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The emergence and unprecedented rapid global spread of the SARS-CoV-2 coronavirus that causes COVID-19 have inflicted a heavy toll on nations, cities, and individuals – and the systems that support them.
Grappling with the initial phases of the COVID-19 outbreak required fast, nimble, and flexible action plans to manage those infected with the virus but also to manage the steady flow of every other non-COVID patient.
The UPMC Rehabilitation Institute and the Department of Physical Medicine and Rehabilitation at the University of Pittsburgh School of Medicine rose to the challenge along with colleagues and departments across the UPMC health care system to develop and implement a coordinated and flexible plan to address and optimize patient care during the COVID-19 pandemic.
The UPMC Rehabilitation network comprises 14 adult inpatient rehabilitation units within 11 hospitals and one pediatric unit located at UPMC Children’s Hospital of Pittsburgh. With 264 total beds, this is the largest rehabilitation network in western Pennsylvania and one of the largest in the United States.
Developing a COVID-19 operations plan for such an extensive rehabilitation network required a coordinated and multidisciplinary team of collaborators to devise effective strategies and operating methodologies to position the UPMC Rehabilitation Institute and its network of locations to maintain its patient care duties and adapt or change as warranted to the evolving nature of the pandemic.
The UPMC Rehabilitation Institute and the Department of Physical Medicine and Rehabilitation began planning for operational changes to transform patient care routines on March 13. By March 30, barely two weeks later, all elements were in place and operationalized, but were flexible for changes and adaptations to be made as the situation with COVID-19 evolved.
“We literally changed how the entire network functions in two weeks, which is a testament to our staff’s ability to conceive of and adjust to new operating conditions that quickly, but also how resolved our partners across the system were to provide the necessary support and guidance to facilitate the new procedures,” says Timothy Kagle, vice president of operations at UPMC Presbyterian Shadyside and president of the UPMC Rehabilitation network.
The Centers for Medicare and Medicaid (CMS) that relaxed the requirements for patients to be physically on the rehabilitation unit for treatment. This would become important for providing rehabilitation services remotely to COVID-19 positive patients sequestered in the acute units and for the use of telemedicine services either for those patients in the hospital or for patients at home.
Also suspended by CMS during the pandemic is the so-called three-hour rule, which roughly states that typically patients requiring inpatient rehabilitation need to have three hours of therapy every day.
"When CMS suspended the rule, we were able to accept some patients who either did not need or could not do the three-hour minimum – those patients who would normally have gone to a skilled nursing facility. We were able to admit some of these patients, provide them with a rehabilitation level of care and discharge them to their home," says Mr. Kagle.
While some specialties and practices across the UPMC system saw dramatic decreases in patient volume due to the suspension of elective procedures or patients deferring care until a later date, patient volume at the UPMC Rehabilitation Institute remained virtually unchanged.
"We typically operate at 89% to 91% occupancy, and during the initial wave of the pandemic we experienced only a small decrease in patient census to around 80%. Patient volume remained high, so we had to leverage all of the changes to our operational plan to treat our patients safely and maximize efficiency," says Amy Pietrolaj, division administrator for the Department of Physical Medicine and Rehabilitation.
Operational changes included maintaining six feet of separation between patients, using dining rooms and lounges to conduct therapy sessions to minimize crowding in the gyms, and changing who received therapy sessions on the weekend to only those individuals who had 180-minute regulatory needs. Restricting or discouraging patients from bringing personal items into the hospital from home was necessary along with curtailing group activities to maintain social distancing guidelines. Furthermore, dining procedures were modified that allowed individuals to take their meals in their rooms if safe to do so, or they were appropriately spaced if eating in common areas.
Additionally, COVID-19 specific units were constituted at two of the network’s inpatient rehabilitation facilities that experienced high volumes of COVID-positive admissions and also had significant numbers of COVID-positive patients that required rehabilitation.
At the outset of the pandemic, in order to maintain enough staff to handle patient care situations, a reserve team was implemented that saw half of the physician staff transition to working off-site with telemedicine capabilities while the other half continued to operate out of the inpatient units at the hospitals.
"Splitting the staff gave us a much-needed reserve force in the event the situation with the virus progressed and our hospital teams were inundated or exposed," says Mr. Kagle.
Because of the global scope of the pandemic and the speed at which not only the virus was transmitting but the speed at which the knowledge base about the virus was progressing, communicating changes in how to manage actual virus patients sometimes changed daily. So too did how to provide general patient care to all the non-COVID infected individuals.
"The plan we created gave us the foundational principles upon which to operate, but at the height of the initial COVID-19 infection phase, we were changing operational details and procedures – sometimes hourly – because of how fast the situation evolved," says Ms. Pietrolaj. “Disseminating that information clearly and rapidly to our staff at all of our sites was critical to maintaining a high degree of operational flexibility and optimal patient care.”
The Department, led by Chair Gwendolyn Sowa, MD, PhD, developed weekly update emails from leadership that was, and continue to be, distributed to every staff member with the latest information on the virus and operational parameters. Early in the pandemic, regular virtual town hall meetings served to communicate new information and gather feedback, allowing staff to remain calm and focused during a rapidly changing situation.
"Things like mask usage guidelines changed so rapidly that we had to have a way to communicate effectively at any moment. Very few of us have ever experienced working in that kind of environment. We all learned together and fast," says Ms. Pieterolaj.
The COVID-19 pandemic has forced the health care community to quickly integrate telemedicine across practices and hospitals to facilitate patient care and expand patient access in a world under varying degrees of lockdown and social distancing measures. Many specialties for which telemedicine was rarely used, if at all, had to engineer new approaches to using the technology to help manage their patients.
"Telemedicine is not a tool we have used in the past. Rehabilitation medicine has always been a hands-on, face-to-face endeavor. However, it was the only good way to treat some patients and interact with families remotely when they could not come to the hospital. We jumped in and tried to perfect our approach as we worked,” says Debbie Tan, MD, assistant professor of and director physical medicine and rehabilitation services at UPMC St. Margaret. “I think everyone acknowledged and embraced that we did not have 100 percent of the answers ironed out at the start of this unprecedented change in operation. That mindset and willingness to learn as we go was the key to making telemedicine work for us.”
Fortunately for everyone involved, the number of COVID-19 positive patients across the UPMC Rehabilitation Institute's network of sites has remained manageable. Dr. Tan was able to treat several of these patients at UPMC St. Margaret via a telemedicine link to their acute COVID-19 unit.
"We worked with the nursing staff on the COVID units to see our patients and provide the necessary care instructions and consultations for the rehab-specific patients. We were able to obtain the information about our patients, interact with them and the nursing staff, and provide a seamless experience," says Dr. Tan.
Telemedicine visits for families and visitors of patients were leveraged for several reasons, more so than for treating actual COVID-19 positive patients in the hospital. Since all of the hospitals were on lockdown with strict no visitation policies in place to help mitigate community spread of the virus, telemedicine was the only way families and loved ones could visit with patients.
Just as important was using telemedicine to provide families with the training and discharge information they would need to help care for the patient at home or another facility. Staff was able to video record some of the therapy sessions, and nursing could review how to perform tube feedings or administer medications, for example.
"The plan called for telemedicine visits as much as possible for training and family meetings, unless in-person training was needed to facilitate a safe patient discharge. In those cases, we had a defined protocol in place for how those trainings would be scheduled and conducted, with the family member being instructed beforehand how things would play out during their trip to the hospital," says Dr. Tan.
Unfortunately, the world will have to wait and see how the next phases of the COVID-19 pandemic will evolve.
"We are hoping for the best, but even more so now than before, we are prepared for the worst and what could be visited upon us in the future with this virus. The work that our Department and Institute rushed into operation is scalable and adaptable should we see flare-ups of COVID-19 in the coming months that affect our patients and facilities. The experience also positions our network to adapt to similar situations or emergencies in the future," says Ms. Pietrolaj.
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