If there is a statement I am using often in trainings these days it is, “There is simply not a clear rehabilitation road map for post-acute care in the COVID-19 patient.”
The COVID-19 patients may be flooding some hospital systems across our nation presently. However, the reality is they will soon need post-acute rehabilitative care, and we as care providers need to be ready to serve them.
Our acute-care counterparts are working tirelessly on improved care and survival rates while also initiating the recovery process.
As a result, many post-acute care providers are left asking themselves the following questions:
“What is the best practice for treating the COVID-19 patient?”
“What are the long-term impacts of the disease?”
“What is length of stay of the recovery process going to look like?”
Staying tuned in to the most recent research can be challenging even in “normal” times, and in present days requires us to be super sleuths capable of integrating anecdotal reports, research from other countries that may or may not have similar populations, regional trends, and the slow but growing stream of evidence.
One such publication, the Journal of the American Medical Association (JAMA), has recently opened viewing of their published literature on COVID to the general public. I highly recommend perusing their site and digging into the content.
In an April 22 JAMA article titled “Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area,” the following question was explored:
What are the characteristics, clinical presentation and outcomes of patients hospitalized with coronavirus disease 2019 (COVID-19) in the US?
The findings in this case included 5,700 patients hospitalized with COVID-19 in the New York City area. The most common comorbidities were hypertension, obesity, and diabetes.
Among patients who were discharged or died (n = 2634), 14.2% were treated in the intensive care unit, 12.2% received invasive mechanical ventilation, 3.2% were treated with kidney replacement therapy and 21% died.
Providing care status post an ICU stay is not a new challenge to SNF providers. However, with the uniqueness of the COVID-19 patient, and the regional volume to which they may require post-acute rehab, we should also consider the added complexity of mechanical ventilation and overall days in the ICU.
Providers should complement care planning and policy updates associated with medical complexities and comorbidities, cohort units and PPE with an awareness of Post-intensive Care Syndrome, or PICS.
PICS is made up of health problems that remain after critical illness. They are present when the patient is in the ICU and may persist after the patient returns home.
These problems can involve the patient’s body, thoughts, feelings, or mind and may affect the family.
PICS may show up as an easily noticed drawn-out muscle weakness, known as ICU-acquired weakness; as problems with thinking and judgment, called cognitive (brain) dysfunction; and as other mental health problems.
The Society of Critical Care Medicine provides a comprehensive overview for patients, families and caregivers on the impacts of PICS including the following:
ICU-acquired weakness (ICUAW) is muscle weakness that develops during an ICU stay and can impact activities of daily living difficult, including grooming, dressing, feeding, bathing and walking
ICUAW is noted to occur in:
- 33% of all patients on ventilators
- 50% of all patients admitted with severe infection, which is known as sepsis
- Up to 50% of patients who stay in the ICU for at least one week
Cognitive or brain dysfunction
- The society website notes that after leaving the ICU, 30% to 80% of patients may have these kinds of problems with some improving during the first year after discharge from the hospital and others never achieving full recovery.
Other mental health problems
- Additionally, the society states critically ill patients may develop problems with falling or staying asleep, and may have nightmares and unwanted memories. Their reactions to these feelings may be physical or emotional.
In closing, times are trying, no doubt. But I would also say they are challenging us to practice at the top of our license, continue to be life-long learners, engage in the new research and give our patients the very best of clinical care.
Renee Kinder, MS, CCC-SLP, RAC-CT, is Vice President of Clinical Services for Broad River Rehab and a 2019 APEX Award of Excellence winner in the Writing–Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty, and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).