Covid-19: the challenge of patient rehabilitation after intensive careBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1787 (Published 06 May 2020) Cite this as: BMJ 2020;369:m1787
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It is with great interest that we have read Thornton’s article on ‘Covid-19; the challenge of patient rehabilitation after intensive care’ (1), following so quickly after the British Society of Rehabilitation Medicine (BSRM) published their position statement ‘COVID-19 and Rehabilitation Medicine’ (2). While the first peak seems to be subsiding in the acute services, the field of Rehabilitation Medicine is soon to experience its own initial caseload as we begin to understand the needs of those recovering from COVID-19.
Thornton’s article highlights the need for post-COVID rehabilitation and the potential for a number of survivors to have longer and more complex recoveries compared to other intensive care unit (ICU) patients. It highlights three clear examples of case studies relevant to post ICU rehabilitation that would likely provide a basis on which to rehabilitate COVID-19 patients. The BSRM position statement sets out considerations for providing rehabilitation in a post-COVID era and also sets out pathways and co-ordinated networks for providing these services at both individual and organisational levels. Futhermore, the British Thoracic Society has just performed a survey, with over 1000 healthcare professionals responding, recommending a bespoke rehabilitation programme to concentrate on symptom management, return to function and eventually, to work (3).
In concert with Thornton, the BSRM and the BTS, a timely review of relevant literature is required, to enable application of the rehabilitation principles in accordance with evidence-based sequelae of COVID-19. The Defence Medical Rehabilitation Centre (DMRC) Stanford Hall has produced a consensus statement with recommendations for those who are managing patients rebuilding their lives after surviving COVID-19 (4). This consensus, recently published in the British Journal of Sports Medicine (BJSM), aims to provide an overarching series of recommendations for the likely requirements of multi-disciplinary rehabilitation in an active population.
It was developed by a panel of specialists in rehabilitation medicine, sport and exercise medicine (SEM), rheumatology, psychiatry, anaesthestics and pain, with some authors also dual accredited in general practice. A literature review was conducted to further the rehabilitation knowledge base in the areas of cardiac, pulmonary, neurorehabilitation, exercise medicine, musculoskeletal, psychological, SEM and general medical, using literature gathered from previous coronavirus epidemics and early data from COVID-19.
Evidence based recommendations were developed in those seven areas and discussed in a meeting with all authors present in person or on videotelephone, with 36 recommendations agreed and scored using a Likert scale. These recommendations will be used by DMRC Stanford Hall to support an inpatient and residential rehabilitation programme for military COVID-19 survivors, with prospective data capture planned to validate our recommendations.
By publishing this consensus statement in the BJSM, we hope that our recommendations can be used as a foundation to build much needed rehabilitation services for those patients requiring support in regaining optimal occupational and physical function. The statement is intended to be of particular use not only for those planning for delivery of rehabilitation services at a population level but also for those working within the multidisciplinary teams and in primary care.
1) Thornton J. Covid-19: the challenge of patient rehabilitation after intensive care. BMJ 2020;369:m1787
2) British Society of Rehabilitation Medicine. Rehabilitation in the wake of Covid-19 - A phoenix from the ashes. 2020 https://www.bsrm.org.uk/downloads/covid-19bsrmissue1-published-27-4-2020... (Date accessed 1/6/20)
3) Ingh SJ, Barradell A, Greening N, Bolton CE, Jenkins G, Preston L, Hurst JR. The British Thoracic Society survey of rehabilitation to support recovery the Post Covid-19 population. medRxiv preprint doi: https://doi.org/10.1101/2020.05.07.20094151
4) Barker-Davies RM, O’Sullivan O, Seneratne KPP et al. The Stanford Hall consensus statement for post Covid-19 rehabilitation. Br J Sports Med Epub ahead of print [31 May 2020] doi:10.1136/bjsports-2020-102596
Competing interests: No competing interests
With over 25,000 deceased – probably thousands more, considering the patients who have died without a proper diagnosis, in their households or in residencies – Spain has been severely hit by the Covid-19 outbreak. In Castile and Leon region, with a total population of 2,388,548 inhabitants, there are over 16,993 confirmed cases; 8,010 patients have been hospitalized, 536 of them to intensive care units (ICUs) (90% under mechanical ventilation), and 1,770 patients have died establishing a mortality rate over 10% . In order to face this challenging situation, we also transformed our hospitals, working teams, and organization adapting operating rooms (ORs) and postanesthesia care units (PACUs) into ICUs in record time . Our ICUs doubled bed capacity – from 216 to 527 beds – and their occupation increased by 163% with respect to their regular maximum capacity.
To deal with the shortness of ICUs capacity effectively, our regional health-care system further put in place Covid-19 intermediate care unit (IMCUs) infrastructures consisting of a 24-hour healthcare multidisciplinary team with capacity to perform non-invasive mechanical ventilation in monitored beds. This Covid-19 IMCUs were implemented with two major objectives: avoiding overwhelmed of ICUs, concentrating and taking care of candidate patients to ICU; and favoring and incrementing “step-down” from the ICUs.
In our experience, these Covid-19 IMCUs can significantly reduce mortality when perfectly coordinated with the ICU team. We have identified several scenarios in which these units can be of great value. First, there are certain patients – usually at the early stages of the disease – with apparent clinical stability, but with signs of potential severe disease at admission as significant radiological anomalies or mild organ failure in the laboratory analysis. To our knowledge, Covid-19 can be a rapidly progressing disease, and patients might worsen within hours. In these cases, close monitoring helped us in the early identification of patients who needed to be transferred to the ICU for mechanical ventilation. Second, some patients who presented clinical deterioration and were candidates for invasive ventilatory support, were also transferred to our Covid-19 IMCUs. This allows continuous monitoring and frequent evaluation by the ICU team, reducing the delay of the intubation and transfer to the ICU when needed. Third, these units are an alternative to patients whose ICU admission has been initially discarded. Some of these patients might benefit from non-invasive mechanical ventilation, as it provides further time for recovery. Finally, a very interesting clinical scenario for these units is for patients who have been recently discharged from ICUs who – in all cases – still need close monitoring. Furthermore, in our experience this last scenario reduced the assistance burden in ICUs, as some patients could be discharged earlier when this kind of assistance was provided, generating extra ICUs capacity.
With the Covid-19 curve flattening, the creation of Covid-19 IMCUs has allowed us to build up hospital assistance capacity for severely ill patients; either in tertiary or secondary hospitals. Further to act as a “step-up” or “step-down” between the general ward and the ICU, we have used these units to provide assistance to patients whose ICU admissions were not prioritized. In our opinion, Covid-19 IMCUs organization should be encouraged in all hospitals as a response to the emerging challenges of this pandemic.
Competing interests: No competing interests