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 Table of Contents  
PERSPECTIVE
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 75-79

The vital role of inpatient rehabilitation facilities in a large health system: The COVID-19 pandemic


1 Department of Rehabilitation Medicine, The Winifred Masterson Burke Rehabilitation Hospital, White Plains, NY, USA and Montefiore Medical Center; Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA, USA
2 Department of Rehabilitation Medicine, The Winifred Masterson Burke Rehabilitation Hospital, White Plains, NY, USA and Montefiore Medical Center, Bronx, NY, USA
3 Department of Rehabilitation Medicine, Montefiore Medical Center, Bronx, NY, USA
4 Department of Rehabilitation Medicine, The Winifred Masterson Burke Rehabilitation Hospital, White Plains, NY, USA

Date of Submission20-Apr-2020
Date of Decision12-May-2020
Date of Acceptance27-May-2020
Date of Web Publication01-Sep-2020

Correspondence Address:
Dr. Carolin Dohle
Burke Rehabilitation Hospital, 785 Mamaroneck Avenue, White Plains, NY 10605
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisprm.jisprm_14_20

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  Abstract 


The current COVID-19 pandemic has put the global health-care system into an unprecedented crisis, leaving hospitals overwhelmed and desperate for additional capacity. As of April 20th, 2020, New York State had the most COVID-19 cases in the US. We here describe the process of transforming our freestanding rehabilitation hospital to help to create additional capacity for our parent system, the Montefiore Health System. This transformation required creating a capacity to handle an increased number of patients with higher medical complexity. The sequence of steps taken at Burke Rehabilitation Hospital to rise to the challenge is outlined in this article.

Keywords: COVID-19, health systems, rehabilitation


How to cite this article:
Dohle C, Oh-Park M, Gitkind A, Menkes J, Bartels M. The vital role of inpatient rehabilitation facilities in a large health system: The COVID-19 pandemic. J Int Soc Phys Rehabil Med 2020;3:75-9

How to cite this URL:
Dohle C, Oh-Park M, Gitkind A, Menkes J, Bartels M. The vital role of inpatient rehabilitation facilities in a large health system: The COVID-19 pandemic. J Int Soc Phys Rehabil Med [serial online] 2020 [cited 2020 Oct 22];3:75-9. Available from: https://www.jisprm.org/text.asp?2020/3/3/75/294128




  Introduction Top


In New York State (NYS), the number of COVID-19 cases has exponentially increased from 0 in January 2020 to 230,597 as of April 17, 2020, with 17,131 fatalities [Figure 1]a. Early projections predicted a bed need far above available beds [Figure 1]b.[1]
Figure 1: (a) New York State cases (blue) and fatalities (red) between March 11 and April 18. (b) Early projections estimated a need for 3808 beds, more than twice the number of available beds. C. Timeline of actions taken at Burke Rehabilitation Hospital in response to the COVID-19 pandemic. Figure 1 (a) and 1 (b) courtesy of Montefiore Network Performance Group, MHS COVID-19 Daily Brief, April 20, 2020

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Burke rehabilitation is a 150-bed freestanding acute inpatient rehabilitation facility (IRF) located in White Plains, NY, with ten ambulatory rehabilitation sites. Burke is a member of the Montefiore Health System (MHS), which comprises 11 hospitals with a total capacity of 3200 beds. At least 60% of our patients are admitted with a neurologic condition as the primary diagnosis, with the remaining patient population comprised posttransplant, orthopedic, cardiovascular, and general deconditioning/rehabilitation patients.

The MHS academic main campus is located in the Bronx, NY, with affiliated hospitals dispersed throughout the Bronx, Westchester, Rockland, and Orange Counties. Given our central location in Westchester County, the New York epicenter in the onset of this pandemic in the United States, MHS hospitals were inundated with coronavirus disease-19 (COVID-19)-positive patients.

At the time of this writing, over 2,079 patients were admitted to MHS who were COVID-19 positive. Severe acute respiratory syndrome coronavirus 2 (SARS-COV2) is a virus that enters the lungs, attaches to type 2 lung cells, and leads to a characteristic multifocal pneumonia.[2] The term COVID-19 has been used to describe the illness caused by SARS-COV2. Patients can be left with a significant degree of disability and reduced lung function,[3] rendering them unable to be discharged home. Patients are also presenting with central neurologic syndromes,[4] cardiac issues,[5] and peripheral muscle issues.[3] In addition, patients test positive for the virus for weeks after becoming symptomatic,[6] further complicating their discharge. This created an obstruction in the throughput of patients. We here describe the process of transforming Burke Rehabilitation Hospital to serve the needs of patients of the MHS and our neighboring partners during this medical crisis.


  Phase 1: Gearing up Top


To assist in freeing resources at the acute care hospitals in the MHS and region, Burke Rehabilitation had to prepare for a new role in the health system. Achieving the new role required a number of changes in rapid succession:

Establishing a command center and twice-daily meetings

Early on, it became clear that multidisciplinary communication and coordination of efforts on the highest level of the organization would be of paramount importance. To this extent, twice-daily multidisciplinary meetings under the leadership of Burke's chief executive officer (CEO), involving leaders of all divisions of the hospital, were established. At each meeting, the following was reviewed: (1) scheduled admissions and their needs (oxygen demand and supply, negative pressure rooms, and personal protective equipment [PPE]), (2) hospital-wide PPE levels and par levels in stock in the institution, (3) staffing levels, callouts, and attrition rate due to illness, (4) steps to create overflow beds, (5) care and management of COVID-19 patients, and (6) staff well-being and morale. The following steps were a direct result of these high-level discussions [Figure 1]c.

Restriction of visitors and entry to the hospital

To decrease the risk of exposure through visitors, on March 11, 2020, visiting hours were initially restricted to twice daily, between the hours of 12 pm–2 pm and 4 pm–7 pm.

As the number of cases in the community grew, concerns for visitors posing an exposure risk to our patients outweighed the possible benefit of having patients see their loved ones. As a result, all visitations were suspended on March 16, 2020. A notable exception was visitation for discharge planning purposes.

Recognizing the impact of visitation restrictions on patients and families, Burke turned to technology to overcome this separation. iPads were purchased and are now used to facilitate virtual visits for patients and family via FaceTime. When necessary, patients are aided by therapy staff. The Patient Experience Department proactively identifies patients that would like to take advantage of this opportunity.

Staff wellness checks

At Burke Rehabilitation Hospital, entry to the hospital was limited to two entrances. Since March 14, 2020, all staff have to undergo temperature screening upon their arrival and are asked if they had noted for any potential COVID-19 consistent symptoms [Figure 2]a. Once cleared, staff is given a sticker to be placed on the ID. The sticker color varies each day. Staff that cannot be cleared are asked to contact their personal physician for further management.
Figure 2: (a) A wellness check was performed on all staff entering the hospital. (b) Outpatient therapy staff was re-deployed to help distribute personal protective equipment. (c) One of our therapy gyms was converted into a 14-bed surge unit. (d) Negative pressure rooms were created with the use of HEPA filters

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Closing of ambulatory sites

On March 16, 2020, we closed our adult fitness center. Our 600 members are now provided weekly education and home programs via videos and e-mails. Our fitness center staff created two full-body basic workouts for patients to follow along as well as two informational videos about the benefits of exercise that are available to members through email and the Burke homepage. We also created a Facebook page where our members can stay in contact with us and each other. On March 19, 2020, our cardiac and pulmonary rehab programs closed, given the group nature of the programs and the high risk of those patient populations. All other ambulatory sites were sequentially closed between March 25 and April 10, 2020, with one outpatient therapy facility remaining open for patients with urgent rehabilitation needs (trauma, postfracture, recent surgery, recent stroke, recent spinal cord injury, and acute pain).

Burke now services between 50 and 60 patients daily, Spaced out over time in order to adhere to social distancing recommendations, a 90% reduction from the patient volume of 600 patients/day prior to the onset of COVID. The staff from those sites was re-deployed to allow for increased staffing in the IRF and asked to help in new roles as the focus included more COVID-19-positive patients.

Re-deploying ambulatory therapy staff for the inpatient hospital

With outpatient locations closed, Burke ambulatory staff were given the opportunity to be re-deployed to the inpatient hospital. Due to the surge of patients, these staff members are counted onto fill vital roles at the hospital. A command center assigns staff a daily basis to the following redeployment areas: nursing assistance, inpatient rehabilitation, unit clerks, admitting and screening, social work, environmental services, shipping and receiving, mailroom, central supply, information technology, and security. In addition, outpatient therapy staff was trained to perform arrival staff wellness checks and aided in handing out PPE [Figure 2]b.

Creation of negative pressure rooms and a 14 bed surge unit

On March 23, 2020, the Governor of NYS, Andrew Cuomo, issued an “Executive Order Number 202.10” mandating all hospitals to increase their staffed bed capacity by 50% over their pre-COVID-19 average daily census (ADC). Under Burke's license, our 150 beds are duly licensed to be used for medical surgical patients, as well as acute rehabilitation.

For Burke, implementing the executive order meant increasing our bed compliment from a pre-COVID-19 ADC[7] of 135- to 203-bed capacity. The hospital already had bed space to increase 15 beds to its licensed capacity of 150 beds.

To accomplish achieving the remainder of the surge beds, on April 3, 2020, Burke converted three of our inpatient gyms to inpatient open bed space with distinct units of 14 beds, 20 beds, and 19 beds, [Figure 2]c.

Equipment that needed to be acquired included beds, separation curtains, bedside commodes, medication carts, and oxygen equipment among other needs. Surge beds were designated for non-COVID-19 patients and for patients without high-level nursing care needs since proper solation and higher level nursing care would be harder to provide in these new beds.

In addition, 16 negative pressure rooms were created by installing High Efficiency Particulate Air (HEPA) filters [Figure 2]d. Careful inspection was done for the selection of these rooms to avoid recirculation of the air back to the adjacent rooms.

Streamlining of the patient referral and screening process

The waiver of the CMS 1135 rule allowed more flexibility in rehab admissions.[8] Our traditional referral process was initiated by a referral from the acute care hospital social work or case management department following interdisciplinary team (IDT) rounds. If acute rehabilitation services were recommended, and Burke identified as an appropriate and acceptable site, an electronic or faxed referral was sent. The loop was closed when the Burke physician formally accepted the patient and a bed was offered. It was quickly apparent that this traditional system of assessment for admission was not going to be adequate to the needs of the system and local hospitals with a rapidly rising volume of patients overwhelming both clinical care services and traditional discharge mechanisms. Now, a physician leader within the physical medicine and rehabilitation department reviews referrals for acute rehabilitation from the directorship of discharge planning. The physiatrist personally assesses each patient for appropriateness and discusses the patients with a Burke physician at designated times each day. The admitting department participates in these calls and immediately matches the clinical needs of each patient with bed availability. A brief preadmission screen is completed, and transportation simultaneously arranged.


  Phase 2: Maintenance Top


Changing team rounds from twice a week to daily to allow for greater throughput

To maintain a steady patient flow through the continuum of care and avoid patients staying for a prolonged period of time, daily IDT briefs were held during which patients were discussed that may be appropriate for discharge. We also critically evaluated our discharge process; for example, patients' discharge date was generally moved up to the afternoon of their last therapy day, rather than the following days. Opportunities for enhanced home care services and training of families to accept patients safely home were also explored in more detail. The additional IDT rounds allow for facile decision-making and changes in discharge.

Distribution of personal protective equipment

In the COVID-19 crisis, PPE availability has been a well-known issue. This was also true for Burke as being an IRF; high levels of PPE were not usually needed and were not stored on site. As we were faced with increased numbers of patients, we calculated the PPE needs for each patient to be cared for by staff per day. Our initial calculations were based on 5–10 COVID-19 patients in house. The run rate of gowns was calculated as 10 times the number of patients. Our original estimates of 10 patients soon proved to be well below the actual volume, and at the peak, we have had up to 89 patients COVID-19 positive a day, creating a daily run rate of 700 surgical masks, 1350 gowns, 350 N95 masks, and 10 boxes of gloves. With much equipment traditionally produced in China, PPE had to be sourced from other countries. Burke Rehabilitation Hospital participates in a coordinated MHS supply chain system that uses central logistics and a prescriptive ordering system to help members of the health system meet their PPE needs. These daily formal requisitions through the MHS supply chain are conducted in addition to working with our traditional group purchasing organizations and regular vendors through central supplies.

Due to these daily concerted efforts, Burke is now able to distribute a surgical mask and a respirator mask (N95) daily to all clinical and ancillary staff in brown paper bags. The reallocated ambulatory therapy staff helped bag and distribute the PPE and maintained a ledger with names of staff qualifying to receive N95s.

With these precautions, 52 of 946 staff reported either being COVID-19 positive or having COVID-like symptoms.

Daily coordinating calls among the chief executive officers of Hudson Valley Hospitals and coordination with the Medical Center in the Bronx

Within MHS, the Hudson Valley Hospital System consists of Burke Rehabilitation Hospital, White Plains Hospital, New Rochelle Hospital, Mount Vernon Hospital, Nyack Hospital, and St. Luke's Cornwall Hospital, as well as two MHS affiliates, St. John's Riverside Hospital and St. Joseph's Hospital. Daily conference calls with the CEOs of these hospitals help to evaluate the needs of all members of the system and aid in the appropriate allocation of resources. This included the allocation of PPE, oxygen equipment, beds and also the assessment of patient census and critical areas of need for staff or ventilators, as well as equipment and staffing needs for any increase in beds. The numbers generated by the Hudson Valley Hospitals were shared with a command center in the Bronx that integrates the needs and allocated resources across all hospitals in the system.

Medical and rehabilitation management of COVID-19 patients

Since March 20, a daily medical update is held by the chief medical officer, discussing medical protocols of COVID-19 management, ethical issues, testing protocols, and guidelines from NYS Department of Health (DOH), the Centers of Disease Control (CDC), and the MHS Epidemiologist, among other topics. Testing for COVID-19 was initially quite limited and slow. This meant that patients who were at risk persons under investigation (PUI) had to be isolated, causing a high volume of PPE use while waiting for up to 72 h for test results. This also caused a lack of flexibility in admitting patients as PUI could not be cohorted with other patients. Since April 5, rapid testing for COVID-19 is available with a turnaround time of 1 h. The staff has been trained in the nasopharyngeal swab technique to minimize false-negative results.

Rapid availability of test results enables us to avoid the need to isolate PUIs until a COVID-19 diagnosis is confirmed and preserves valuable PPE. According to the CDC guidelines, isolation precautions can be discontinued on a time-based versus test-based basis. For patients being discharged home, we recommend discontinuation of isolation precautions according to the CDC guidelines.[9] For patients remaining in the hospital, being transferred to subacute facilities or being discharged home with high-risk household members, we adhere to the CDC-recommended test-based strategy.[9]

A comprehensive instruction manual is given to COVID-19-positive patients who are discharged home.[10]

Bedside therapy is being provided on a compressed schedule for patients with COVID-19 infection. Therapists use telemedicine services to perform education while maintaining social distancing. In the outpatient department, a pilot trial of delivering speech therapy through telemedicine is underway.

To further help with the medical management, our partner acute care hospital deployed three internists/hospitalists to Burke, recruited from the ambulatory and hospitalist setting. These hospitalists provide in-person consultant services Mondays to Saturdays and are available for phone consultations on Sundays. In addition, two physiatrists from other sites within the department of rehabilitation medicine and five fellows of pain medicine, sports medicine, and cardiac rehabilitation joined the medical team. These additional physicians were placed on the on-call roster to provide optimal coverage overnight.

Respiratory therapy visits patients on oxygen at least daily. Room air trials (RATs) are done frequently to wean patients off nasal oxygen. Arterial blood gases (ABGs) are used to help to guide this decision resulting in a 116% increase in ABG utilization rate. Patients requiring positive airway pressure or nebulizer treatments are maintained in negative pressure rooms-where possible, nebulizer treatments are changed to metered-dose inhalers to minimize aerosol generation. The above measures resulted in an acute care transfer rate of COVID-19 patients of 4.2% (10/264 cases between February 19, 2020, and April 30, 2020).

Staff wellness and morale

The cards of cheer program is an outreach program in which members of the general public draw pictures and write words of encouragement and inspiration for patients and staff.

To help staff to maintain a clean home environment, a clothing changing station is set up in one of the therapy gym areas. A designated occupational health physician is available for consultation and is working with NYS DOH and county DOH to answer staff questions. On April 17, the local fire department, police department, and ambulance corps together with the White Plains Mayor visited Burke to support the staff and celebrate their dedication during this pandemic. Burke Board of Trustee members sent meals to staff and cheering messages. For the month of April, a weekly free meal was extended to daily free meals to all staff. Additional dining areas were created in the sports center and outdoor patio area to ensure that staff can enjoy their meal while maintaining social distancing.


  Phase 3: Looking to the Future Top


Focusing again on rehabilitation diagnosis

Burke will be able to best support our partner hospitals by admitting COVID-19 patients that have a rehabilitation condition from their COVID-19 disease, as well as traditional rehabilitation patients with or without COVID-19 diagnosis. Burke will care for COVID-19-positive patients for months and possibly years to come. As the curve of new infections is now flattening, it is becoming clearer that many COVID-19 patients may be left with a lasting disability requiring them to undergo rehabilitation before they are able to return home.

We are currently evaluating the feasibility of creating a dedicated COVID-19 wing, with dedicated staffing, to maintain the rest of the institution as COVID-19 free. As the desperate need for beds subsides, we will close our surge unit when possible and re-open our inpatient rehabilitation gyms.

Maintaining internal medicine presence at burke

Burke will be caring for COVID-19 patients far in future and has overall seen an increase in medical complexity of our patients in the past 2 years. We will continue to supplement our medical staff with hospitalists that will be available to help manage this patient population.


  Conclusion Top


The COVID-19 pandemic has cast unprecedented hardship on the global health-care system. The MHS is located in one of the earliest and most severely affected areas in the United States. We here demonstrate that cute inpatient rehabilitation hospitals are in a unique position to help their acute care partners by offloading medical/surgical patients in the convalescent phase. Doing so requires flexible staffing, by training and redeploying staff to best serve a rapidly changing patient population, as well as careful planning and a multidisciplinary effort of all parts of the organization.

Communication across the health system is key, PPE levels and par rates need to be carefully monitored, and high levels of need anticipated. Telecommunication through e-mail, Facebook, and FaceTime can help maintain communication with patients while mitigating exposure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Coronavirus in the U.S.: Latest Map and Case Count. The New York Times; 20 April, 2020. Available from: https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html#states. [Last accessed on 2020 Apr 20].  Back to cited text no. 1
    
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Kiekens C, Boldrini P, Andreoli A, Avesani R, Gamna F, Grandi M, et al. Rehabilitation and respiratory management in the acute and early post-acute phase. “Instant paper from the field” on rehabilitation answers to the Covid-19 emergency. Eur J Phys Rehabil Med 2020; [doi: 10.23736/S1973-9087.20.06305-4].  Back to cited text no. 3
    
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Asadi-Pooya AA, Simani L. Central nervous system manifestations of COVID-19: A systematic review. J Neurol Sci 2020;413:116832.  Back to cited text no. 4
    
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Kochi AN, Tagliari AP, Forleo GB, Fassini GM, Tondo C. Cardiac and arrhythmic complications in patients with COVID-19. J Cardiovasc Electrophysiol. 2020;31:1003-8  Back to cited text no. 5
    
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Liu WD, Chang SY, Wang JT, Tsai MJ, Hung CC, Hsu CL, et al. Prolonged virus shedding even after seroconversion in a patient with COVID-19. J Infect 2020. pii: S0163-4453(20)30190-0.  Back to cited text no. 6
    
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Lardieri A. Gov. Andrew Cuomo Orders Hospitals to Increase Capacity by 50%. March 23, 2020. Available from: https://www.usnews.com/news/health-news/articles/2020-03-23/new-york-gov- andrew-cuomo-orders-hospitals -to-increase-capacity-by-50. [Last accessed on 2020 Apr 20].  Back to cited text no. 7
    
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Lynch C. Section 1135 Waiver Flexibilities – New York Coronavirus Disease 2019; 26 March, 2020. Available from: https://www.medicaid.gov/state-resource-center/disaster-response-toolkit/federal-disaster-resources/entry/54067. [Last accessed on 2020 Apr 13].  Back to cited text no. 8
    
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Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance). Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp disposition-hospitalized-patients.html. [Last accessed on 2020 Apr 20].  Back to cited text no. 9
    
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Ambrose AF, Bartels MN, Verghese TC, Verghese J. Patient and caregiver guide to managing COVID-19 patients at home. J Int Soc Phys Rehabil Med 2020;3:53-68  Back to cited text no. 10
    


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Abstract
Introduction
Phase 1: Gearing up
Phase 2: Maintenance
Phase 3: Looking...
Conclusion
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