APTA receives many questions regarding management of patients during the pandemic — whether patients are asymptomatic, diagnosed or suspected COVID-19, or recovering from the illness. The following information addresses many of your concerns, for outpatient, home health, long-term care, acute care, and school-based settings, as well as in the areas of post-intensive care syndrome, post-acute sequelae of SARS-CoV-2, and wound care, and provides recommendations for helping your patients stay active while they're at home.
All information is based on national and international recommendations and guidelines, when available. This information is not intended to be applicable to every scenario, but to give you information to make decisions based on the best available evidence and your professional judgment. As more information arises, this information will be updated.
As we continue to live with COVID-19, many outpatient physical therapy providers could see a surge in “long COVID,” which the National Institutes of Health now refers to as post-acute sequelae of SARS-CoV-2 infection, or PASC. All providers should learn more about PASC and how it can be recognized and managed in the outpatient setting.
Determining if Patients Should Be Seen in Person in the Outpatient Setting Because of Heightened Risk of COVID-19 Transmission
All health care providers are at some risk for exposure to COVID-19, whether in the workplace or in the community. Providers in any risk exposure category (high, medium, low, or no risk) who develop signs or symptoms compatible with COVID-19 must contact their established point of contact (public health authorities or their facility's occupational health program) for medical evaluation prior to returning to work. If an employee is confirmed to have the infection, the employer should inform other employees and patients who were in contact with the individual up to 48 hours before becoming symptomatic, keeping the confidentiality of the affected employee as required by the Americans With Disabilities Act. All employees should self-monitor for symptoms and respond accordingly. Read about more APTA outpatient resources.
One challenge to providing outpatient care is cancellation of appointments, whether by the provider or the patient. If you determine with your patient that in-person care should be discontinued or delayed, you should carefully explain options for different care delivery models to the patient, along with the reasons for doing so, such as the importance of protecting them, the people around them, your other patients, and you and your staff. You'll find resources to help you with these efforts on the APTA Telehealth webpage.
Consider these factors for in-clinic physical therapy sessions:
- Are you (or is your patient) experiencing symptoms of COVID-19, or feeling unwell?
- Have you (or has your patient) been in close contact with someone who is suspected to have, or was diagnosed with, COVID-19?
- Have you (or has your patient) traveled to an area deemed high risk?
- Will your patient's condition worsen or deteriorate if physical therapist services are not provided?
- Are you (or is your patient) in a high-risk category, such as diabetes, heart condition, or older age?
- Can you safely screen your patient for COVID-19 symptoms?
- Is appropriate PPE available?
You, and anyone on your staff, should stay home if:
- You are experiencing any symptoms of COVID-19.
- You are not feeling well for any other reason.
- You have been in close contact with someone who is suspected to have, or was diagnosed with, COVID-19.
- You recently traveled to an area deemed high risk.
- You are a high-risk individual, and PPE is not available and social distancing guidelines cannot be adhered to. (Also see CDC's Guidance for Business Employers.)
The length of time that you or anyone on your staff should stay home if they are asymptomatic but have been exposed to someone suspected or diagnosed with COVID-19 depends on their epidemiologic risk classification per CDC guidance. Criteria for return to work for you or your staff after being symptomatic or diagnosed with COVID-19 varies depending on whether a test-based or non-test-based strategy was used.
Consider an alternative care model and/or advise patients to not come into your clinic if:
- They are experiencing any symptoms of COVID-19.
- They are not feeling well for any other reason.
- They have been in close contact with someone who is suspected to have, or was diagnosed with, COVID-19.
- They cannot be provided appropriate PPE.
- They are in the high-risk category. (Also see CDC's People at Higher Risk and Special Populations.)
If a patient requires care and cannot be seen in person:
- Advise Medicare patients that they have an option for telehealth services (during the public health emergency) as well as communication technology-based services (e-visits, virtual check-in, etc.).
- Before advising patients covered by other payers, follow the payer's updated policies, or contact the payer to determine the option for telehealth or other remote services.
Physical Space and Operations To Reduce Risk of Infection
In facilities that are providing care to patients who require in-person physical therapist services, here are some general modifications to consider:
- Evaluate your treatment and waiting room space design to ensure that patients are always a minimum of six feet apart from one another.
- Perform proper hand hygiene frequently after touching surfaces and patients.
- Provide one-on-one patient care only.
- Clean all equipment, devices, and surfaces between each patient interaction per CDC recommendations.
- Adjust your scheduling to minimize the number of patients in the waiting room and to minimize patient overlap. Do not have patients reuse the same sign-in pen.
- Take patient temperatures upon entry to treatment and ask about recent travel.
- Advise patients to wear a face mask or covering always while in the clinic. If your patient does not have a mask, provide one.
- If you are treating a patient who is suspected or confirmed to have COVID-19, or if you or the patient is in a high-risk category, use recommended PPE (mask and gloves), and follow the CDC Standard Precautions for All Patient Care. If protective gear is not available, cancel the in-person visit and provide remote services to the extent appropriate and available.
- If possible, provide home programs for the patient to follow to prevent deconditioning while the patient cannot attend therapy sessions.
- If a patient requires care and cannot be seen in person, contact the referring physician as well as the payer to determine the option for telehealth or other remote services.
- Develop a communication plan for contacting all active patients to notify them of clinic hour changes, reschedule or cancel appointments, and transition as appropriate to eligible telehealth services and other needed communications. The plan should include disaster preparedness and how patients will be contacted in any sudden onset disaster.
Home Health Setting
Advise Medicare patients that they have an option for telehealth services (during the public health emergency) as well as communication technology-based services (e-visits, virtual check-in, etc.).
HPSO has written an article on home care in the time of the novel coronavirus that details information on important considerations to providing home health care.
As with outpatient settings, one challenge impacting patient care is cancellation of appointments, whether by the provider or the patient. If you determine with your patient that in-person care should be discontinued or delayed, you should carefully explain options for different care delivery models to the patient, along with the reasons for doing so, such as the importance of protecting them, the people around them, your other patients, and you and your staff. You will find resources to help you with these efforts on the APTA Telehealth webpage. It is recommended that you suspend any cancellation or rescheduling fees during the emergency and document the reasons for cancellation or suspension of care.
Under the APTA Code of Ethics for the Physical Therapist, you should provide notice and information about alternatives for obtaining care if you terminate the provider relationship while the patient or client continues to need physical therapist services.
Long-Term Care Facilities Setting
Specific to long-term care facilities, including skilled nursing facilities and assisted living communities, the American Health Care Association and the National Center for Assisted Living have published guidance on restricting visitors, nonessential personnel, and community activities to prevent COVID-19 from spreading.
Acute Care Setting
Inpatient facilities manage patients who require physical therapist services that are vital to their recovery or maintained health. There are many resources on various aspects of the management of patients with COVID-19.
- APTA, the APTA Academy of Cardiovascular & Pulmonary Physical Therapy, APTA Acute Care, World Physiotherapy, and other international professional associations have endorsed the Physiotherapy Management for COVID-19 in the Acute Hospital Setting: Recommendations to Guide Clinical Practice. The guidance focuses on workforce planning and preparation including screening for physical therapy, as well as the actual delivery of interventions and PPE requirements. It includes more than 60 recommendations ranging from shift planning to the specific types of PPE PTs should wear.
- The World Health Organization provides technical guidance on the clinical management of COVID-19 for individuals with mile, moderate, severe, and critical disease. This document includes a section on rehabilitation for patients with COVID-19.
- “Rehabilitation Considerations During the COVID-19 Outbreak,” published by the Pan American Health Organization includes information on the rehabilitation needs associated with the consequences of ventilatory support and prolonged immobilization and bed rest.
- Physiopedia has free online documents and courses for the respiratory management of COVID-19, including specific clinical syndromes associated with COVID-19 outlined by WHO. Also, the British Thoracic Society has compiled information, guidance, and resources to support the respiratory community during the COVID-19 pandemic, including information specific to management of critical care patients, safety of nebulizer use, interstitial lung disease, obstructive sleep apnea, and more.
- "How Can Acute Care PTs Add Value in a Pandemic?" is a collection of resources from APTA's Acute Care, whose website includes a number of webinar recordings and other resources.
- "Physical Therapist Determination of Discharge Disposition in the Acute Care Setting" published in the Journal of Acute Care Physical Therapy in July 2019.
School-Based Physical Therapist Services
APTA has prepared specific guidance for PTs and PTAs working with the pediatric population during the COVID-19 pandemic. Information on school closings and IEP services and remote learning can be found in the document.
The Alliance of Wound Care Stakeholders state that wound care is an essential, not elective, service that prevents hospital admissions and emergency department visits among a fragile cohort of patients at high-risk of COVID-19.
Post-Intensive Care Syndrome
Patients who have been in the ICU due to COVID-19 may experience post-intensive care syndrome, or PICS, which involves health problems that are present when the patient is in the ICU and may persist after the patient returns home. These problems can involve ICU-acquired weakness, cognitive or brain dysfunction, and mental health conditions.
ICU-acquired weakness is muscle weakness that develops during an ICU stay, such as with COVID-19. It occurs in:
- 33% of all patients on ventilators.
- 50% of all patients admitted with severe infection, known as sepsis.
- Up to 50% of patients who stay in the ICU for at least one week.
Patients who develop the condition experience difficulty in performing activities of daily living, and may take more than a year to fully recover.
Cognitive or brain dysfunction consists of problems with remembering, paying attention, solving problems, and organizing and working on complex tasks, and it occurs in 30%-80% of patients after leaving the ICU. Some people improve during the first year after discharge, while others never fully recover.
Critically ill patients also may develop problems with falling or staying asleep, be subject to nightmares and unwanted memories that trigger physical or emotional reactions, and have symptoms of posttraumatic stress disorder, or PTSD. Read more about PICS from the Society of Critical Care Medicine.
These articles in APTA's journal PTJ offer more insight into physical therapist management of PICS:
- "Home and Community-Based Physical Therapist Management of Adults With Post–Intensive Care Syndrome" (April 2020)
This PTJ article reports the prevalence and clinical presentation of PICS and provides recommendations for physical examination and outcomes measures, plan of care, and intervention strategies. The authors call for a "yellow flag" screening by PTs to include asking patients who have been hospitalized if they spent time in an ICU and for how long, and if they needed a ventilator, as they could be experiencing or be at risk for PICS.
- "Physical Impairments Associated With Post-Intensive Care Syndrome" (June 2018)
This systematic review published in PTJ examines impairments in physical, mental, or cognitive abilities, or a combination of these in individuals who have survived a critical illness that required intensive care.
Recommendations for Patients To Stay Active While They're at Home
Several resources have been developed to encourage physical activity while people are social distancing and staying in their homes.
- General Exercises - Videos (geared towards geriatric and pediatric patients)
- Physical Activity Toolkit (ChoosePT.com)
- Physical activity resources (Physical Activity Alliance)
- General physical activity guidelines (American College of Sports Medicine)
- Activity tips (National Council on Aging)