Addressing Hospital Deconditioning and Physical Impairment to

Establish a COVID-19 Hospital Throughput Framework

Michael Friedman, PT, MBA

Senior Director, Program Development

Director Activity and Mobility Promotion (AMP)

Johns Hopkins Medicine

Dr Sapna R Kudchadkar, MD, PhD

Associate Professor

Associate Vice Chair for Research

Johns Hopkins School of Medicine

@HopkinsAMP @RehabHopkins @ICUrehab

Holly Russell, MS, OTR/L

Team Leader, ACS

Johns Hopkins Hospital

Nicole Frost, M.A. CCC-SLP, BCS-S

Team Leader, ACS

Johns Hopkins Hospital

Sowmya Kumble, PT, MPT, NCS

Clinical Resource Analyst

Johns Hopkins Hospital

Megan Hosey, PhD

Assistant Professor

Rehabilitation Psychology

Johns Hopkins School of Medicine

Objectives

• Review the challenges of addressing hospital deconditioning and

physical impairment in the COVID-19 environment

• Introduce the Johns Hopkins “Hospital direct Home” rehabilitation and

recovery framework

• Present practical ideas to overcome barriers to providing interventions

to address physical impairment in the COVID-19 environment

• Share intervention references and resources

FRAMEWORK DEVELOPMENT

Pre-COVID-19: Bedrest is Bad

Hospital-acquired physical impairment is

associated with INCREASED:

• Hospital-acquired complications

• Hospital length of stay

• 30-Day readmissions

• Nursing home and rehab stays

• Long-term impaired physical function

Covinsky et al. J Am Geriatr Soc. 2003; 51: 451-458.

Brown et al. J Am Geriatr Soc. 2004; 52: 1263-1270.

Brown et al. JAMA. 2013; 310: 1168-1177.

Hoyer et al. J. Hosp. Med. 2014; May;9(5):277-82

Disease

DebilityCo-morbidity

Leverage Our Models of Care:

Activity and Mobility Promotion (AMP), Adult

ICURehab, and Pediatric ICU (PICU Up!)

Essential concepts:

• Early and frequent mobilization

• Systematic measurement of function – “Common Language”

• Interdisciplinary team:

– nursing, rehabilitation team, respiratory team and medical team

• Normalize the 24 hour clock

– Sleep, Rest, Active

– ADLs: mobility with purpose

– Orientation to day and night

Critical Care Rehabilitation

Interdisciplinary Activity Mobility Program (AMP)

Rehabilitation

Consultation

Inpatient

Rehabilitation

Facilities

Homecare

Outpatient

Rehabilitation

Pre-COVID-19: Rehabilitation Continuum

COVID-19: Recipe for Physical Impairment

Treatment

• Sedation practices

• Mechanical ventilation

• Oxygen support

• Prolonged length of stay

• Bedrest

• ICU length of stay

Infection control

• Social isolation

• PPE conservation

• Reduce clinician access

• Redeployed nurses

• Access to mobilization equipment

WHO guidelines’ recommend management of COVID-19 includes prevention of hospital

acquired debility by actively mobilizing patients throughout the course of illness and addressing

functional decline.

Critical Care Rehabilitation

Interdisciplinary Activity and Mobility Program

(AMP)

Rehabilitation

Intervention

Inpatient

Rehabilitation

Facilities

HomecareOutpatient

Rehabilitation

COVID-19: Altered Health System

“Hospital Direct Home” Framework

1. “Common Language” of function

a. Capacity: AM-PAC Inpatient Mobility and Activity Scales (6 Clicks)

b. Performance: Johns Hopkins – Highest Level of Mobility (JH-HLM)

2. Utilize established ICU rehab criteria

3. Stratify patients

4. Establish formal interdisciplinary activity and mobility plans

5. Communicate variance from plans

AM-PAC Inpatient Short Forms – “6 Clicks”

Basic Mobility Daily Activity

© 2007, Trustees of Boston University

To complete the AM-PAC

Score all six questions, 1-4 as indicated.

Add the scores for each question to calculate a TOTAL score (6-24).

HOSPITAL DIRECT HOME

When not medically stable to participate……

• Sedated/ paralyzed

• Respiratory therapy support

• Prone team

• Communication with nursing re: splinting needs (OT)

Standard of Care

• Frequency based on variance from baseline function

• PT/OT:

– AM-PAC® 6 –Clicks

– Regular pressure relief and mobility activities with nursing

• upright positioning, range of motion exercises

• out of bed as tolerated using safe patient handling equipment

• SLP:

– Swallow: Regular diet with thin liquids

– Cognition: Baseline cognitive deficits

– Trach: Waiting on tracheostomy change to improve tolerance of speaking valve

Acute Hospital Rehabilitation

Intensive Service (ARISE)• Daily therapy as tolerated & based on needs

• Physiatrist consulted as appropriate to coordinate multi-disciplinary care plan

• PT/OT:

– AM-PAC® 6 –Clicks raw scores

– Functional level consistent with post-acute rehabilitation

– Daily mobility activities within safety limits supported by nursing

– Promote participation in ADLs

• SLP:– Swallow: NPO, pureed diet, thickened liquids

– Cognition: Requires cognitive evaluation

– Trach: Progressing towards decannulation

– Targeted daily interventions to promote swallow recovery and removal of tracheostomy

Enhanced Recovery After COVID (ERAC)

• Surgical Pathway concept

– High intensity / Short length of stay on caseload concept

– Targeted rehabilitation interventions for the first 3 days

– Telehealth as appropriate

• PT/OT: AM-PAC® 6 –Clicks raw scores

– Daily mobility activities using a nurse led AMP

– Focus on independent ADLS in preparation to self-quarantine post discharge home

• SLP:

– Swallow: minced and moist diet or soft and bite sized diet

– Cognition: Requires cognitive interventions

– Trach: Requires speaking valve interventions

Nurse driven Activity and Mobility Promotion

(AMP)

• AM-PAC® 6 –Clicks raw scores

• Maximize mobility and participation in ADLs

• PT/OT consult as needed

TRANSDISCIPLINARY

PRACTICAL TIPS

Practical tips you can implement:

• Transdisciplinary approach

• Head bone – Delirium/ Anxiety

• Body bone – AMP #everyBODYmoves

• Alternative care models

– Telemedicine

– Self –quarantine

• Family and caregiver support

Rehabilitation

(PT, OT, SLP, Rehab Psych)

Nursing

Respiratory Therapy

Physicians

(Critical Care,

Physiatry,

Hospitlaists)

PATIENT

Transdisciplinary

Approach

Delirium

ICUDelirium.org

Delirium:

Basics of

Prevention

• Screen every shift

• Review medications that increase risk

• Early mobility

• Optimize sleep hygiene and day-night cycles

• Orient to date/time/place

• Optimize communication

Rehab Teams: Delirium Superheroes!

#everyBODYmove in the room

BEFORE

Visit www.hopkinsmedicine.org/pmr/amp for #everyBODYmoves materials

JH-HLM Driven Exercises

Alternative Care Strategies

• Phone Consult

– For patients on a supination/pronation schedule

– Splinting and positioning recommendations for nursing

• Telehealth in Hospital

– Patient: I-Pad and Zoom

– Discipline specific goals

– Consideration: patient ability to manage technology

– Treatment Examples:

• PT: exercises, breathing techniques, energy conservation/fall prevention education

• OT: energy conservation/sleep education, exercises, home set-up/safety; delirium prevention

• SLP: motor speech, cognitive, voice, and dysphagia

• All: discharge planning, equipment instruction, family training/engagement

Self Quarantine – Safe Discharge

With Family in Home:

• Independent with bed mobility and toilet transfers

• Ambulatory to/from bathroom using assistive device if needed OR independent transfers

to/from bedside commode

• Independent lower extremity dressing

• Independent for other basic ADLs – self-feed, sponge bathe, grooming, taking medications

• Safe with distant supervision – mobility, cognition, self-care; safety plan in place

Without Family in Home:

• Addition of:

• Home mobility and basic IADL independence

• Able to manage cell phone in case of emergency; safety plan

• Plan for community support – groceries, medication

Considerations: Telehealth

Managing Anxiety

• Always screen for delirium!

• Breathlessness management and education

• Cognitive Behavioral/ Self-management Strategies

• COVID specific concerns

– Media depictions of survival and long odds

– COVID stigma

– Fear of infecting family/ loved ones

– Guilt/shame/sadness about reduced independence with basic ADL

Family & Caregiver support

• Baseline status

• Rehab updates

• Virtual family training

Hart, J. L., Turnbull, A. E., Oppenheim, I. M., & Courtright, K. R. (2020). Family-Centered Care During the

COVID-19 Era. Journal of Pain and Symptom Management.

ONCE HOME

Isn’t this webinar titled a “HOSPITAL physical impairment framework?”

Once Home….

Coming soon to a theater near you:

COVID-19 Multi-Disciplinary Service: Addressing Post-Intensive

Care Syndrome.

The Pulmonary Critical Care Medicine, Physical Medicine &

Rehabilitation and Homecare Collaborative.

RESOURCES

• Planning

• Training

• Maintenance &

Evaluation

https://www.hopkinspep.org/

Resources

• PACER series: Free webinar through APTA

https://learningcenter.apta.org/student/Catalogue/CatalogueCategory.aspx?id=dcbae4dc-

1a13-42ff-b9da-7ba7a62162e9

• APTA endorsed Australian-based guideline for practice guidelines for PT in the Acute

Care Setting with COVID- patients

http://www.apta.org/uploadedFiles/APTAorg/News_and_Publications/Latest_News/News_

Items/2020/Physiotherapy_Guideline_COVID-19.pdf

• Comprehensive living document with links to up to date guidelines, webinars,

resources for both COVID and general critical care therapy by Kyle Ridgway, PT

https://docs.google.com/document/d/16UrBoE0YLikWaXgdUpmO01oO2NTo5fr-

_qkN3EyDvr0/mobilebasic

@ICUrehab

Learn more: hopkinsmedicine.org/pmr/amp

Newsletter and Training: HopkinsAMP@jhmi.edu

The Show Must Go ON! Live or Virtual@Hopkins AMP, @icurehab, @PICU_Up

Thank you

We would like to acknowledge:

• Our many transdisciplinary colleagues from around the globe

who have shared their best practices, treatment models and

research to inform our evolving COVID-19 framework.

• All and we mean all of Johns Hopkins Medicine