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.