Postacute/Long COVID in Pediatrics: Development of a Multidisciplinary Rehabilitation Clinic and Preliminary Case Series.

ABSTRACT: The long-term sequelae after SARS-CoV-2 infections in children is unknown. Guidance is needed on helpful models of care for an emerging subset of pediatric patients with postacute/long COVID who continue to experience persistent symptoms after initial COVID-19 diagnosis. Here, we describe a pediatric multidisciplinary post-COVID-19 rehabilitation clinic model as well as a case series of the initial cohort of patients who presented to this clinic. A consecutive sample of nine patients (pediatric patients <21 yrs of age) who presented to our clinic are included. The most common presenting symptoms were fatigue (8 of 9 patients), headaches (6 of 9), difficulty with schoolwork (6 of 8), "brain fog" (4 of 9), and dizziness/lightheadedness (4 of 9). Most patients had decreased scores on self-reported quality-of-life measures compared with healthy controls. In the patients who participated in neuropsychological testing, a subset demonstrated difficulties with sustained auditory attention and divided attention; however, most of these patients had preexisting attention and/or mood concerns. There were also some who self-reported elevated depression and anxiety symptoms. Pediatric patients with postacute/long COVID may present with a variety of physical, cognitive, and mood symptoms. We present a model of care to address these symptoms through a multidisciplinary rehabilitation approach.

Models of Care for Postacute COVID-19 Clinics: Experiences and a Practical Framework for Outpatient Physiatry Settings.

ABSTRACT: After surviving infection with the SARS-CoV-2 virus, individuals may have persistent symptoms and prolonged impairments that may last for weeks to months. The frequency and heterogeneity of persistent post-COVID conditions have created challenges in care. Specialty clinics are being established in response to an increasing need to care for patients with postacute sequelae of SARS-CoV-2 or long COVID syndrome. Although many post-COVID conditions can be bettered through a comprehensive rehabilitation plan, various clinical settings may benefit from differing models of coordinated care. We present five models of care in varying degrees of development and compare processes and adaptations to address the unique needs of each center and their unique patient populations. Forging a path to recovery will necessitate a multidisciplinary team with physiatry involvement to meet the distinctive needs of patients with postacute sequelae of SARS-CoV-2. Furthermore, it is imperative that there be equitable access to this care and commitment from healthcare institutions to provide resources for these programs.

Challenges and Lessons Learned for Acute Inpatient Rehabilitation of Persons With COVID-19: Clinical Presentation, Assessment, Needs, and Services Utilization.

OBJECTIVE: The aim of the study was to present: (1) physiatric care delivery amid the SARS-CoV-2 pandemic, (2) challenges, (3) data from the first cohort of post-COVID-19 inpatient rehabilitation facility patients, and (4) lessons learned by a research consortium of New York and New Jersey rehabilitation institutions. DESIGN: For this clinical descriptive retrospective study, data were extracted from post-COVID-19 patient records treated at a research consortium of New York and New Jersey rehabilitation inpatient rehabilitation facilities (May 1-June 30, 2020) to characterize admission criteria, physical space, precautions, bed numbers, staffing, employee wellness, leadership, and family communication. For comparison, data from the Uniform Data System and eRehabData databases were analyzed. The research consortium of New York and New Jersey rehabilitation members discussed experiences and lessons learned. RESULTS: The COVID-19 patients (N = 320) were treated during the study period. Most patients were male, average age of 61.9 yrs, and 40.9% were White. The average acute care length of stay before inpatient rehabilitation facility admission was 24.5 days; mean length of stay at inpatient rehabilitation facilities was 15.2 days. The rehabilitation research consortium of New York and New Jersey rehabilitation institutions reported a greater proportion of COVID-19 patients discharged to home compared with prepandemic data. Some institutions reported higher changes in functional scores during rehabilitation admission, compared with prepandemic data. CONCLUSIONS: The COVID-19 pandemic acutely affected patient care and overall institutional operations. The research consortium of New York and New Jersey rehabilitation institutions responded dynamically to bed expansions/contractions, staff deployment, and innovations that facilitated safe and effective patient care.

Description and Functional Outcomes of a Novel Interdisciplinary Rehabilitation Program for Hospitalized Patients With COVID-19.

OBJECTIVES: The aims of the study were to describe an interdisciplinary inpatient rehabilitation program for patients recovering from COVID-19 and to evaluate functional outcomes. DESIGN: This is an analysis of retrospective data captured from the electronic health record of COVID-19 patients admitted to the rehabilitation unit (N = 106). Rehabilitation approaches are described narratively. Functional gain was evaluated using the Activity Measure for Postacute Care 6 Clicks, basic mobility and daily activities. RESULTS: Interdisciplinary approaches were implemented to address the medical, physical, communication, cognitive, and psychosocial needs of COVID-19 patients. COVID-19 patients exhibited significant improvements in basic mobility (Activity Measure for Postacute Care for basic mobility, P < 0.001, Cohen d = 1.35) and daily activities (Activity Measure for Postacute Care for daily activities, P < 0.001, Cohen d = 1.06) from admission to discharge. There was an increase in ambulatory distance as well as the percentage of the patients who were able to breathe on room air. At discharge, fewer patients required supplemental oxygen on exertion. Eighty percent of the patients were discharged home after an average length of stay of 17 days. Greater functional improvement was associated with younger age, longer intubation duration, and participation in psychotherapy, but not a history of delirium during hospitalization. CONCLUSIONS: Early rehabilitation is associated with improved mobility and independence in activities of daily living after COVID-19.

Phase-Adapted Rehabilitation for Acute Coronavirus Disease-19 Patients and Patient With Long-term Sequelae of Coronavirus Disease-19.

ABSTRACT: Since the beginning of the COVID-19 pandemic in early 2020, many papers have highlighted the need for the rehabilitation of patients with SARS-CoV-2 infection. Most papers refer to the need for respiratory rehabilitation in the acute phase; however, the fact that the infection also affects other organ systems has to be considered in rehabilitation interventions. Long-term symptoms in many cases severely limit activity and participation and alter quality of life, leading to rehabilitation needs. This article proposes a phase-adapted model of linking the acute, postacute, and long-term symptoms of COVID-19 with the well-established matrix of acute, postacute, and long-term rehabilitation services. A review of currently available recommendations for phase-adapted rehabilitation strategies, including the relevance of prehabilitation within this context, is provided.

Beneficial effects of multi-disciplinary rehabilitation in postacute COVID-19: an observational cohort study.

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) pandemic increases the demand for postacute care in patients after a severe disease course. Various long-term sequelae are expected and rehabilitation medicine is challenged to support physical and cognitive recovery. AIM: We aimed to explore the dysfunctions and outcome of COVID-19 survivors after early postacute rehabilitation. DESIGN: Observational cohort study. METHODS: This study evaluated the postacute sequelae of patients hospitalized for SARS-CoV-2 infection and analyzed rehabilitative outcomes of a subgroup of patients included in the prospective observational multicenter CovILD study. RESULTS: A total of 23 subjects discharged after severe to critical COVID-19 infection underwent an individualized, multiprofessional rehabilitation. At the start of postacute rehabilitation, impairment of pulmonary function (87%), symptoms related to postintensive care syndrome, and neuropsychological dysfunction (85%) were frequently found, whereas cardiac function appeared to be largely unaffected. Of interest, multi-disciplinary rehabilitation resulted in a significant improvement in lung function, as reflected by an increase of forced vital capacity (P=0.007) and forced expiratory volume in one second (P=0.014), total lung capacity (P=0.003), and diffusion capacity for carbon monoxide (P=0.002). Accordingly, physical performance status significantly improved as reflected by a mean increase of six-minute walking distance by 176 (SD±137) meters. Contrarily, a considerable proportion of patients still had limited diffusion capacity (83%) or neurological symptoms including peripheral neuropathy at the end of rehabilitation. CONCLUSIONS: Individuals discharged after a severe course of COVID-19 frequently present with persisting physical and cognitive dysfunctions after hospital discharge. Those patients significantly benefit from multi-disciplinary inpatient rehabilitation. CLINICAL REHABILITATION IMPACT: Our data demonstrated the highly promising effects of early postacute rehabilitation in survivors of severe or critical COVID-19. This findings urge further prospective evaluations and may impact future treatment and rehabilitation strategies.

Neuropsychological Features of Severe Hospitalized Coronavirus Disease 2019 Patients at Clinical Stability and Clues for Postacute Rehabilitation.

OBJECTIVES: To report the cognitive features of patients with severe coronavirus disease 2019 (COVID-19) entering the postacute phase, to understand whether COVID-19 acute respiratory distress syndrome itself could result in long-term cognitive deficits, and to determine whether neuropsychological treatment after the acute stage might represent a specific rehabilitation need. DESIGN: Case series. SETTING: Rehabilitation hospital. PARTICIPANTS: We assessed the general cognitive functioning through tablet-supported video calls in 9 of 12 consecutive patients (N=9) admitted to the hospital at least 30 days earlier for acute respiratory distress syndrome due to COVID-19. Three patients were excluded based on the exclusion criteria. None of the patients presented cognitive symptoms before hospitalization. MAIN OUTCOME MEASURE: General cognitive functioning, measured using the Mini-Mental State Examination (MMSE) test. RESULTS: A general cognitive decay was observed in 3 patients (33.3%) who had a pathologic score on the MMSE, with a specific decline in attention, memory, language, and praxis abilities. The cognitive malfunctioning appears to be linearly associated with the length of stay (in d) in the intensive care unit (ICU). The longer the amount of time spent in the ICU, the lower the MMSE score, indicating a lower global cognitive functioning. CONCLUSIONS: Our results indicate that some patients with COVID-19 might also benefit from neuropsychological rehabilitation, given their possible global cognitive decay. The link between neuropsychological functioning and the length of stay in the ICU suggests that neurocognitive rehabilitative treatments should be directed explicitly toward patients who treated in the ICU, rather than toward every patient who experienced acute respiratory distress syndrome owing to COVID-19. However, given the limitation of a case series study, those hypotheses should be tested with future studies with larger samples and a longer follow-up period.

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.

Physical Medicine and Rehabilitation and Pulmonary Rehabilitation for COVID-19.

This analysis extrapolates information from previous studies and experiences to bring physical medicine and rehabilitation perspective and intervention to the multidisciplinary treatment of COVID-19. The purpose of pulmonary rehabilitation in COVID-19 patients is to improve symptoms of dyspnea, relieve anxiety, reduce complications, minimize disability, preserve function, and improve quality of life. Pulmonary rehabilitation during the acute management of COVID-19 should be considered when possible and safe and may include nutrition, airway, posture, clearance technique, oxygen supplementation, breathing exercises, stretching, manual therapy, and physical activity. Given the possibility of long-term disability, outpatient posthospitalization pulmonary rehabilitation may be considered in all patients hospitalized with COVID-19.

Postacute inpatient rehabilitation for COVID-19.

This case describes the successful pulmonary rehabilitation of a premorbidly independent female in the early 80s who was admitted for acute respiratory distress syndrome secondary to COVID-19 requiring 14 days of intubation. Patient was admitted to the acute rehabilitation unit 1 month after hospitalisation. Patient initially had poor endurance and was only able to ambulate with a front wheel walker for 150 feet, and also had tachycardia and decreased oxygen saturation after ambulation. During patient's rehabilitation course, therapy was focused on improving activity tolerance. Ten days after admission, patient was able to ambulate without an assistive device for 250 feet and with a rollator for over 900 feet. Patient also showed improvement in gait speed, heart rate, oxygen saturation after ambulation and incentive spirometer volume. This case demonstrates that pulmonary rehabilitation is an important component of inpatient care for patients with COVID-19 to improve functional exercise capacity and aerobic capacity.

Role of Rehabilitation Department for Adult Individuals With COVID-19: The Experience of the San Raffaele Hospital of Milan.

The rapid evolution of the health emergency linked to the spread of severe acute respiratory syndrome coronavirus 2 requires specifications for the rehabilitative management of patients with coronavirus disease 2019 (COVID-19). The symptomatic evolution of patients with COVID-19 is characterized by 2 phases: an acute phase in which respiratory symptoms prevail and a postacute phase in which patients can show symptoms related to prolonged immobilization, to previous and current respiratory dysfunctions, and to cognitive and emotional disorders. Thus, there is the need for specialized rehabilitative care for these patients. This communication reports the experience of the San Raffaele Hospital of Milan and recommends the setup of specialized clinical pathways for the rehabilitation of patients with COVID-19. In this hospital, between February 1 and March 2, 2020, about 50 patients were admitted every day with COVID-19 symptoms. In those days, about 400 acute care beds were created (intensive care/infectious diseases). In the following 30 days, from March 2 to mid-April, despite the presence of 60 daily arrivals to the emergency department, the organization of patient flow between different wards was modified, and several different units were created based on a more accurate integration of patients' needs. According to this new organization, patients were admitted first to acute care COVID-19 units and then to COVID-19 rehabilitation units, post-COVID-19 rehabilitation units, and/or quarantine/observation units. After hospital discharge, telemedicine was used to follow-up with patients at home. Such clinical pathways should each involve dedicated multidisciplinary teams composed of pulmonologists, physiatrists, neurologists, cardiologists, physiotherapists, neuropsychologists, occupational therapists, speech therapists, and nutritionists.

Post-Acute Care Preparedness in a COVID-19 World.

Coronavirus disease 2019 (COVID-19) has led to a surge of patients requiring post-acute care. In order to support federal, state and corporate planning, we offer a four-stage regionally oriented approach to achieving optimal systemwide resource allocation across a region's post-acute service settings and providers over time. In the first stage, the post-acute care system must, to the extent possible, help relieve acute hospitals of non-COVID-19 patients to create as much inpatient capacity as possible over the surge period. In the second stage after the initial surge as subsided, post-acute providers must protect vulnerable populations from COVID-19, prepare treat-in-place protocols for non-COVID-19 admissions, and create and formalize COVID-19 specific settings. In the third stage after a vaccine has been developed or an effective prophylactic option is available, post-acute care providers must assist with distribution and administration of vaccinations and prophylaxis, develop strategies to deliver non-COVID-19 related medical care, and begin to transition to the post-COVID-19 landscape. In the final stage, we must create health advisory bodies to review post-acute sector's response, identify opportunities to improve performance going forward, and develop a pandemic response plan for post-acute care providers. J Am Geriatr Soc 68:1150-1154, 2020.

A Health System Response to COVID-19 in Long-Term Care and Post-Acute Care: A Three-Phase Approach.

BACKGROUND: The Seattle, WA, area was ground zero for coronavirus disease 2019 (COVID-19). Its initial emergence in a skilled nursing facility (SNF) not only highlighted the vulnerability of its patients and residents, but also the limited clinical support that led to national headlines. Furthermore, the coronavirus pandemic heightened the need for improved collaboration among healthcare organizations and local and state public health. METHODS: The University of Washington Medicine's (UWM's) Post-Acute Care (PAC) Network developed and implemented a three-phase approach within its pre-existing network of SNFs to help slow the spread of the disease, support local area SNFs from becoming overwhelmed when inundated with COVID-19 cases or persons under investigation, and help decrease the burden on area hospitals, clinics, and emergency medical services. RESULTS: Support of local area SNFs consisted of the following phases that were implemented at various times as COVID-19 impacted each facility at different times. Initial Phase: This phase was designed to (1) optimize communication, (2) review infection control practices, and (3) create a centralized process to track and test the target population. Delayed Phase: The goals of the Delayed Phase were to slow the spread of the disease once it is present in the SNF by providing consistent education and reinforcing infection prevention and control practices to all staff. Surge Phase: This phase aimed to prepare facilities in response to an outbreak by deploying a "Drop Team" within 24 hours to the facility to expeditiously test patients and exposed employees, triage symptomatic patients, and coordinate care and supplies with local public health authorities. CONCLUSIONS: The COVID-19 Three-Phase Response Plan provides a standardized model of care that may be implemented by other health systems and SNFs to help prepare and respond to COVID-19. J Am Geriatr Soc 68:1155-1161, 2020.