role in the acute and longer-term response to the COVID-19 pandemic. Physical therapists around the globe have been involved in developing guidance for the management of COVID-19, whether through participating in international guideline writing groups, national advocacy efforts to promote the role of physical therapy in relation to or at the local management and front-line clinician level. [2] [3] [4] Professional organization and health care leadership teams are reexamining traditional physical therapist roles and scope of practice to determine how the physical therapy profession can best respond during this pandemic. 3, 4 Evidence-based management promotes the use of research evidence among other factors (experiential evidence, organizational evidence, patient and stakeholder preferences) to aid in decision making. 5, 6 While lack of time, knowledge, or skills to assess and evaluate research evidence are common barriers to evidence-based management, partnerships between decision makers and researchers, and access to evidence are facilitators of this process. 6 The application of evidence-based management approaches, even within the time constraints imposed by a pandemic situation, has the potential to improve the comprehensiveness and effectiveness of the decisions that ensue. In mid-April 2020, members of this team were contacted to fulfill an evidence-review request from physical therapy leadership at an urban tertiary care facility, to inform hospital planning efforts related to COVID-19. We decided to conduct a rapid review, as a summary of the S C R I P T 5 evidence was required within a short time period to help with health care planning related to this urgent issue. [7] [8] [9] The purpose of this rapid review was to provide an overview of the pandemic and physical disaster management literature and summarize physical therapy-specific operational considerations to assist hospital-based planning and response efforts during the COVID-19 pandemic. The rapid review team included three physical therapist clinician researchers (K.W., J.P., S.W.), a health librarian (N.A.), and a member of the facility physical therapy leadership team (A.S.). The review request was made on April 17, 2020. The team was assembled, and the initial protocol was finalized over the following week, and a four-week timeline to complete the review was agreed upon. Weekly updates were provided to the physical therapy management team throughout the review process, with key papers and documents forwarded as deemed necessary. The specific methods used to balance the rapid nature of the review with the intent to provide a relevant and comprehensive summary are outlined in Table 1 . [7] [8] [9] Rayyan QCRI (Hamad Bin Khalifa University, Doha, Qatar) was used to facilitate the review. 10 Inclusion criteria are listed in Figure 1 . [H2] Data Sources. Figure 2 . [H2] Study selection. To produce a response within a 4-week time frame, we used the method of single-person abstract screening, full text screening and data extraction with second-person validation at each step. The study selection process is outlined in Figure 3 . 11 [H3]Title and abstract screening. A first pass screen of the retrieved titles and abstracts was conducted by the health librarian team member. Included articles were then divided among physical therapist researcher team members for screening and second person validation. Second person validation of excluded articles also occurred. If there was a discrepancy at the screening stage the article was included for full text review. [H3]Full text screening: Full texts of included articles were then screened to determine inclusion or exclusion, divided among three team members (K.W., J.P., S.W.), and validated by a second person. Discrepancies were resolved through discussion. [H2] Data extraction. Data were extracted from the included articles by three reviewers (K.W., J.P., S.W.) into a table with common headings, which were revised throughout the review process through discussion, resulting in the headings used in Table 2 were summarized in narrative format. Risk of bias and quality appraisal of the included articles were not conducted due to the rapid nature of the review process. Eighty articles were retrieved for full text screening; 60 of these were assessed to not meet the inclusion criteria (Fig. 1 ). Of the 20 included articles, seven were specific to the COVID-19 pandemic. 2, [12] [13] [14] [15] [16] [17] Twelve articles discussed the role of physical therapy in response to physical disaster situations [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] and one was a guidance document found on a Canadian hospital website that was deemed relevant for organizational planning by physical therapy management. 30 Nine articles with concrete actionable considerations relevant to hospital-based physical therapy operations during the COVID-19 pandemic are summarized in Table 2 The following is a narrative synthesis of recommendations or actions from the articles included in Table 3 , across the five categories of organizational actions, staffing considerations, physical therapist roles, physical resources, and other considerations. Organizational actions included implementation of COVID-19 symptom screening protocols for staff and for patients as part of the preadmission process. [12] [13] [14] Visitors were limited or prohibited, and communication with families done by telephone. 12, 16 In certain instances, rehabilitation areas were converted into acute medical units for patients with COVID-19, 2, 12 and it was suggested to compile education / resources for physical therapists redeployed to these areas, or to intensive care units without recent experience. 2, 28, 29 One article discussed the use of video-consultation on wards dedicated to COVID-19 as a method to reduce the frequency of direct contact. 16 Specific and limited indications for hands-on inpatient physical therapy treatment for patients were outlined in another article. 17 Therapy efforts were directed toward safe and early hospital discharge for patients not affected by COVID-19, with referral to other appropriate services where available. 12, 13, 16 The need for new admissions for inpatient rehabilitation was carefully evaluated. 13 Within-hospital outpatient services were largely discontinued, and the majority of articles highlighted virtual care or telerehabilitation as important options to allow for continued rehabilitation service provision where possible. [12] [13] [14] 16 , communication. 2, 12, 14, 17, 28 Finally, the importance of planning for follow-up and postacute rehabilitation needs of patients affected by COVID-19 was recognized. 16 Staffing considerations included a focus on ensuring adequate staffing levels, proper staff training, and staff and patient safety. Most of the articles discussed the strategy of creating teams that would have minimal interactions with each other 14 and distinct assignments either toward treating patients with COVID-19, or toward treating patients without COVID-19 (intensive care unit or burn unit in the case of the Bali bombing disaster). 2, 28, 29 This strategy aimed to reduce the risk of infection transmission between wards and staff, while allowing for continued clinical care by a fully staffed team should another team become ill or need to isolate. 14 Hours of work were adjusted to minimize interaction between staff, 2, 12, 16 and conserve personal protective equipment (PPE). 16 Additional recommendations to ensure adequate staffing included offering extra shifts to part time staff, allowing staff to cancel / postpone planned leaves, 2 and redeploying staff to intensive care units, wards designated to COVID-19, or to other areas to support discharge or preventive care depending on the skill set of the therapist. 2 Adequate training and mentorship for redeployed staff was emphasized, 2 as well as training for proper donning and doffing of PPE. 14 There was special mention to consider the risk of infection for staff with chronic health conditions and to provide work from home options where possible. 14 Provision of childcare and / or temporary living quarters were also recommended as measures to support staff. 14 In the article describing the response to the bombing in Bali, increased staffing was maintained for six months after the initial event to accommodate ongoing and outpatient needs of patients. 28, 29 Physical therapist roles related to hospital-based management of COVID-19 were discussed for both the outpatient and inpatient setting. The importance of maintaining some level of outpatient therapy was highlighted to prevent functional decline, hospital visits or potential admission of patients not affected by COVID-19. 15 It was recognized that this may be delivered in patients' homes or a community setting (where possible), or using telerehabilitation or virtual care. 15 where resources are at capacity. 15, 17 The need for physical therapists to follow infection control guidelines, use proper PPE and to work collaboratively with the interdisciplinary team to limit the number of staff directly exposed to patients with COVID-19, while still providing best care was highlighted. 2, 14, 17, 28, 29 Physical resource recommendations focused on ensuring adequate and appropriate PPE availability for the various procedures (including aerosol-generating procedures) that physical therapists are involved with. 2, 13, 14 Physical space considerations included planning for preadmission screening, as well as organizing space and rehabilitation equipment to comply with infection control and physical distancing recommendations. 13, 28, 29 There was an emphasis 12 on proper equipment cleaning or using single use / disposable equipment. 2, 14 One article suggested planning for use of uniforms or implementation of a protocol that staff change their clothes at the end of a shift to minimize infection spread. 2 As for other considerations, while a number of articles indicated a role for mentorship and education for physical therapists, one article specifically highlighted the creation of a "physical therapy task force" to help therapists improve skills that may be required to care for patients with COVID-19. 17 Reflections on physical therapy involvement in the Bali bombing disaster discussed the difference between an "individualized" versus a "best for most" approach to care. These authors reported that the staffing measures taken (see Table 3 ) and an individualized philosophy of care contributed to the facility achieving service quality and patient outcomes during the disaster response that were equivalent to what was achieved in non-disaster times. 28, 29 [H2] Summary: Physical therapist roles in physical disaster scenarios Ten articles included in our review contained actionable items for a physical therapy workforce that were not immediately relevant given the current local situation with COVID-19. [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] Our team decided to retain these studies and summarize them narratively as certain recommendations may become more relevant should the situation with the pandemic worsen. They may also provide useful guidance for other regions or scenarios. All of these articles provided recommendations for physical therapists working during, or in the after-math of natural or human-made disasters, such as floods and landslides, 18 Because physical therapy is focused on function, therapists play an important role in discharge planning with patients injured in disasters and in educating other medical staff regarding criteria for safe discharge. 21, 22 Identifying the need for follow-up and organizing outpatient rehabilitation services has been noted as an important role physical therapists can assume. 18, 20, 21 This may include setting up telerehabilitation options, 18, 26 community-based rehabilitation, 21, 22 and free services provided by physical therapist volunteers. 18 There was also general consensus that physical therapists can contribute beyond their traditional roles, for example in triaging patients, assessing vital signs, and providing first aid. 19-21, 23-27, 31 Physical therapists' expertise in assessing and treating orthopedic conditions has allowed them to work in "physician extender" roles in field hospitals, freeing orthopedic surgeons for the most critical cases, resulting in more timely treatment for all and fewer unnecessary evacuations. 19 Strengths of this review include a focused and time sensitive review which was designed to inform health system planning and response to COVID-19, and a team composition that included physical therapists, a health librarian, and a member of the physical therapy leadership team. Limitations of this review are primarily related to the measures taken to ensure adherence to the four-week timeline; including (1) use of a single primary screener / reviewer with secondary validation rather than two full screeners / reviewers; (2) lack of quality assessment or risk of bias assessment of included articles; (3) lack of an update prior to publication. We will monitor our local situation as well as national and international need to determine whether future updates are warranted. Physical therapists have an important role to play in response efforts related to major events impacting health and wellness, including the COVID-19 pandemic. The evidence presented within this review can be used to inform facility-based and regional planning efforts during the No sources of funding were obtained for this work. This review was not registered. The Visitors were not permitted to enter facilities. Health care workers communicated with patients' families via telephone. Preadmission screening of patients for COVID-19 was initiated. An initial plan to keep one hospital free of COVID-19 (and only admit rehabilitation patients who were prescreened an unsuccessful. Rehabilitation beds, wards, and entire hospitals were converted to acute medical wards to accept patients with COVID Inpatient rehabilitation stays were shortened for patients who did not have COVID-19. Care continued through home available. Outpatient rehabilitation services were discontinued although the need for these services still existed; telerehabilitatio consultations and home exercise programs to patients. Rehabilitation professionals experienced significant levels of stress in the face of uncertainty and change. In response, support and allowed more involvement in decision-making processes. Physical and rehabilitation medicine physicians received fewer referrals for consultations from acute services. Health professionals' work hours were adjusted to minimize interactions between staff assigned to areas with active in social activities were limited for hospital employees. The rehabilitation teams focussed on stabilizing patients' medical conditions and preventing complications while prov assistive devices. This paper offers recommendations to ensure adequate rehabilitation care is provided while also protecting rehabilitation professionals and patients and limiting the spread of COVID-19. Institute screening to identify people who have COVID-19 symptoms (eg, inform the public, conduct remote assessme and/or questionnaires). Increase capacity to assist with early discharge from acute care. Assist with early and safe discharge to community, home, or outpatient rehabilitation where these options are Carefully evaluate potential admission of patients to inpatient rehabilitation from home or community to ensur Postpone admission or find alternate pathways for care where possible. Outpatient care and home-based services should: Ensure care is available so that functional decline does not occur and/or disability does not worsen. Consider alternate care options (eg, remote consultation, telerehabilitation) for individuals with chronic conditi Apply exceptions to individuals with chronic conditions who may experience rapid deterioration if not provided Ensure personal protective equipment (PPE) is available. Organize a designated physical space for preadmission screening. Organize space, equipment, and access to service to comply with distancing requirements. How should the rehabilitation community prepare for 2019-nCoV? Choon-Huat Koh et al 14 (2020) This special communication provides general recommendations for the rehabilitation community with a focus on physical distancing and infection control. Telerehabilitation should be implemented when possible. If patients are to be seen face-to-face, implement a screening protocol prior to their attendance. Managers must keep staff continually updated on the evolving situation and related policies and actions. The communication system must allow for open discussion in both directions (manager to staff, and staff to manager) Staff must be appropriately trained in donning and doffing PPE, and mask fit. Work in teams that are always physically distanced from each other, and that have the required clinical skills to contin becomes ill or needs to self-isolate. When assigning staff coverage, consider the risk to staff with chronic respiratory conditions of working in high risk are Facilitate staff to work from home when feasible. To allow staff to be available to work, provision of childcare needs to be considered, as well as temporary living quarte return home between shifts for fear of infecting others in their household. PTs should strictly follow public health policy regarding handwashing, staying home if symptomatic, and using appropr Physical Resources Hospitals should procure adequate supplies of PPE, including planning for a surge of cases. Rehabilitation equipment must be properly disinfected. Provide creams or lotions to assist with skin irritation resulting from repetitive hand washing and PPE use. The essential role of home-and community-based physical therapists during the COVID-19 pandemic Falvey et al 15 (2020) This point of view article responds to some long-term care, assisted living, and other community facilities defining home and community PT as being "nonessential" during COVID-19. Consider telehealth when in-person visits are not permitted but recognize this may introduce and/or exacerbate access to technology or inability to engage in telehealth for social, cognitive or other reasons. Rehabilitation and respiratory management in the acute and early postacute phase: "Instant paper from the field" on rehabilitation answers to the Covid-19 emergency Kiekens et al 16 (2020) This paper is a summary of a webinar presented on March 26, 2020, organized by the Italian Society of Physical and Rehabilitation Medicine. Visitors were no longer allowed to attend hospitals. Patients were discharged early when possible. Typical rehabilitation activities and admissions were decreased or discontinued. Used video consulting to connect with COVID-19 specific wards to reduce need for all staff to continually come in dire Develop plans for rehabilitation in the postacute phase for individuals who experienced severe illness due to COVID-1 Ensure that discharged patients were contacted to promote continuity of care. The pandemic is placing high psychological burden on health care professionals which may have long-term consequen Staffing Considerations Health care professionals worked longer shifts to reduce contact between personnel and patients with COVID-19 and PT Roles PTs supported nurses in basic nursing care, and in prone positioning patients in the intensive care unit (ICU). Telerehabilitation by video or telephone should be implemented where possible. Defer all face-to-face PT sessions except the following (with use of appropriate PPE): Inpatient respiratory physical therapy. Postoperative treatment for mobility and respiratory function. Treatment following fractures. Treatment in the "immediate postacute phase of disabling heart disease and neurological patients". Reintroduce hands-on treatment only when the evolving pandemic situation allows, and only when the patient's healt Provide accurate information to provide assurance to staff. Support the mental health and morale of PTs, as psychological health will impact functioning of the health care system Staffing Considerations PTs made themselves available at atypical times (e.g. evenings and weekends) in response to need. Due to the nature of PT treatment and the inability to maintain physical distancing of 1.5m, appropriate PPE should be PTs must follow all International Health Regulations. PTs participated in activities not normally within their routine (e.g. triage, screening). PTs can provide the following support within interdisciplinary teams: "Qualified care in the different modalities of non-invasive ventilation". Assess and intervene for respiratory fatigue. Compile relevant educational resources for PTs who may be deployed to the ICU. Institute a protocol for frequent communication with staff. Engage in planning at the institutional level for designating spaces where patients with COVID-19 will be treated and varying number of patients (see article for sample plan). Recognize the impact of stress and workload on staff and provide support and access to needed resources. Additional PT staff will be needed. Possible solutions include: Scheduling extra shifts for part time staff. Allowing staff to cancel or postpone leave. Recruiting new staff to fill temporary or casual positions (e.g. PTs in research, administration, or academic positi Lengthening work shifts. Identify staff with relevant skills (cardiorespiratory or critical care experience) and assign to COVID-19 wards. Identify PTs with specific ICU expertise that are not currently working in ICU and redeploy to ICU. PTs with less familiarity with cardiorespiratory skills should be in positions that support discharge, rehabilitation, or p hospital use among people without COVID-19. PTs with ICU skills should be in a position to mentor less experienced PTs, and help with assessment, screening and de patients with COVID-19. Staff at higher risk should not be assigned to COVID-19 specific isolation zones. When scheduling, include extra time needed to ensure proper PPE use, and atypical activities (e.g. repetitive disinfect Create teams that will work with patients with COVID-19 and teams that will not, and limit contact between the team PT Roles Adhere to local, provincial, and national infection control policies and recommendations. PTs can assist in prone positioning in ICU, and train staff in proning protocols. PTs should work with other team members to reduce the total number of staff exposures to patients with COVID-19. an appropriate mobility aid, another health care professional who is already in the room with the patient can trial the Physical Resources When planning for space, consider that negative-pressure rooms (ideal), or a single room with the door closed are ind generating interventions are necessary as part of PT treatment with patients with COVID-19. Identify the equipment necessary for PT treatment and take steps to minimize cross-contamination risk (e.g. use sing available). Avoid use of speciality equipment that is not easily cleaned. Inventory rehabilitation equipment and develop a protocol for provision of that equipment to different areas within t contamination. Provide sufficient PPE for airborne precautions, which are strongly recommended when respiratory PT treatments are Plan for use of uniforms or scrubs or a protocol for changing clothes at the end of a shift to prevent the spread of the Maintaining physical therapy standards in an emergency situation: Solutions after the Bali bombing disaster Edgar et al 28 (2005) Companion paper: First response, rehabilitation, and outcomes of hand and upper limb function: Survivors of the Bali bombing disaster. A case series report Edgar et al 29 (2006) This report summarizes the actions taken to ensure high quality PT services with a surge in patients with burns after the 2002 Bali bombing. Initial support from the entire hospital and higher-level administration including government was required to ensure high quality, individualized PT care. Twice daily meetings occurred between administration and relevant units to ensure that patients received the approp to support those staff who did not typically work with burn patients. Staffing was increased in the ICU and the Burn Unit to allow 24-hour coverage. These two staff groups did not interac PT service coverage was increased from the usual 5 days/week to 7 days/week. PTs who were less familiar with the treatment of burns or working in the ICU were quickly trained and given instructio different times (morning, afternoon, night, and weekend) to accommodate staff shifts. Increased staffing was possible through the assistance of student PTs, and the secondment of staff with appropriate e These additional staff positions were maintained for 6 months post-event to help with the ongoing outpatient needs The role of senior PTs transitioned from clinical to administrative multidisciplinary case management duties. Junior PTs decreased their time spent on non-clinical duties such as tracking caseload statistics. PTs led (with support from Medical Illustrations) the rapid development and prominent posting of individualized posi the ICU. This assisted all health care staff to maintain optimal positioning. Individualized exercise programs were also posted bedside, which allowed all health care staff to encourage participa early responsibility for their rehabilitation, and facilitated communication with the patient if language was a barrier. Physical Resources Extra exercise equipment was procured and set up in a space designated only for patients with burns. This supported infection control procedures. Rehabilitation in the gym became a positive group experience with encouragement from Other Considerations The focus of the PT staff from the beginning was keeping quality of service and outcomes on par with those of non-di the most" philosophy which often occurs in mass casualty situations. Post-event, a review of PT statistics demonstrated that patients affected by the bombing received an equivalent frequ lower (6.8%) duration of PT contact during the crisis period in comparison to usual times. Shoulder active range of motion, grip strength, and patient-reported outcome measures demonstrated a similar time mass casualty situations. As a result of this experience, the hospital has increased its stores of burn and splinting supplies and implemented a t skills are maintained in various areas. a PT = physical therapist. World Health Organization. Coronavirus disease 2019 (COVID-19) situation Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations Canadian Physiotherapy Association. The CPA's statement on coronavirus (COVID-19) Physical therapist management of patients with diagnosed or suspected COVID-19 Evidence-based management Barriers, facilitators, process and sources of evidence for evidence-based management among health care managers: A qualitative systematic review The use of rapid review methods for the U.S. Preventive Services Task Force A scoping review of rapid review methods Issues in conducting and disseminating brief reviews of evidence Rayyan -a web and mobile app for systematic reviews Reprint--preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement Instant paper from the field" on rehabilitation answers to the Covid-19 emergency Impact of COVID-19 outbreak on rehabilitation services and Physical and Rehabilitation Medicine (PRM) physicians' activities in Italy. An official document of the Italian PRM Society (SIMFER) How should the rehabilitation community prepare for 2019-nCoV? The essential role of home-and community-based physical therapists during the COVID-19 pandemic Rehabilitation and respiratory management in the acute and early post-acute phase Italian physical therapists' response to the novel COVID-19 emergency Physical rehabilitation in the context of a landslide that occurred in Brazil The beneficial relationship of the colocation of orthopedics and physical therapy in a deployed setting: Operation Iraqi Freedom Continuous post-disaster physical rehabilitation: a qualitative study on barriers and opportunities in Iran The role of physical therapists in the medical response team following a natural disaster: Our experience in Nepal Lessons from the 2015 earthquake(s) in Nepal: implication for rehabilitation Physiotherapy in disaster management: physiotherapist view Physical therapists' vital role in disaster management When disaster strikes: PT/PTA preparedness. PT: Magazine of Physical Therapy Important but underused: PTs, PTAs, and disaster response When disaster strikes Maintaining physical therapy standards in an emergency situation: solutions after the Bali bombing disaster First response, rehabilitation, and outcomes of hand and upper limb function: survivors of the bali bombing disaster. A case series report Alberta Health Services Allied Health. Allied Health Skills to Support COVID-19 Across the Continuum The role of the physical therapist in disaster planning Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: Report of an expert panel