Physical Therapy for Hospitalized Patients With COVID-19 in Isolation: Feasibility and Pilot Implementation of Telehealth for Delivering Individualized Therapy.

OBJECTIVE: To optimize the ability of hospitalized patients isolated because of coronavirus disease 2019 (COVID-19) to participate in physical therapy (PT). DESIGN: This was a prospective quality improvement trial of the feasibility and acceptability of a "hybrid" in-person and telerehabilitation platform to deliver PT to hospitalized adults. SETTING: Inpatient wards of a tertiary care, multispecialty academic medical center in the greater New York City metropolitan area. PARTICIPANTS: A convenience sample of 39 COVID-19-positive adults (mean age, 57.3y; 69% male) all previously community dwelling agreed to participate in a combination of in-person and telerehabilitation sessions (N=39). INTERVENTIONS: Initial in-person evaluation by physical therapist followed by twice daily PT sessions, 1 in-person and 1 via a telehealth platform meeting Health Insurance Portability and Accountability Act confidentiality requirements. The communication platform was downloaded to each participant's personal smart device to establish audiovisual contact with the physical therapist. MAIN OUTCOME MEASURES: We used the 6-clicks Activity Measure of Post-Acute Care (AM-PAC) to score self-reported functional status premorbidly and by the therapist at baseline and discharge. RESULTS: Functional status measured by AM-PAC 6-clicks demonstrated improvement from admission to discharge. Barriers to participation were identified and strategies were planned to facilitate use of the platform in the future. CONCLUSIONS: A consistent and structured protocol for engaging patient participation in PT delivered via a telehealth platform was successfully developed. A process was put in place to allow for further development, recruitment, and testing in a randomized trial.

Early Mobilization: Changing the Mindset.

BACKGROUND: Staff in the surgical intensive care unit (SICU) had several concerns about mobilizing patients receiving mechanical ventilation. OBJECTIVE: To assess and improve the mindset of SICU staff toward early mobilization of patients receiving mechanical ventilation before, 6 months after, and 1 year after implementation of early mobilization. METHODS: The Plan-Do-Study-Act model was used to guide the planning, implementation, evaluation, and interventions to change the mindset and practice of SICU staff in mobilizing patients receiving mechanical ventilation. Interventions to overcome barriers to early mobilization included interdisciplinary collaboration, multimodal education, and operational changes. The mindset of the SICU staff toward early mobilization of patients receiving mechanical ventilation was assessed by using a survey questionnaire distributed 2 weeks before, 6 months after, and 1 year after implementation of early mobilization. RESULTS: The median score on 6 of 7 survey questions changed significantly from before, to 6 months after, to 1 year after implementation, indicating a change in the mindset of SICU staff toward early mobilization of patients receiving mechanical ventilation. The SICU staff agreed that most patients receiving mechanical ventilation are able to get out of bed safely with coordination among personnel and that early mobilization of intubated patients decreases length of stay and decreases occurrence of ventilator-associated pneumonia, deep vein thrombosis, and skin breakdown. CONCLUSIONS: SICU interdisciplinary team collaboration, multimodal education, and operational support contribute to removing staff bias against mobilizing patients receiving mechanical ventilation.

The "Fistula VAC," a technique for management of enterocutaneous fistulae arising within the open abdomen: report of 5 cases.

BACKGROUND: Management of intestinal fistulae in open abdominal wounds remains a significant clinical challenge for those caring for patients surviving damage control abdominal operations. Breaking the cycle of tissue inflammation, infection, and sepsis, resulting from leakage of enteric contents, should be a major goal in the approach to these complex patients. We describe a technique utilizing vacuum assisted closure (VAC) which achieves control of enteric flow from fistulae in open abdominal wounds. METHODS: The fistula-VAC is fashioned from standard sponge supplies, negative pressure pumps, and ostomy appliances. The fistula-VAC was changed every three days prior to split thickness skin grafting, and every five days following grafting. RESULTS: Five patients underwent application of the fistula-VAC. All patients had complete diversion of enteric contents. This enteric diversion allowed for successful skin grafting in all patients. CONCLUSION: Application of the fistula-VAC should be considered a useful option in treating patients with intestinal fistulae in open abdominal wounds.

Acute isolated suprascapular nerve palsy limited to the infraspinatus muscle: a case report.

Suprascapular nerve palsy resulting in isolated weakness of the infraspinatus muscle is subtle at its onset and must be differentiated from cervical radiculopathy or bone and joint diseases of the shoulder, especially in the presence of pain. The literature suggests an association of cumulative trauma with ganglionic cyst formation and entrapment neuropathy of the suprascapular nerve in the spinoglenoid notch. Here we present clinical, electrodiagnostic, and radiologic features in a young patient who presented with a 2-week history of isolated, painless weakness of the right shoulder. His electromyography showed acute denervation of the right infraspinatus muscle. Magnetic resonance imaging revealed a ganglionic cyst in the spinoglenoid fossa and edema in the infraspinatus muscle consistent with denervation. The patient recovered after removal of the cyst.