For patients diagnosed with, or recovering from COVID-19

Information for acute care physicians and allied health

This document provides guidance to acute care physicians and allied health professionals on referring people who are diagnosed with, or are recovering from COVID-19 to multidisciplinary rehabilitation assessment and management.

On this page

Scope

This document provides information

  • acute care physicians including, but not limited to, ICU physicians, respiratory physicians and emergency department clinicians
  • allied health practitioners and other clinicians providing rehabilitation in the acute setting, or in cardiac and/or pulmonary rehabilitation in the outpatient setting.

It outlines the criteria, method and communication expectations for referring people diagnosed with, or recovering from COVID-19 for assessment by rehabilitation medicine and multidisciplinary rehabilitation management.

What is multidisciplinary rehabilitation?

Rehabilitation medicine can offer a wide range of services that have been shown to improve patient outcomes and decrease length of hospital stay.1

Multidisciplinary rehabilitation teams are led by rehabilitation medicine physicians who coordinate and prioritise a process of care by nurses, doctors and allied health therapists. They also coordinate medical liaison with other specialist clinical teams (e.g. respiratory, intensive care specialists, neurology, vascular, cardiac, etc.) as well as oversee ongoing management of comorbidities as required.

The settings in which these services are provided include:

  • in-reach, where an acute hospital inpatient is provided rehabilitation in conjunction with ongoing acute care needs
  • inpatient and outpatient rehabilitation, involving transfer to a rehabilitation facility or home
  • virtual rehabilitation and rehabilitation in the home for patients recovering from moderate or severe COVID-19 in the home.

The impact that timely referral can have to patient flow, health economics, patient outcomes and the release of acute and ICU beds should not be underestimated in the COVID-19 setting; and is well established in longitudinal studies in NSW.2

Multidisciplinary rehabilitation regularly and easily integrates with existing single therapy disciplines on acute wards, such as physiotherapists delivering early pulmonary or reconditioning rehabilitation. This coordinated care assists clinicians delivering single therapy care to complement their services with other disciplines of allied health (e.g. speech pathologists and occupational therapists), with care delivery coordinated by rehabilitation physicians according to the Principles to support rehabilitation care.3

Applicability

  • For those people diagnosed with moderate to severe COVID-19 being managed in the ward environment or in the intensive care unit.
  • For those who have been diagnosed with, or are recovering from extra-pulmonary complications of COVID-19, or those with persistent symptoms who are being managed in the community.

Referrals

There are a number of criteria to consider for referring COVID-19 patients for a multidisciplinary rehabilitation medicine assessment, these may include two or more of the following:

  • anyone who has spent more than seven days on a ventilator or is expected to be ventilated for more than seven days 4, 5
  • inability to mobilise independently
  • inability to self-care, feed, dress, wash and toilet without assistance
  • evidence of malnutrition (greater than 10% of weight loss and/or a BMI less than 18.5–20kg/m2), or those who have received parenteral nutrition 6
  • swallowing and/or communication impairment
  • intercurrent acute stroke, acute myocardial infarct, acute limb ischemia venous thromboembolism and/or acute requirement for haemodialysis
  • critical care myopathy and/or neuropathy, including Guillain Barre Syndrome
  • new onset of dyspnoea and/or oxygen de-saturation (pulse oximetry below 92% (88% for COPD) on room air after 5m walk) 7
  • persisting cognitive impairment in a person with no evidence of cognitive impairment pre-COVID-19 diagnosis (MMSE<26/30 when the CAM delirium screening tool is negative)
  • pain significantly impacting function at a VAS >4 8
  • any patient with pre-existing disability, including those with developmental disability, neuromuscular disability and intellectual disabilities
  • when a single discipline therapist requests more intensity of therapy or inpatient/in-reach multidisciplinary rehabilitation to improve patient outcomes
  • when clinically, the patient appears unlikely to recover to premorbid level of function by the time of planned discharge.

Ongoing communication

Rehabilitation medicine services include ongoing communication strategies with the referring acute teams and the preparation of virtual care teams and community services to continue care in the home for those with ongoing symptoms. Types of communication include:

  • written discharge summaries
  • phone contact with GPs
  • email and online communication with virtual care clinics
  • direct phone or online contact with rehabilitation in the home teams and virtual care teams for the purposes of transfer of care.

How to refer

Processes for referral for a rehabilitation medicine assessment will vary between and within LHDs but will include referrals to rehabilitation medicine team members made by phone, text, email, online and face to face.

In the event that your hospital does not have a rehabilitation medicine service on site, contact can be made to the ACI Rehabilitation Community of Practice secretariat Ms Louise Sellars on 0409 382 268, to identify the closest local services.

Methodology

This document was developed by members of the Rehabilitation Community of Practice Executive group in consultation with directors of rehabilitation services, rehabilitation physicians and other rehabilitation clinicians working in both the public and private sectors. Document authors identified and reviewed relevant published research. Searches using Twitter between 1 August and 15 September 2020 were conducted using hashtags #covidrehab, #rehabilitation, #LongCovid and #rehab.

The rationale for the communications and referral documents comes from five key sources:

  • existing international guidelines on rehabilitation for those suffering from COVID-191 9-15
  • research regarding early rehabilitation for a variety of conditions that cause temporary or permanent disability 16-18
  • existing Agency for Clinical Innovation documents regarding models of care for rehabilitation 19, 20
  • limited evidence for early rehabilitation following COVID-19 21-27
  • research on the use of early rehabilitation for patients in ICU.9 528-39

References

  1. British Society of Rehabilitation Medicine. Rehabilitation in the wake of COVID-19 – a phoenix from the ashes. London: BSRM; 2020.
  2. South Eastern Sydney Local Health District, Directorate of Ambulatory and Primary Health Care. COAG Subacute Programs Report: Rehabilitation 2009/10-2011/12. Sydney: SESLHD; 2012.
  3. NSW Agency for Clinical Innovation. Principles to support rehabilitation care. Sydney: ACI; 2019.
  4. Girard TD, Alhazzani W, Kress JP, et al. An Official American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from mechanical ventilation in critically ill adults. Rehabilitation protocols, ventilator liberation protocols and cuff leak tests. Am J Respir Crit Care Med. 2017;195(1):120-133. doi: 10.1164/rccm.201610-2075ST.
  5. Herridge MS, Chu LM, Matte A, et al. The RECOVER program: Disability risk groups and 1-year outcome after 7 or more days of mechanical ventilation. 2016;94(7):831-844. doi: 10.1164/rccm.201512-2343OC.
  6. Singer P, Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;28(1):48-79. doi: 10.1016/j.clnu.2018.08.037.
  7. Thevarajan I, Buising KL, Cowie BC. Clinical presentation and management of COVID-19. Med J Aust. 2020;213(3):134-137. doi: 10.5694/mja2.50698.
  8. Boonstra AM, Schiphorst P, Henrica R, et al. Cut-off points for mild, moderate and severe pain on the visual analogue scale for pain in patients with chronic musculosketal pain. Pain. 2014;155(12):2545-50. doi: 10.1016/j.pain.2014.09.014.
  9. Liang T, Yu L. Handbook of COVID-19 Prevention and Treatment. Hangzhou: Zhejiang University School of Medicine; 2020.
  10. Boldrini P, Bernetti A, Fiore P; SIMFER Executive Committee, SIMFER Committee for International Affairs. Impact of COVID-19 outbreak on rehabilitation services and Physical and Rehabilitation Medicine physicians’ activities in Italy. An official document of the Italian PRM Society (SIMFER). Eur J Phys Rehabil Med. 2020;56(3):316-318. doi: 10.23736/S1973-9087.20.06256-5.
  11. World Health Organization. Disability considerations during the COVID-19 outbreak [Internet]. Geneva: WHO; 2020.
  12. Faux SG, Eagar K, Cameron ID, et al. COVID-19: planning for the aftermath to manage the aftershocks. Med J Aust. 2020;213(2):60-61.e1. doi:10.5694/mja2.50685.
  13. Koh G, Hoenig H. How Should the Rehabilitation Community Prepare for 2019-nCoV? Arch Phys Med Rehabil. 2020;101(6):1068-1071. doi: 10.1016/j.apmr.2020.03.003.
  14. Lew HL, Oh-Park M, Cifu DX. The War on COVID-19 Pandemic: Role of Rehabilitation Professionals and Hospitals. Am J Phys Med Rehabil. 2020;99(7):571-572. doi:10.1097/PHM.0000000000001460.
  15. Royal College of Anaesthetists. Clinical Guide for the prevention, detection and management of thromboembolic disease in patients with COVID-19. London: RCoA; 2020.
  16. Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev. 2013(9):CD000197. doi: 10.1002/14651858.CD000197.pub3.
  17. Mak J, Wong E, Cameron I. Australian and New Zealand Society for Geriatric Medicine: Position Statement – Orthogeriatric Care*. Australasian journal on ageing. 30. 162-9.10.1111/j.1741-6612.2011.00557.x.
  18. Ahmed NN, Pearce SE. Acute care for the elderly: literature review. Popul Health Manag. 2010 Aug;13(4):219-25. doi: 10.1089/pop.2009.0058. PMID: 20735247.
  19. NSW Agency for Clinical Innovation. NSW Rehabilitation Model of Care Principles. Sydney: ACI; 2015.
  20. NSW Agency for Clinical Innovation. Principles to Support Rehabilitation Care. Sydney: ACI; 2020.
  21. Grasselli G, Zangrillo A, Zanella A, et al. Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy. JAMA. 2020 Apr 28;323(16):1574-1581. doi: 10.1001/jamma.2020.5394
  22. Khan F, Bhasker A. Medical rehabilitation in pandemics: towards a new perspective. J Rehabil Med. 2020;52(4): jrm00043. doi: 10.2340/16501977-2676.
  23. Guidon AC, Amato AA. COVID-19 and neuromuscular disorders. Neurology. 2020;94(22) 959-969. doi: 10.1212/WNL.0000000000009566.
  24. NSW Agency for Clinical Innovation. Rapid evidence check: rehabilitation needs of post-acute COVID-19 patients. Sydney: ACI; 2020.
  25. Li X, Guan B, Su T, et al. Impact of cardiovascular disease and cardiac injury on in-hospital mortality in patients with COVID-19: a systematic review and meta-analysis. Heart. 2020;106:1142-1147. doi: 10.1136/heartjnl-2020-317062.
  26. Kipps C, Hamer M, Hill N, et al. Enforced inactivity in the elderly and diabetes risk: initial estimates of the burden of an intended consequence of COVID-19 lockdown. medRxiv. 2020.06.06.20124065; doi: 10.1101/2020.06.06.20124065. Epub ahead of print.
  27. Hosey MM, Needham DM. Survivorship after COVID-19 ICU stay. Nat Rev Dis Primers. 2020;6(1). 60. doi: 10.1038/s41572-020-0201-1.
  28. Taito S, Yamauchi K, Tsujimoto Y, et al. Does enhanced physical rehabilitation following intensive care unit discharge improve outcomes in patients who received mechanical ventilation? A systematic review and meta-analysis. BMJ Open. 2019;9:e026075. doi: 10.1136/bmjopen-2018-026075.
  29. Chang R, Elhusseiny KM, Yeh Y, et al. COVID-19 and mechanical ventilation patient characteristics and outcomes – A systematic review and meta-analysis. medRxiv. 2020.08.16.20035691. doi: 10.1101/2020.08.16.20035691. Epub ahead of print.
  30. Van der Schaaf M, Beelen A, Dongelmans DA, Vroom MB, Nollet F. Functional status after intensive care: a challenge for rehabilitation professionals to improve outcome. J Rehabil Med. 2009;41(5):360-6. doi: 10.2340/16501977-0333.
  31. Centre for Clinical Practice at NICE (UK). Rehabilitation After Critical Illness [Internet]. London: NICE (UK); 2009.
  32. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373(9678):1874-82. doi: 10.1016/S0140-6736(09)60658-9.
  33. Calvo-Ayala E, Khan BA, Farber MO, et al. Interventions to improve the physical function of ICU survivors: a systematic review. Chest. 2013;144(5):1469-1480. doi: 10.1378/chest.13-0779.
  34. Kayambu G, Boots R, Paratz J. Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med. 2013;41(6):1543-54. doi: 10.1097/CCM.0b013e31827ca637.
  35. Li Z, Peng X, Zhu B, Zhang Y, Xi X. Active mobilization for mechanically ventilated patients: a systematic review. Arch Phys Med Rehabil. 2013;94(3):551-61. doi: 10.1016/j.apmr.2012.10.023.
  36. Stiller K. Physiotherapy in intensive care: an updated review. Chest. 2013;144(3):825-847. doi: 10.1378/chest.12-2930.
  37. Devlin JW, Skrobik Y, Gélinas C, et al. Clinical Practice Guidelines for the Prevention and Management Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018;46(9):e825-e873. doi: 10.1097/CCM.0000000000003299.
  38. NSW Agency for Clinical Innovation. Physical Activity and Movement: a Guideline for Critically Ill Adults. Sydney: ACI; 2017.
  39. Mehlhorn J, Freytag A, Schmidt K, et al. Rehabilitation interventions for postintensive care syndrome: a systematic review. Crit Care Med. 2014; 42(5):1263-71. doi: 10.1097/CCM.0000000000000148.

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Feedback on this document can be provided to ACI-Rehab@health.nsw.gov.au

Document information

Developed by

Members of the Rehabilitation Community of Practice Executive group with consultation from COP members.

Consultation

The Intensive care, Emergency Department, Virtual care, Respiratory, Primary care, Community health and Aged care / Aged health COPs reviewed draft versions of this document. Feedback received has been incorporated.

Endorsed by

Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning, NSW Ministry of Health.

Reviewed by

Louise Sellars, Rehabilitation Network Manager.

For use by

Acute care physicians, including those working in intensive care and respiratory wards, and allied health clinicians working in acute facilities.


Current as at: Friday 22 July 2022
Contact page owner: Health Protection NSW