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  • Practice Guidelines Emerge for Physical Therapy and COVID-19 in Acute Hospital Setting

    The Australian-based recommendations, endorsed by APTA, the APTA Cardiovascular and Pulmonary Section, and the APTA Academy of Acute Care Physical Therapy, emphasize proper PT training, careful patient screening, and the use of PPE.

    A new set of recommendations for provision of physical therapist services related to COVID-19 in the acute hospital setting acknowledges the necessity of involvement of PTs well-trained in respiratory physical therapy, but cautions that facilities should be judicious in their use. The recommendations have already been endorsed by APTA, its Cardiovascular and Pulmonary Section, and the APTA Academy of Acute Care Physical Therapy, albeit with a few caveats that not all of the Australia-based guidance will apply in the U.S. The guidance will be published soon in the Australian Journal of Physiotherapy.

    The recommendations are limited to PTs and "other relevant stakeholders" in acute care settings who are providing care to patients with suspected or confirmed COVID-19. The guidance focuses on workforce planning and preparation including screening for physical therapy as well as the actual delivery of interventions and personal protective equipment requirements, and includes more than 60 recommendations ranging from shift planning to the specific types of PPE PTs should wear.

    Among the recommendations:

    • Facilities should consider organizing separate teams to manage COVID-19 versus noninfectious patients.
    • PTs who are practicing within the ICU should have specialized knowledge of working in that setting, while other PTs in the facility who have ICU experience but aren't currently working in the ICU, as well as PTs without recent cardiorespiratory experience, should be facilitating rehabilitation and discharge planning for non-ICU/non-COVID-19 patients.
    • PTs with "advanced" ICU skills should be supported to screen patients with COVID-19, with some being identified as "clinical leaders."
    • Staff who are pregnant should avoid exposure to COVID-19.
    • Physical therapist examination and interventions should be provided only when there are clinical indications for need such as “mobilisation, exercise and rehabilitation e.g. in patients with comorbidities creating significant functional decline and/or (at risk) for ICU acquired weakness” with guideline authors writing that "unnecessary review of patients with COVID-19 within their isolation room/areas will also have a negative impact on PPE supplies."
    • If aerosol generating procedures (AGPs) are required, they should be conducted in a negative-pressure room, or at least in a single room with the door closed, with a minimum number of staff, all wearing PPE. Coming and going should be minimized during the AGP.
    • PTs should not implement AGPs, including humidification or noninvasive ventilation, without first obtaining agreement with a "senior doctor."
    • PTs should take droplet and airborne precautions, including the use of a high filtration mask, when providing mobilization exercise and there is a risk of the patient coughing or expectorating mucous.
    • Direct physical therapist interventions should be considered only when there are "significant functional limitations (e.g. [risk for] ICU-acquired weakness, frailty, multiple comorbidities, advanced age)" in the patient.
    • Staff should be trained in donning and doffing PPE, including N95 fit-checking.
    • For COVID-19 infected patients who may require AGPs, airborne precautions should be followed that include an N95/P2 mask, fluid-resistant long-sleeve gown, goggles/face shield, and gloves. The guidelines also recommend hair cover and shoes that are impermeable to liquids.

    The recommendations also include guidance on patient screening for the appropriateness of PT involvement and an overview of medical management of patients with COVID-19.

    Because the guidelines were developed in relation to the Australian physical therapy environment, some of the recommendations aren't directly applicable to typical U.S. acute settings, where respiratory therapists tend to perform some of the activities associated with physiotherapists in Australia.

    Still, says Bill Boissonnault, PT, DPT, DHSc, FAPTA, APTA's executive vice president of professional affairs, the resource should be carefully reviewed by physical therapists and facilities in the U.S.

    "These guidelines are solid, sensible, and timely," Boissonnault said. "During this crisis, the focus needs to be on connecting the PTs trained for ICU and respiratory physical therapy with only the COVID-19 patients who meet the criteria for treatment. Within the acute hospital setting, we can best respond to the pandemic by making careful, informed decisions that avoid needlessly risking the spread of this disease but also provide needed physical therapy care for patients. These recommendations can help facilities achieve that goal."

    In addition to endorsement from APTA, its Cardiovascular and Pulmonary Section, and the APTA Academy of Acute Care Physical Therapy, the recommendations also have received support from the World Confederation for Physical Therapy, The Australian Physiotherapy Association, the Canadian Physiotherapy Association, AIR (the association of Italian respiratory physical therapy), the UK's Association of Chartered Physiotherapists in Respiratory Care, and the International Confederation of Cardiorespiratory Physical Therapists.

    Visit APTA's Coronavirus webpage for more information on the pandemic as it relates to the profession.

    Comments

    • what are therapist's/institutions doing when rehab facilities are not taking in patients? Currently, we are in direct contact evaluating and treating all patients so they do not lose their functional mobility

      Posted by Christine on 3/26/2020 3:02 PM

    • What should PT's with pregnant spouses practice at this time? Are the spouses at a similar risk to exposure if the PT is in contact with this population? And should the PT limit or discontinue exposure to this population if so?

      Posted by David on 3/26/2020 6:29 PM

    • Where are the home health guidelines/guidance?

      Posted by Dara Storch on 3/26/2020 10:54 PM

    • Hi , do we have any case studies in this pandemic situation of corona and benefits from Physiotherapy. Dr.Sujeer Basha Physical Therapist India

      Posted by Sujeer Basha on 3/27/2020 1:13 AM

    • Hi, Still wondering what the practice guidelines are for skilled nursing facilities, specifically non-urgent outpatients who are elderly and at increased risk for complications of exposure.

      Posted by John Kahn on 3/27/2020 7:43 AM

    • Please tell me there are more guidelines coming with specific guidance in the SNF setting, especially addressing pregnant PT’s in the SNF setting.

      Posted by Amanda on 3/27/2020 8:04 AM

    • Isn't this an ideal scenario to utilize telehealth for PT? Either with the assistance of a caregiver at the originating site or independently, PT can be very effective in an acute care setting, administered from a distant site. Maybe not every session, but as a supplement to available on-site staff, telehealth PT could relieve some of the burden and risk of on-site care right now. I urge acute care PT departments to consider this option, either with existing staff or contracting to PTs in your communities who are eager to be a part of the solution. Many of them have hours of downtime they could contribute to your efforts. PTs in outpatient settings and other areas where visits are significantly lower than normal, reach out to your hospitals, nursing homes and other local facilities. They don't want more traffic in the facility, but they want help and probably haven't considered this option. Telehealth PT can make a huge impact for people who really need our services now.

      Posted by Daniel Seidler -> =OU]<M on 3/27/2020 12:36 PM

    • Does the APTA have guidelines for school based therapists providing teletherapy during school closure?

      Posted by Karen Paltz on 3/27/2020 2:16 PM

    • Google Doc with Resources https://docs.google.com/document/d/16UrBoE0YLikWaXgdUpmO01oO2NTo5fr-_qkN3EyDvr0/edit?usp=sharing

      Posted by KYLE J RIDGEWAY on 3/27/2020 10:19 PM

    • You’re posting guidelines from Australia. Why isn’t the APTA writing guidelines for acute care and home health?

      Posted by Lee Ann Lloyd on 3/29/2020 11:20 AM

    • Are there any guidelines for SNF? We do have a lot of droplet precaution patients and started receiving +covid-19 patients from local hospitals. Thank you.

      Posted by Mike on 3/29/2020 2:23 PM

    • There are no guidelines for SNF. We do get patients from local hospitals with positive covid-19 and on droplet precautions. We are being told that it is okay to tx those patients with the regular procedure mask on per CDC! These guidelines should also apply to patients in subacute setting that are positive for covid-19 or are on droplet precaution!

      Posted by Mike on 3/29/2020 2:31 PM

    • I'd like to echo Dan's comment: Isn't this an ideal scenario to utilize telehealth for PT? Either with the assistance of a caregiver at the originating site or independently, PT can be very effective in an acute care setting, administered from a distant site. Maybe not every session, but as a supplement to available on-site staff, telehealth PT could relieve some of the burden and risk of on-site care right now. I urge acute care PT departments to consider this option, either with existing staff or contracting to PTs in your communities who are eager to be a part of the solution. Many of them have hours of downtime they could contribute to your efforts. PTs in outpatient settings and other areas where visits are significantly lower than normal, reach out to your hospitals, nursing homes and other local facilities. They don't want more traffic in the facility, but they want help and probably haven't considered this option. Telehealth PT can make a huge impact for people who really need our services now. In following the above guidelines, acute care institutions can set up a team of therapists to screen/evaluate COVID patients and then communicate with a team of therapists that can provide telehealth to these patients to prevent them from declining in status and moving into the ICU. Also, there needs to be a plan set in place when these people are discharged and telehealth would be a wonderful platform to utilize for these patients in the outpatient setting. See article: https://www.nbcnews.com/health/health-news/post-intensive-care-syndrome-why-some-covid-19-patients-may-n1166611. Third party payers need to get on board. So please contact your state legislature.

      Posted by Mary Roberts on 3/30/2020 2:38 PM

    • is there any preference for younger PT over older to work with COVID-19 patients, and should indications be more restricted than for every patient staying in bed on respirator? (age, medical prognosis,..)

      Posted by youssef on 3/31/2020 3:58 AM

    • If PTs are taking this much precaution in the ICU in Australia with droplet and airborne precautions, what does it mean to the PTs that are still working in direct contact with patients in non acute settings? Or is that still "best" judgement as mandated by our administrators? Furthermore, if ICU physios are taking care with avoiding aerosol generating techniques with "mobilizing" techniques (ie coughing) wouldn't exercising also cause the same even? Or is that just not the same thing? (Even though gyms are closed down all over the world.)

      Posted by Jenna on 3/31/2020 9:04 PM

    • What are the guidelines and precautions to be followed by pregnant PTs in acute care settings in addition to the precautions that are to be followed for COVID-19? In acute care settings there is a higher risk of exposure - prior to rule outs or a positive test and an unprotected exposure - to health care practitioners due to the evolving medical condition of a patient. There are no specific guidelines for pregnant HCPs and COVID 19 due to lack of time and research with this infection.

      Posted by Renuka on 4/1/2020 8:54 AM

    • Now, the shift will be in home health. Especially in New York City, they will doing a triage whether a patient needs hospitalization or not. Some patients will require home care. What is the guidance of APTA in the home health.

      Posted by Nemesio Felix on 4/4/2020 10:37 AM

    • Is anyone providing more therapy in acute care in hopes to eliminate the need for skilled or inpatient rehab admissions?

      Posted by Cindi Pierotti -> ?LX[B on 4/20/2020 1:54 PM

    • @Nemesio: Please see: http://www.apta.org/PatientCare/COVID-19/PatientManagementAdult/ http://www.apta.org/PTinMotion/News/2020/03/31/WhereThingsStandPracticeGuidance/ https://www.medbridgeeducation.com/blog/2020/04/incorporating-telehealth-into-home-health-care-part-1-practical-strategies/ https://www.apta.org/PTinMotion/News/2020/04/14/HPSOHomeHealthTips/ https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html Please note that APTA continues to update the above guidance and also is working to develop additional practice guidance. Please stay tuned for additional information and check this page frequently: http://www.apta.org/Coronavirus/

      Posted by APTA staff on 4/21/2020 8:49 AM

    • @Renuka: please see this guidance from the CDC related to COVID-19 and pregnancy: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/pregnancy-breastfeeding.html

      Posted by APTA staff on 4/21/2020 9:39 AM

    • Hi, I was wondering if there was any literature or official release of HEP for covoid positive pts in acute care that we could implement in our hospital setting. Thanks, Kara Yeager, PT, DPT

      Posted by Kara Yeager on 4/22/2020 4:50 PM

    • Hi, I am also wondering what are the appropriate guidelines for PPEs for PTs working with covid positive patients in acute care setting. Please help. Thanks, Shikha Vaidya PT, DPT

      Posted by Shikha Vaidya -> CHY_EI on 4/25/2020 1:50 PM

    • @Kara: you may want to check out this article that appeared in PTJ: Home and Community-Based Physical Therapist Management of Adults With Post-Intensive Care Syndrome: https://academic.oup.com/ptj/advance-article/doi/10.1093/ptj/pzaa059/5818366

      Posted by APTA staff on 4/28/2020 6:49 AM

    • @Shika: We recommend following CDC guidelines: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html

      Posted by APTA staff on 4/28/2020 6:51 AM

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