Since the first case of SARS-CoV-2 infection was detected in the United States in January 2020, there has been over 18.5 million detected cases in the US with over 325,000 deaths as of Dec. 24, 2020. Patients with SARS-CoV-2 infection, which causes COVID-19 disease, may present with varying symptoms. Some patients do not report any symptoms while others succumb to severe illness with multi- organ failures, and some result in death. There are emerging data on medical co-morbidities as a result of COVID-19, but the long-term consequences are still to be determined. Furthermore, little is published in the literature regarding the rehabilitation of patients with COVID-19 disease as only few rehabilitation hospitals in the US are capable of caring for patients with active COVID-19 disease (in other words, patients who are still considered to be in the infectious state).
Brooks Rehabilitation Hospital has been at the forefront of this pandemic, caring for patients with COVID-19 disease and also those who recovered from this illness but still have ongoing medical co-morbidities and functional impairments. This case report highlights the potential medical complexity, cognitive and functional impairments, and prolonged course of recovery in a patient with COVID-19 disease. It also includes a review of the important demographics and pertinent rehabilitation data/outcomes of patients with COVID-19 disease who were cared for at Brooks Rehabilitation Hospital. Having a better understanding of the sequelae of COVID-19 disease and the rehabilitation needs of patients with COVID-19 disease will likely lead to better care and improved quality of lives.
Case Study
Patient A is a 77-year-old previously healthy and independent man, a practicing physician, who was diagnosed with SARS-CoV-2 infection in July 2020 from a work- related exposure. He developed acute hypoxic respiratory failure, with CXR and CT chest showing extensive bilateral pulmonary infiltrates. He was also found to have small acute bilateral pulmonary embolism (PE). He required high flow oxygen supplementation, but did not require mechanical ventilation during the entire hospital stay. He was treated with steroids and remdesivir. After 25 days of hospitalization at acute care hospital, he was transferred to an inpatient rehabilitation hospital (IRH).
On admission, the patient was able to be on room air with O2 saturation at 98%, and required 3 LPM of O2 with exertion. Quite common in patients with coronavirus disease (COVID-19), patient never reported shortness of breath (SOB) symptom, even when breathing at 30 breaths per minute and/or when O2 saturation decreased below 90%. During the inpatient rehabilitation stay, he had two episodes of pulmonary setbacks with increasing SOB symptoms and higher O2 demand, diagnosed with pneumonia. He responded to antibiotics and steroids. CT chest two months after initial diagnosis showed diffuse chronic interstitial changes, with resolving PE. At the time of discharge from IRH almost 2.5 months later, he required 2 LPM O2 supplementation at rest, and up to 4 LPM O2 during exertional activities.
From a functional perspective, the patient required minimum to moderate amounts of assistance to transfer and ambulate at the time of IRH admission. Cognitively, his orientation log (OLOG) was 24/30 and he had difficulties with all cognitive domains, including memory, understanding, expression, and basic problem solving skills. At the time of discharge from IRH, he was able to ambulate at a stand-by assistance level, sometimes requiring cueing to manage his oxygen tubing and settings. Cognitively, his OLOG at discharge is 28/30, with some improvement in cognition, but still has difficulties with memory, understanding and expression, and problem solving. He was discharged home with his family.
The brief synopsis of the case described above highlights the potential medical complexity, cognitive and functional impairments, and long courses of recoveries in patients with COVID-19. The attention in the news and media often focus on SARS- CoV-2 infection rates and deaths, but those who survive may experience long- lasting sequelae from COVID-19 (Kakodkar). Exposures and infection rates among healthcare workers is an emerging problem (Barranco). Other industries where people congregate closely at work are at increased risks as well, such as workers in meat and poultry processing facilities (Dyal). Patients with COVID-19 may require prolonged hospitalizations, often needing inpatient rehabilitation (Sheehy). Inpatient rehabilitation hospitals play a significant role in caring for patients with COVID-19 and related complex comorbidities (McNeary). There are guidelines and best practices for the rehabilitation of patients with COVID-19 at the acute care settings, but not many rehabilitation hospitals have the capability of caring for these patients (McNeary, Kim). To my knowledge, Brooks Rehabilitation Hospital is the only rehabilitation hospital in Florida, and in the Southeast United States, which has the capability of caring for patients with active COVID-19 disease.
Fortunately, Brooks Rehabilitation was able to quickly meet the needs of patients with active COVID-19. Extensive renovations and rehabilitation planning were needed to ensure the safety of patients and staffs. A designated unit, enclosed with negative pressure rooms, in the hospital was dedicated to care for patients with COVID-19.
A total of 50 (fifty) patients received care in this unit during the period of April 15, 2020 through October 1, 2020. It should be emphasized that all these patients were with SARS-Cov-2 infections and considered at high risk for transmissions to others as well as high risk for potential complications. The demographics and pertinent rehabilitation data of those patients were:
- Date range: April 15, 2020 through October 1, 2020
- Number of patients: 50
- Average age: 73
- Gender: Men: 21, Women: 29
- Average length of time between diagnosis and admit to COVID-19 unit: 11.2 days
- Average walking Functional Independence Measure (FIM) on admit: 3.2
- Average walking FIM on discharge: 4.2
- Average length of stay in COVID-19 unit: 17.5 days
- Disposition: home 29 (58%), skilled nursing facility 14 (28%), acute hospital 6 (12%), death 1 (2%)
- Patients discharged with O2 need: 15 patients (30%)
Ten of those 50 patients were diagnosed with SARS-CoV-2 infections while they were at Brooks Rehabilitation Hospital and were moved to the COVID-19 unit immediately after diagnosis of COVID-19.
The toll on patients suffering from COVID-19 includes prolonged hospitalizations at acute care as well as at IRH. As previously described by Kim et al, McNeary et al, Grabowski et al, and Sheehy and others, we are just beginning to understand the long-term sequelae of COVID-19. Brooks Rehabilitation has been at the forefront of
caring for patients with COVID-19 since the beginning of his pandemic. With extensive experience in caring for patients with complex sequelae of COVID-19, Brooks is well prepared to care for patients with all levels of care needs post-acute hospitalization.
References:
Barranco R, Ventura F. Covid-19 and infection in health-care workers: An emerging problem. Med Leg J. 2020 Jul;88(2):65-66. doi: 10.1177/0025817220923694. Epub 2020 May 22. PMID: 32441196. Dyal JW, Grant MP, Broadwater K, et al. COVID-19 Among Workers in Meat and Poultry Processing Facilities – 19 States, April 2020. MMWR Morb Mortal Wkly Rep 2020;69:557–561. PMID: 3244119.
Dyal JW, Grant MP, Broadwater K, et al. COVID-19 Among Workers in Meat and Poultry Processing Facilities – 19 States, April 2020. MMWR Morb Mortal Wkly Rep 2020;69:557–561.
Grabowski DC, Joynt Maddox KE. Postacute Care Preparedness for COVID-19: Thinking Ahead. JAMA. 2020;323(20):2007–2008. doi:10.1001/jama.2020.468.
McNeary, L., Maltser, S. and Verduzco-Gutierrez, M. (2020), Navigating Coronavirus Disease 2019 (Covid-19) in Physiatry: A CAN Report for Inpatient Rehabilitation Facilities. Journal of Injury, Function and Rehabilitation, 12: 512-515.
Kim SY, Kumble S, Patel B, Pruski AD, Azola A, Tatini AL, Nadendla K, Richards L, Keszler MS, Kott M, Friedman M, Friedlander T, Silver K, Hoyer EH, Celnik P, Lavezza A, González- Fernández M. Managing the Rehabilitation Wave: Rehabilitation Services for COVID-19 Survivors. Arch Phys Med Rehabil. 2020 Sep 22:S0003-9993(20)30955-2. doi: 10.1016/j. apmr.2020.09.372. Epub ahead of print. PMID: 32971100; PMCID: PMC7506328.
Sheehy LM. Considerations for Postacute Rehabilitation for Survivors of COVID-19. JMIR Public Health Surveill. 2020;6(2):e19462. Published 2020 May 8. doi:10.2196/19462
Kakodkar P, Kaka N, Baig MN. A Comprehensive Literature Review on the Clinical Presentation, and Management of the Pandemic Coronavirus Disease 2019 (COVID-19). Cureus. 2020 Apr 6;12(4):e7560. doi: 10.7759/cureus.7560. PMID: 32269893; PMCID: PMC7138423.