The COVID-19 pandemic raised many questions for the rehabilitation community. Most notably, how do you provide for the rehabilitation needs of those who currently have or are recovering from such an easily transmitted disease, while keeping the rest of your patient population safe? Learning from the experiences of rehab experts from around the globe, Alberto Esquenazi, MD, Chief Medical Officer at MossRehab discusses the approach he took in creating the first of its kind COVID-19 rehabilitation unit.
Here is a transcript of our conversation with Alberto Esquenazi, MD:
Welcome to another episode of MossRehab Conversations. Among the many challenges presented by the spread of the Coronavirus is providing effective physical rehabilitation as patients move toward recovery. One solution is a special unit created at MossRehab Elkins Park by Dr. Alberto Esquenazi.
Dr. Esquenazi: I'm the chief medical officer at MossRehab which is part of Einstein Healthcare Network. I am also the John Otto Haas Chair of PM&R and I have been privileged to develop the CORE+ Unit.
I'd like to thank you for joining us Dr. Esquenazi. Please describe the CORE+ Unit and also tell us what you hope it will accomplish.
Dr. Esquenazi: What we've termed now the CORE+ Unit, CORE for COVID Positive Rehabilitation Care Unit. We felt that this was an important step looking at how we could better the care of patients with rehabilitation needs under this very serious pandemic that we are working in. I had discussions with colleagues who were ahead of the curve time-wise because of their location in China in Korea and Japan and in Europe who had found themselves in great difficulty providing patients with rehabilitation care because of the fact that these patients had COVID positive status. Also they gave us a heads up that these patients were going to have great needs for rehabilitation. They either had been seriously ill because of the virus and in many cases had been put on a ventilator and so this really plays a whole new spectrum of rehabilitation needs for patients and we thought it would be best if we could be prepared for it and be really in a circumstance where we could assure our staff that they were going to be in a safer environment by having a designated unit. We were able to segregate geographically space within Moss to one wing of a floor where we actually could keep these patients away from those that were healthy or undiagnosed, and most important, that we could reassure our staff that with appropriate personal protective equipment and training, they would remain as safe as it's possible. And so the concept of this unit grew from that and I was fortunate enough that our administrative staff here at Moss and physicians, therapists and nurses were willing to work with me developing the concept and we opened our doors fully prepared to deal with the rehabilitation needs of patients recovering from COVID.
Did you modeled this after what you heard about in the other countries? Where did the idea come from and is Moss among the first in the U.S. to try something like this?
Dr. Esquenazi: We are one of the very first units to open that was specifically planned to do this. So we did not model after anybody else because in Europe they really got caught by surprise. They were not expecting that these patients we're going to need rehabilitation and in fact many rehabilitation units were turned into acute care hospital units. New York City, many of the larger institutions closed its rehabilitation units and converted those beds into acute care. So we were in a privileged position in which we were ahead in thinking and a little behind in the infection curve. And so it allowed us to prepare in a more systematic manner and really develop appropriate policies, procedures and education for our staff and be sure that we were able to deliver outcomes that were appropriate for these patients to return home.
In speaking to your colleagues did you get any advice on how to create something like this? And what variations are there in the model that you're using at Moss?
Dr. Esquenazi: I think that what we are seeing is really across the world, what has happened is that the major concern has been how do we deal with these patients that are early in their recovery but can have substantial changes in their health status in a minute to minute manner and so the fact that MossRehab is located in the same building as a acute care hospital gives us some of that benefit that if we have a patient who is in rehabilitation and needs quickly to increase the care delivery, we can move those patients to our acute care neighbor which is just a floor away.
In regards to what advice we receive from other places, I think the advice was very valuable but was mostly around how to care for them in the sense of watch for their oxygenation, watch for the development of blood coagulation or problems, watch for issues with their tolerance to exercise, and we've actually discharged a number of patients home and they have been very appreciative of having had the opportunity to receive this kind of care which would have been highly complicated in any other environment.
What I hear you saying I think is that there are rehab patients who were subsequently diagnosed with COVID and COVID patients who need rehab after a bout with the virus. Are there others that you're dealing with as well? What types of patients are you taking in?
Dr. Esquenazi: Yeah I think you have narrowed the two major groups of patients. So we still have our regular rehabilitation unit for patients who have rehabilitation needs open and working. But this particular unit is segregating patients who have rehabilitation needs and have superimposed COVID infection or those that have had COVID infection and we're left with sequelae from that that requires rehabilitation.
So then, what services are you offering on this unit?
Dr. Esquenazi: Patients get the full array of rehabilitation services that we provide at Moss and that includes having physical medicine and rehabilitation specialists lead the team of nurses, physiotherapists, occupational therapists, speech pathologists, neuropsychologists, social workers and any other staff that we may need to help us care for this individual. In addition to that we have wonderful support staff from pulmonary therapists, respiratory therapists to consulting staff and nutritionists and others who are available to assist us in the care of these patients. The only limitation they have currently is they can not go out of the unit for activities such as recreational therapy or a cultural therapy, activities that we would play in other areas of the hospital.
What was the staff's reaction to being a part of this unit?
Dr. Esquenazi: As you can imagine, anybody that is being asked to participate in caring for a disease that we don't have a cure and a disease that we don't understand very well yet can create significant anxiety and I don't think that was an inappropriate reaction from staff. But with education, with reassurance, with information, with transparency, I think staff realized the importance of doing this. We had the ability to really focus on those items that created a sense of confidence and reassurance that what we were doing was right. And I think as they have now experienced, you know I meet with staff periodically and they have expressed really great pride in the work that they are doing and even though they were and they continue to be fearful of the virus and as I always tell staff, fear is good if it keeps you safe. Fear is not good if it makes you not be able to do what you're supposed to do and so that has been really an incredible reaction and I'm so proud of the team that has worked in this unit and as I said, help discharge patients to the community. We've had a young individual that had a neurological injury and then became infected with COVID-19 and this individual would have not been able to get the care that we can provide in a rehabilitation facility like Moss if it had not been for this unit and was discharged last week to his wife who's pregnant, eight and a half months, and they will both celebrate the birth of their baby fairly soon. So that's you know pretty unique. You can see why staff feel very rewarded by the work that they're doing. Again, even though they are nervous and anxious about what they are doing, I think they clearly understand that they are benefiting incredibly this patient population.
You mentioned protective equipment. What other precautions are necessary for the staff and for the patients?
Dr. Esquenazi: Well, patients are segregated to single rooms. They have their door closed when they are in the room. The therapy area and the equipment that's available in it is segregated for the patients who are in that unit. No piece of equipment comes out unless it has been disinfected. Patients are using masks. Staff are using the highest level of mask protection and face shields that are recommended by the CDC and the Pennsylvania Health Department and are vetted by our infectious disease and PPE program at Einstein. And in addition to that, staff has been fully trained and gets supervised on how to put on and take off their protective equipment. We are not quarantining the physician at the current time. We are not doing that because they are okay to go home as long as we are taking their temperature every day when they arrive and when they leave. So we are trying to be sure that we are following all the protocols to be sure that they are not taking infection with them.
Did you meet any obstacles in creating this unit and maintaining it?
Dr. Esquenazi: Maintaining it? We have not. In creating it, there was resistance initially to the idea. You know as a leader you can come up with ideas but you have to get in front of them and really guide the process. And when you know that you're putting potentially people at risk, you know that can be pretty powerful. So really being sure that we had crossed all the T's and dotted all the I's and had done all the appropriate training, education, and vetted each individual to work in this unit was critical to me and certainly to the process.
And how is it working so far?
Dr. Esquenazi: Well, in two weeks we've taken care of 15 patients, discharged three of them to a home. One of them was this young individual who went to his young wife soon to have a baby. The other was a couple, husband and wife, who both had COVID infection and one of them was pretty seriously ill. The other one was ill but did not require a ventilator and they both now have gone home together and you can imagine that after nearly a month of hospitalization, the ability to go back to their own community in their own environment is a huge step in the right direction for them. So, we are making good progress. We are in a small number of cases because you know we are limited to what we have from the point of view of space and staffing. We are highly satisfied that we are making a dent on this terrible disease and that we are helping our acute care partners to move patients who otherwise would have been sitting in acute care waiting to get better by providing really much more intensive rehabilitation and a path to return home in their community.
Is there a specific crew that's working in this unit or are they rotating through? How is it staffed?
Dr. Esquenazi: The staff that is assigned to this unit is dedicated. So we have a crew of nurses and therapists that are dedicated. We have four attending physicians who are essentially taking rotations every two weeks. They are on for two weeks and then they are away for two weeks so that we have sufficient medical support for the unit. The staff was initially staff who worked in that unit and volunteered to remain there. Then we had additional staff who volunteered from other parts of the hospital. And so it is a dedicated staff. We want to be sure that because of the level of training that these individuals have, they are the ones that are staying within that group of employees.
When you say they have two weeks off, is that related to the two week incubation period?
Dr. Esquenazi: In part it is because they're working 14 days straight so they will get their weekend in the first week, then the second week they're dedicated to doing outpatient services remotely through tele-video and you are correct, it's in part because we want to be sure that they have had a two week period of no exposure and that we can be sure that they are healthy to return to other areas of the hospital or care delivery.
Aside from the added protections, is the administering of therapy different in the unit from in regular units?
Dr. Esquenazi: Yeah, it makes it definitely more challenging. If you imagine being a speech pathologist and these patient's after COVID and particularly if they were intubated, they may have swallowing problems, or speech production problems. Our speech pathologists are working with them, and when you're doing that, part of the treatment may elicit coughing which is one of the areas that we are concerned about because when you cough or you sneeze, you're spreading a virus. So that creates a challenge for our staff. They need to change the way they're providing care. Our neuropsychologist and psychologist are counseling patients through video linkage rather than direct face-to-face to reduce potential exposure. And then the area where patients receive physiotherapy or occupational therapy is more limited in the sense that we want to keep patients from each other and then from staff at an appropriate physical distance even though they are all using appropriate equipment and they are all the patients at least known to be positive. We want to be sure that we are not promoting re-infection because we don't know if that is a potential mode of transmission. So it does create a change in the way we provide therapy and we've had to adjust to do that.
So now that you've been in operation for a while and other people in health care have seen what you are doing, have you been getting questions or reactions to your efforts?
Dr. Esquenazi: Yes. There's been lots of questions and inquiries about what we are doing and how others could potentially replicate what we've done here. We've also made our initial development protocols available to other institutions and I'm aware that they are using it in other places across the country and certainly in Europe. And recently we got to publish the first paper which is an international collaboration called The COVID-19 Pandemic, The Role of Physical Rehabilitation Medicine Specialist, a Clinical Perspective, and that was accepted for publication. It's on E-Pub at this point but it will get published in The Journal of Rehabilitation Medicine which is one of the top European journals. So you know, we want to make this information available so that others can look at ways in which they can create their own. It doesn't have to emulate ours but they certainly can use our experience as a way for them to develop their own.
Are there any lessons that you would share with others?
Dr. Esquenazi: Yeah, I think the most important is you need to have a clear vision of what you want to accomplish. You need to be able to put that vision in a clear statement so that people can react to it. You need to be sure that you gain the support of other key players in the system and that together, you work at educating and dispelling misinformation, which is not rare to see across an event like this and be sure that you keep people focused on what the mission is and drive really the message on the basis of that mission. And by doing that you can really get people to accept this.
When we get to whatever is going to be normal after COVID, will this conversion still be around? Will it have a long-lasting impact on how Moss treats its patients?
Dr. Esquenazi: Oh, I think it will. You know I've spent endless hours rewriting policies and procedures for things that we really never thought about in great detail because you know we never had to worry about those things. But we have had to change things that are as simple as how you have patients eat their meals, to how patients receive therapy, how patients are transported from one area of the hospital to another or from one service need to another. So all of those things have definitely changed and I think it's going to have a long-term impact and we will have learned from this. And even when the virus is under control, either because we have adequate vaccination or the virus essentially will fade, if that's possible, we really will be left with a way of thinking and a way of approaching care delivery that will be quite different and substantially changed.
Is there anything else you'd like to add. Dr. E?
Dr. Esquenazi: My thanks to the team that has been participating in this CORE+ Unit. You know I asked for volunteers and a great number of people stepped in who said you know this is something I'm willing to work in if we have the right training. And I think they need to be recognized. They are the true heroes. Providing health care under these circumstances is quite complex and certainly it creates a high degree of anxiety. But they've done a terrific job and I value them very much for their continued support in a relentless dedication to the work they do.
Well certainly we value your contributions here and thank you very much for speaking with us today. It's been a pleasure. We've been speaking with MossRehab Chief Medical Officer Dr. Alberto Esquenazi. To learn more on this topic, go to MossRehab.com and be sure to subscribe or check back at our website for other discussions with pioneers in physical medicine. I’m Bill Fantini. Thanks for joining us on MossRehab Conversations.
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