Functional Impact of Telehealth Physical Therapy Services on Patients Post Hematopoietic Stem Cell Transplant

BACKGROUND AND PURPOSE: Stem cell transplantation (SCT) in patients with hematological cancers results in longstanding physical changes. Commonly reported symptoms include chronic fatigue, global weakness, interference with activities of daily living (ADLs) and aerobic deconditioning. Aside from the sequela of symptoms experienced post SCT, these patients remain in an immunosuppressed state for several months following discharge from the hospital. Patients are often advised by their medical team to isolate themselves unless to attend follow-up outpatient clinic appointments. With the COVID-19 pandemic, this functional gap in the continuum of care worsened. As a result, SCT patients are both hesitant and discouraged to pursue outpatient or home health physical therapy even when these services are warranted. Thus, there is great need for options to safely optimize function for people post-SCT that are suitable in today's ever-changing environment. The purpose of this case series is to describe the functional impact of incorporating telehealth into the continuum of care for post SCT patients. CASE DESCRIPTION: 9 patients post inpatient admission for SCT were triaged to telehealth PT based on their scores on the Short Physical Performance Battery (SPPB) and the Activity Measure for Post Acute Care (AM-PAC) at the time of discharge from inpatient care. Scores on the SPPB ranged from 5-11, and AMPAC scores ranged from 21-24, demonstrating physical impairment. Patients were scheduled to receive telehealth twice a week. Sessions consisted of therapeutic exercises monitored via secure video software. Lab values were monitored via electronic medical record to assess appropriateness for therapy prior to each session. Rating of perceived exertion (RPE) scale and patientowned pulse oximeter were used to monitor patient fatigue levels. Patients' progress was assessed via Lower Extremity Functional Scale (LEFS), Brief Fatigue Inventory (BFI) and 5-times sit to stand (5xSTS) scores. OUTCOME(S): One year post telehealth implementation, patients reported improved independence and achievement of selfselected goals. Notable patient quotes include, "I feel less fearful in climbing up and down the stairs, and I feel more independent with laundry and cooking.which was very important for me." Additionally, patients reported a decrease in LEFS and BFI scores. Initial LEFS scores averaged 40% and dropped to 20% by discharge. Similarly, BFI scores dropped by 2 points at discharge, reflecting improved self-reported functional performance and a return to pre transplant fatigue levels. 5xSTS scores decreased by greater than 3 seconds in 6 of 9 patients, with one patient performing where previously unable. DISCUSSION: Telehealth services provide an additional method of care delivery to those unable to seek it in the traditional sense. For the severely immunocompromised, physical therapy via telehealth provides direct connection to providers trained in oncology rehabilitation serving as a feasible bridge between inpatient and outpatient care for amelioration of side effects associated with SCT.

From the Editorial Board: Charles N. Kahn III, MPH

Appealing prior authorization decisions is frequently onerous and disheartening for patients as well as their providers—indeed, few Medicare beneficiaries and providers pursue such appeals.2 In September 2018, the HHS Office of Inspector General (OIG) reported on Medicare Advantage (MA) plan prior authorization policies and appeals.2 The OIG found high rates of overturned prior authorization and payment denials and identified problems related to denials of care and payment. [...]as managed care plans consider their postpandemic policies, they should examine the impact of prior authorization requirements, including on access to postacute care. Actions to reduce the burden of prior authorization, interfere less with patient care, save administrative costs, and better target overuse, waste, and abuse include: * ensure prior authorization decisions are timely and negative determinations indicate the reason for the denial;* sunset programs with very high approval rates;* improve transparency by providing detailed information on prior authorization policies and tracking and reporting rates of approvals and denials;* increase standardization of prior authorization policies, operations, and forms through the use of electronic transmission of prior authorization requests;* ensure prior authorization programs adhere to evidence-based medical guidelines and include continuity of care for individuals transitioning between coverage policies;* eliminate additional prior authorization for medically necessary services performed during a surgical procedure that already received, or did not initially require, prior authorization;and * establish "gold carding," under which payers reduce prior authorization requirements for providers that have demonstrated a consistent pattern of compliance, improving efficiency and resulting in more prompt delivery of health care services.

The Essential Role of Population Health During and Beyond COVID-19

Am J Manag Care. 2021;27(3):123-128. https://doi.org/10.37765/ajmc.2021.88511 _____ Takeaway Points Robust population health management integrates analytics and agile clinical programs and is adaptable to optimize outcomes and reduce risk during population-level crises. * The coronavirus disease 2019 pandemic revealed the tenuousness of care delivery based on fee-for-service reimbursement models. * Population-level data and care management facilitate identification of demographic-based disparities and community outreach. * Telemedicine and integrated behavioral health have ensured primary care and specialty access, and mobile health and postacute interventions shifted site of care and optimized hospital utilization. * Beyond the pandemic, population health is a cornerstone of a resilient health system and can improve public health while mitigating risk in a value-based paradigm. _____ Prior to the coronavirus disease 2019 (COVID-19) pandemic, the US health care system was in the midst of major transformation—shifting away from the inefficiencies of fee-for-service toward value and patient-centeredness. [...]registries for hypertension, diabetes, and chronic kidney disease identified the highest-risk patients to receive laboratory monitoring or medical procedures, prioritizing those who were likely to need dialysis in the near future.5,6 Similarly, a registry of patients with frailty, defined by the Johns Hopkins ACG System, was used to identify patients for augmented home-based care and goals of care outreach.7,8 Care Management: Delivering Public Health to High-risk Patients and Addressing Disparities For the last decade, the integrated care management program (iCMP) has been an essential component of PHS population health to coordinate care, improve outcomes, and reduce cost for high-risk patients by leveraging a dedicated nurse, social worker, or community health worker.9,10 This team was utilized as a public health workforce to provide outreach to patients at increased risk for adverse outcomes, including elderly patients, frail patients, and those with complex health conditions. The Home Hospital program provides inpatient level of care to low-acuity patients in their homes, and the Mobile Integrated Health (MIH) program uses paramedics to further support home-based care delivery.12 During the pandemic, these programs expanded capacity to prevent potential COVID-19 exposure in patients requiring hospital care and to monitor patients with COVID-19 who were recovering at home, reducing inpatient utilization and preserving higher-acuity resources.13 Within the first 46 days of MIH expansion, teams evaluated 102 patients with confirmed or suspected COVID-19, with 92.2% of patients able to continue care at home. Postacute care is critical to identify safe locations for patients with and without COVID-19 to recover and to maintain inpatient hospital capacity.14 PHS mobilized an existing collaborative of long-term acute care hospitals and skilled nursing facilities (SNFs) to address the surge in postacute capacity by creating unified admission plans, creating COVID-19–specific SNFs, and supporting personal protective equipment (PPE) provision to facilities.15 This team's expertise was extended to support the creation of a 1000-bed field facility called Boston Hope Medical Center, with a dual focus on respite care for homeless populations and postacute care for those recovering from COVID-19.16 The University of Washington also collaborated with postacute partners to develop a comprehensive strategy for COVID-19, which included establishing clear criteria for facility admission, providing PPE training, equipping testing supplies, and developing isolation plans.17 Population-based postacute strategies during the pandemic helped prevent delays in discharge, spread of infection, and overwhelmed facilities to mitigate the effects of the public health crisis.14,18 Behavioral Health: Providing Psychological Support at a Time of Great Need COVID-19 has brought numerous mental health challenges due to elevated stress, financial insecurity, and exposure to traumatic events.19 To address these needs, we adapted existing programs in behavioral health management, substance use disorders, and digital health.

Cognitive and psychological consequences of moderate-tosevere COVID-19 pneumonia: associations with clinical variables in convalescent patients without previous comorbidities

Background: Cognitive impairment has been reported in the aftermath of severe acute respiratory syndrome due to coronavirus 2 (SARS-CoV-2) infection. We investigated the possible association between cognitive impairment and the main clinical and functional variables in a cohort of convalescent COVID-19 patients without premorbid diseases. Method(s): Convalescent COVID-19 patients referring to of a post-acute care facility for pulmonary rehabilitation were consecutively screened for inclusion. All the enrolled patients completed standardized tests to assess cognitive functions, features of psychological distress such as anxiety, depression, post-traumatic stress disorder (PTSD) and quality of life, and cardiac and pulmonary functional status. Result(s): The 63 enrolled patients (mean age 59.82+/-10.78, male = 47) showed a high rate of clinically relevant depressive symptoms (76.2%) and anxiety (55.5%), and a high prevalence of PTSD (44.4%). About half of the total sample showed reduced cognitive efficiency (44.4%). Most impaired cognitive domains were verbal fluency and longterm spatial memory. The level of cognitive impairment showed a direct correlation with the alteration of blood pressure circadian rhythm (rho=. 410, p=.002) and an inverse association with PaO2 (rho= -.264, p=. 03) and DLCO% values (rho= -.252, p=. 02). Conclusion(s): Our findings indicated a possible association between the reduced cognitive efficiency after COVID-19 and some cardiological and pneumological variables, including some indirect measures of a residual autonomic disorder, such as the presence of an altered BP circadian rhythm.

Functional recovery of hospitalised patients with covid-19: a prospective cohort study

Aim and Objectives: To characterize the functional recovery of hospitalized patients diagnosed with COVID-19 at 3-, 6-, 9- and 12-months post-discharge. Method(s): We are conducting a multi-regional prospective cohort study in hospitalized COVID-19 patients 18 years and older in Canada. Patients are assessed upon admission and at 3-, 6-, 9-, and 12-months follow-up. Data collection is completed via telephone interviews in addition to home visits. Outcomes include the Activity Measure for Post-Acute Care Mobility and Cognition scales and lung function. Result(s): Preliminary data from 242 hospitalized COVID-19 patients (60.1 +/- 13.0 yrs) indicate that the most common self-reported symptoms are fatigue (47%) and shortness of breath (35%) at 12-months follow-up. Our lung function data suggests that 39-46% of post-acute patients with COVID-19 have impaired FEV1 (<80% predicted), and 38- 49% have impaired FVC (<80% predicted) at 3-,6-, 9- and 12-month follow-up. At 12-months, 38-45% of patients continue to have clinically important deficits in cognition and mobility below premorbid levels, respectively, and 55.4% of patients report that COVID-19 continues to impact their daily life activities (Figure 1). Conclusion(s): There is a high prevalence of functional limitations in COVID-19 survivors over 12 months of followup. Our data support the need for multi-disciplinary rehabilitation for patients post-hospitalisation for COVID-19.

MAKING AN IMPACT ON THE COVID PANDEMIC

STATEMENT OF PROBLEM/QUESTION: When hospitals and skilled nursing facilities (SNF) were impacted during the COVID surge, what healthcare delivery model can be used to increase hospital bed capacity while maintaining quality care for marginalized patients with no access to a SNF? DESCRIPTION OF PROGRAM/INTERVENTION: Background - Santa Clara Valley Medical Center is the second largest public safety net healthcare system in California. During the COVID surge, our hospitals experienced a significant demand for hospital beds. At this time, SNFs were impacted and did not accept patients with barriers in discharge planning. Problem: How to safely discharge non-acute patients with no accepting SNF to increase hospital bed capacity. Intervention: Develop a post-acute care team (PACT) for marginalized, non-acute patients. These patients were initially hospitalized for severe medical conditions but could not be safely discharged once stabilized. During the COVID surge, Santa Clara County operationalized a 36-bed, lowacuity hospital called DePaul Health Center (DPHC) through an emergency state-issued alternative care license. DPHC implemented a novel healthcare model for post-acute transitions of vulnerable, non-acute patients during a resource-constrained time period. Of the 131 admissions to DPHC, 42% had unstable housing, 29% had active substance use, and 100% had no accepting SNFs. The operationalization involved: - Training volunteer outpatient providers to work in an inpatient setting with COVID-positive patients. - Building a referral model to include all hospitals in our county. - Transition of care services including: direct transition to drug treatment programs, linkage to medical respites, COVID vaccinations, specialty care followup, and medication delivery/teaching at bedside. MEASURES OF SUCCESS: - Number of hospital bed days saved. - Number of additional potential hospital admissions. - Implementation of high-quality inpatient services for non-acute patients. FINDINGS TO DATE: Over six months, DPHC admitted 127 patients across three county hospitals. DPHC allowed for a potential 446 additional hospital admissions (based on 2232 potential bed days saved and an average hospital LOS of 5 days per hospital admission). KEY LESSONS FOR DISSEMINATION: - Establishing a post-acute care team addresses structural inequities prevalent in our healthcare system for marginalized patients. - Incorporating a post-acute care team improves access to SNF for marginalized patients.

ADDRESSING SOCIAL NEEDS TO ENABLE SUCCESSFUL CARE TRANSITIONS FOR PATIENTS HOSPITALIZED WITH COVID-19: THE CRITICAL ROLE OF COMMUNITY HEALTH WORKERS

STATEMENT OF PROBLEM/QUESTION: The COVID-19 pandemic highlights the disproportionate burden of disease on communities made vulnerable by structural inequities. The pandemic has increased economic hardship, including housing instability, food insecurity and ability to pay bills. Hospitalization for COVID-19 is an opportunity to address unmet healthrelated social needs (HRSNs) and connect patients with community resources. DESCRIPTION OF PROGRAM/INTERVENTION: Community health workers (CHWs) play a critical role in response to public health crises. To address the inequitable burden of COVID-19 on Austin's Latinx population, we implemented a pilot program at an academic hospital where a CHW helps patients navigate care transitions and address unmet HRSNs. The care team referred patients with COVID-19 to the CHW, who met with patients to establish rapport, provide language-concordant communication between the care team and patient/family, deliver health promotion education, and assess HRSNs. MEASURES OF SUCCESS: This includes three typical cases describing key components of the CHW pilot program. CHWs connected patients and families to community resources and facilitated discharge planning and connection with primary care providers. The CHWs continued to follow patients for at least 45 days after discharge to assist with care coordination. We provide qualitative data from patients and healthcare professionals. FINDINGS TO DATE: Patient 1 is a 38-year-old day laborer with hypertension hospitalized with COVID-19 pneumonia. His family of four is undocumented and faced economic insecurity due to loss of work from the pandemic. The CHW assisted with utilities, bills, food and rent through coordination with local organizations to provide direct financial assistance to the family. Patient 2 is a 45-year-old woman with diabetes hospitalized with COVID-19 pneumonia. She is a mother of three children, two with disabilities. In addition to financial insecurity, she identified transportation as a primary HRSN. The CHW arranged financial resources to fix their car, which allowed the family to access school and clinic resources. Patient 3 is a 36-year-old man hospitalized with COVID-19 pneumonia. The CHW connected the family, including three children, with their school social worker, enabling access to financial support for utilities, food and clothes. The CHW arranged free food delivery to their home for four months. The CHW also secured county-based indigent care coverage for the patient, enabling hospital follow-up with a primary care provider. The patient's wife noted, because of the CHW, “We never felt alone” and now feel “capable of navigating a health system that we never felt we had access to.” KEY LESSONS FOR DISSEMINATION: CHWs, as patient advocates and skilled care navigators, build trust, establish longitudinal relationships with patients and address unmet HRSNs that can enable successful care transitions. CHWs can alleviate the disproportionate burden of COVID-19 on individuals with unmet HRSNs. Supporting the work of CHWs within hospital care teams can improve care transitions.

Next-Day Discharge Following Transcatheter Aortic Valve Implantation: An Australian Tertiary Hospital Experience

Background: With increasing utilisation of transcatheter aortic valve implantation (TAVI) for aortic stenosis, there is a need to explore the safety of next-day discharge. We aimed to evaluate the safety and outcomes of next-day discharge following TAVI. Methods: We performed a retrospective analysis of patients who underwent TAVI at a tertiary centre between 2020 and 2021. Included patients were those discharged the next day after TAVI as routine care. Data collected included baseline demographics, Society of Thoracic Surgeons (STS) score, perioperative complications and 30-day mortality rates. Results: Thirty-three patients (33% female, median age 82 years;interquartile range [IQR], 77–84) were discharged the next day post-TAVI. Median STS score was 2.3% (IQR, 1.7–3.6). On pre-TAVI ECG, two patients (6%) had right bundle branch block (QRS duration 147–154 ms). All patients demonstrated well-seated aortic valve prosthesis with no aortic regurgitation on same-day transthoracic echocardiogram. Six patients (18%) had new conduction abnormalities post-TAVI (five transient left bundle branch block, one atrial fibrillation which self-resolved). There were no significant procedural complications including no pericardial effusion or vascular injury. All patients were discharged directly home without the need for subacute care. Two patients (6%) were re-hospitalised within 30 days of discharge: one admitted with presyncope of unclear cause and one required a pacemaker for tachy-brady syndrome. All patients were alive and well at 30 days. Conclusion: We have demonstrated that next-day discharge TAVI is safe in selected patients with an uncomplicated procedure. In the era of COVID, implementation of next-day discharge can reduce unnecessary length of stay and may improve hospital resource allocation.

Differences in Post-Acute Care Healthcare Expenditures After Hospitalization Due to Influenza or Covid-19 Infection

Rationale: The long-term consequences of SARS-CoV-2 infection on patients' health are increasingly recognized. It is unknown if these consequences are common to all severe viral infections or are specific to SARS-CoV-2. A syndrome of persistent exertional dyspnea has been described after influenza infection. Here, we describe patterns in healthcare expenditures for patients hospitalized for either influenza or COVID-19. Methods: We used an all-payer administrative dataset comprised of coding and billing data from over 600 healthcare entities in the United States that use a financial analytics platform by Strata Decision Technology, a private company. The de-identified analytic sample included patients aged 18 years or older who were admitted to a hospital between January 2018 and February 2021 with either an ICD-10 code for COVID-19 (COVID-19 hospitalizations) or for influenza (influenza hospitalizations). Linear regression models were used to evaluate the relationship between infection type (COVID-19 or influenza) and total post-acute healthcare expenditures (post-acute expenditures), defined as cumulative charges 1 month or more after hospitalization. The dependent variable was log-transformed post-acute expenditures and the independent variables included health system classification (academic, multi-site, single site community, and children's) and size (based on operating budget), pre-hospitalization charges, date of admission (spline), gender, and US census region. Analyses were stratified by age (18-44, 45-64, and 65+) and need for ventilation during acute hospitalization. Results: Of the 98222 patients included in our analysis, 83278 (84.8%) were COVID-19 hospitalizations and 14944 (15.2%) were influenza hospitalizations. This patient cohort was 52% female, and contained 36039 (36.7%) patients from the Midwest, 20102 (20.5%) from the Northeast, 32031 (32.6%) from the West, and 9514 (9.7%) from the South. Mean length of stay was 6.78 days. Patients with COVID-19 were more likely to receive mechanical ventilation during hospitalization (3.8%) than patients with influenza (1.8%). Compared to influenza, linear model results suggest that COVID-19 was associated with similar or lower postacute expenditures (see table 1). Results are presented separately by ventilation status to accommodate potentially differential relationships between infection severity, post-acute expenditures, and length of stay in the two patient populations. Conclusion: In previously hospitalized patients, post-acute expenditures are similar between COVID-19 (March 2020-February 2021) and influenza (January 2018- February 2021). Despite the high burden of healthcare utilization related to post-acute sequelae of COVID-19, these findings suggest that individual healthcare expenditures after acute COVID-19 infection are similar to severe influenza infection.

Sub acute cares: when the objective is not clear, one year's experience of ASST Ovest milanese activity

As known after the Resolution N°IX/ 1479 sitting of 30/03/2011 (Lombardy Region Council) Regarding: Management determination of regional health services for the year 2011 - II° Measure of update in the health sector, approves Annex 1: clinical and organizational indications for the conduct of Sub Acute care activities. This is a taking charge, which takes place in a context of sheltered hospitalization, of patients suffering from the sequelae of an acute event or a clinically uncomplicated decompensation of a chronic disease aimed at achieving specific health objectives. Sub Acute cares require the formulation of a treatment plan for each patient that leads to the achievement of specific goals by qualified professionals. Sub Acute cares should not be confused with social-health activities in favor of dependent patients in rehabilitation departments. Enrollment criteria are necessary in addition to the evaluation of the patient's actual clinical condition. Known exclusion factors. In the year 2021 at the U.O. Cure Sub Acute of the Cuggiono Presidio Ospedaliero were admitted 256 patients, M:132, F:124. Noted AII. Evaluated with Braden Scale, Brass Scale and Conley Scale. Our data indicate: 45.3% discharged home, 8.2% deceased, 6.25% transferred to Hospice, 6.25% transferred to Rehabilitation Institute, 10.15% medical relapse and transferred back to medical area, 2.34% surgical relapse and transferred back to surgical area, 3 patients showed COVID-19 infection.

Collaborative Nursing and Nutrition Intervention improves Unintentional Weight Loss at Emory Long Term Skilled Care Facility (Budd Terrace at Wesley Wood Campus)

Background: The consequences of the COVID-19 pandemic in long-term care facilities could be severe for frail and immunocompromised older adults.1 These older adult patients are hypermetabolic due to pressure ulcers, infection, fever, and elevated inflammatory labs such as CRP.1 They experience decreased appetite due to taste and smell changes. The inadequate intake, fat, and muscle loss due to prolonged hospitalization and increased nutrition demands create a negative nutrient balance, leading to unintentional weight loss (UWL).1 According to the Center for Medicare and Medicaid Services (CMS), UWL is defined as a weight loss of 5% in 30 days, 7.5% in 90 days, and 10% in 180 days.2 In this proposal, our focus was unintentional weight loss (UWL) in long-term skilled care patients and how collaborative nursing and dietitian intervention impacts the UWL in this specific population. Methods: The data were collected retrospectively for all patients admitted between May 2020 to March 2021. The patient's demographic data was collected from the chart review using the point click care program. The top five patient diagnoses were retrieved using MDS coding for the study period. Additionally, the most common chronic disease in the geriatric population was used. The red napkin program was initiated in Oct 2020. The red napkin program was initiated to alert the nursing staff for patients with UWL and who also have pressure ulcers. Results: The results indicated that the average census was 152 patients during the study period. The majority of the patients (84%) were long-term care, with more females than males (59 vs 40%). Most of the patients were African American and Caucasian ethnic group. Nearly 40-45% of patients had diabetes, hypertension;one-fourth of the patients had CHF, dialysis, and dementia. During this period, there was a total of 77 patients who had unintentional weight loss as defined by CMS criteria. There were 60 patients before the intervention, and the numbers declined significantly to 33 patients post-intervention. Out of these 33 post-intervention patients, only 17 patients were new, and 16 were from the previous months of the preintervention period. The number has also declined from 12 to 7 expected weight loss related to hospice and comfort care patients. Most patients received oral nutrition supplements to halt weight loss. Four patients received alternate routes of nutrition support (TPN/EN) in addition to an oral diet. Almost 40% of patients had COVID-19 infection, and 38% of patients had pressure ulcers, which may have affected unintentional weight loss. Conclusion: The results indicated that appropriate and timely collaborative dietitian and nursing efforts improve patient outcomes or quality of care to halt unintentional weight loss in long-term skilled care facilities.

Inspiratory muscle training immediately following lung transplantation due to COVID-19: A report of two cases

BACKGROUND AND PURPOSE: Covid-19 is a novel respiratory disease leading to high rates of acute respiratory distress syndrome (ARDS) and causes adverse effects on both the peripheral and respiratory muscles. Despite optimal medical management some patients with severe Covid-19 develop irreversible lung injury. Patients who cannot be weaned from mechanical ventilation (MV) or extracorporeal life support, lung transplantation (LTX) may be the only life-saving option. Inspiratory muscle training (IMT) has been extensively studied in a variety of non-LTX population with results indicating improvements in exercise capacity, diaphragmatic thickness, reduced dyspnea with ADL's and improved quality of life. Several previous studies found that IMT is a feasible and safe modality in ICU patients. A recent study showed significant improvements in the dyspnea index and quality of life following 2 weeks of IMT in Covid-19 patients after weaning from MV. To the best of our knowledge, no studies have investigated the use of IMT immediately after lung transplantation due to Covid-19 in addition to physical therapy intervention. This report describes the effects of IMT on inspiratory muscle strength, perceived dyspnea and physical performance over the course of 22 weeks in two patients post lung transplantation. CASE DESCRIPTION: Two males (45 ± 9 yr, BMI 33.6 ± 0.1 kg/m2) admitted to the hospital with ARDS secondary to Covid-19 underwent double lung transplantation and performed IMT (2 sessions/day;30 breathes, 50% maximal inspiratory pressure, (MIP);5 days/week) in addition to physical therapy immediately following surgery. Inspiratory muscle strength (MIP), perceived dyspnea (Modified Borg Dyspnea Scale, MBS) and physical performance (4- meter walking speed and 5 times sit to stand) were assessed at baseline and weekly for a total of 22 weeks. Length of hospital stay (LOS) was 58 ± 22 days and both patients participated in a 12 week Pulmonary Rehab Program upon hospital discharge. OUTCOMES: There were no adverse events associated with the intervention. IMT resulted in an increase MIP from -25.7 ± 13 cmH2O to -79.8 ± 7 cmH2O (22% to 66% of predicted normal). MBS improved 4 and 2, to 3 and 0 respectively. Baseline physical performance: 4-meter walking speed and 5-time sit to stand test were 0.40 ± 0.3 m/sec and 60 seconds, and improved to 1.28 ± 0.1 m/s and 7 ± 3 seconds, respectively, after IMT. Activity Measure for Post-Acute Care mobility score (AM-PAC) 7 improved from 7.5 ± 0.7 at evaluation to 18 ± 6.4 upon discharge. DISCUSSION: The present case report describes the integration of IMT to physical therapy intervention in two patients immediately following double lung transplantation due to Covid-19. Improvements in inspiratory muscle strength, perceived dyspnea and functional performance following IMT were present in both cases after a 22 week intervention. These results indicate that IMT program should be encouraged in the rehabilitation of patients post Covid-19. Further research is needed to investigate the benefits of IMT for patients requiring lung transplantation and/or post-Covid-19.

Use of commercial outpatient monitoring for near-real-time, acute-and subacute-care telemetry like monitoring in covid-19 pandemic

Introduction: Limited data exist on the role of commercial mobile cardiac telemetry (MCT) monitoring with QT capability as a near-real-time inpatient monitoring tool for COVID-19 stable patients. Our aim was to determine whether outpatient MCT monitoring could be adapted for nearreal-time inpatient arrhythmia and QT monitoring during the COVID-19 pandemic. Methods: We conducted a prospective observational study on patients ≥18 years old with confirmed COVID-19 who required hospitalization between June and December 2020. Data including baseline characteristics and laboratory data were collected. Cardiac rhythms monitored using the MCT monitors (Medilynx Pocket ECG) were analyzed (beat-to-beat analysis). Off-site technicians monitored for arrhythmias 24/7 and notified the physician based on the pre-defined events (QTc ≥500 ms with QRS <120 ms or QTc >520 ms with QRS ≥120 ms or atrial and/or ventricular tachyarrhythmia ≥5 beats). Primary endpoint was the detection of any of the pre-defined events. Results: 29 patients were enrolled in this study. 65.5% were female. There were no significant differences except age in baseline characteristics and laboratory data between those with and without events. Patient age was a significant predictor of events at multivariable analysis [odds ratio 1.08, 95% CI (1.01-1.15);P = 0.023]. Table 1 showed the overall number and events recorded on the MCT monitors. Two patients had new-onset atrial fibrillation (AF) and 5 patients had AF with heart rate >100 bpm. In retrospective analysis, these findings correlated with the 12-lead ECGs performed during their hospital stays. Two patient had significant QTc prolongation noted on the MCT monitor. No adverse events occurred in any of the monitored patients. Conclusions: Our results showed that commercial MCT monitoring can potentially provide a system for detecting clinically relevant arrhythmias and QT prolongation, especially if there is a subsequent shortage of telemetry monitors.

Effect of the COVID-19 Pandemic on Postacute Care Decision Making.

The response to the coronavirus disease 2019 (COVID-19) pandemic in the United States has resulted in rapid modifications in the delivery of health care. Key among them has been surge preparation to increase both acute care hospital availability and staffing while using state and federal waivers to provide appropriate and efficient delivery of care. As a large health system in New York City, the epicenter of the pandemic in the United States, we were faced with these challenges early on, including the need to rapidly transition patients from acute care beds to provide bed capacity for the acute care hospitals. Rehabilitation medicine has always played an essential role in the continuum of care, establishing functional goals while identifying patients for postacute care planning. During this crisis, this expertise and the overwhelming need to adapt and facilitate patient transitions resulted in a collaborative process to efficiently assess patients for postacute care needs. We worked closely with our skilled nursing facility, home care partners, and an acute inpatient rehabilitation hospital to adapt their admissions processes to the patient population with COVID-19, all the while grappling with varying access to vital supplies, testing, and manpower. As the patient criteria were established, rapid pathways were created to postacute care, and we were able to create much needed bed capacity in our acute care hospitals.

Considerations for Postacute Rehabilitation for Survivors of COVID-19.

Coronavirus disease (COVID-19), the infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first reported on December 31, 2019. Because it has only been studied for just over three months, our understanding of this disease is still incomplete, particularly regarding its sequelae and long-term outcomes. Moreover, very little has been written about the rehabilitation needs of patients with COVID-19 after discharge from acute care. The objective of this report is to answer the question "What rehabilitation services do survivors of COVID-19 require?" The question was asked within the context of a subacute hospital delivering geriatric inpatient and outpatient rehabilitation services. Three areas relevant to rehabilitation after COVID-19 were identified. First, details of how patients may present have been summarized, including comorbidities, complications from an intensive care unit stay with or without intubation, and the effects of the virus on multiple body systems, including those pertaining to cardiac, neurological, cognitive, and mental health. Second, I have suggested procedures regarding the design of inpatient rehabilitation units for COVID-19 survivors, staffing issues, and considerations for outpatient rehabilitation. Third, guidelines for rehabilitation (physiotherapy, occupational therapy, speech-language pathology) following COVID-19 have been proposed with respect to recovery of the respiratory system as well as recovery of mobility and function. A thorough assessment and an individualized, progressive treatment plan which focuses on function, disability, and return to participation in society will help each patient to maximize their function and quality of life. Careful consideration of the rehabilitation environment will ensure that all patients recover as completely as possible.