File
M. Barclay1, N. Triteos1, C. Snape1, R. Vamadevan1, C.-A. Wood1, S. Ritchie1, J. Jones1
1Guys and St Thomas' NHS Foundation Trust, London, United Kingdom
Background: The COVID-19 pandemic created unprecedented demand on healthcare services. UK NHS hospitals therefore rapidly expanded Intensive Care Unit (ICU) capacity, redeploying both staff and resources to care for those most severely affected. This Trust, amongst the first UK sites providing care to COVID-19 patients, had higher than average ICU survival rates at 76.2%. Consequently, many patients required post-ICU rehabilitation, provided on re-purposed wards such as the Older Person’s Unit (OPU).
Purpose: To describe the phenotype of patients post step-down from ICU. Analysis of patient data provides insight into impairments on admission and discharge following a period of rehabilitation. Data supports development of future planning for healthcare service demands, including the provision of appropriate physiotherapy.
Methods: Data on post-ICU COVID-19 survivors were collected prospectively at two time-points, admission and discharge (23rd April – 25th June 2020). Including demographics (age, gender, ethnicity), ICU history, measures of physical function (6m gait-speed, Chelsea Physical Assessment score [CPAX]), breathlessness, fatigue, and discharge details including ongoing impairments and community needs. Data were analysed using descriptive statistics. Ethical review was through local Trust governance process (ID: 11002).
Results: Twenty-eight patients completed an episode of care. Mean age 58 years (11.6 SD), male (64%), Black, Asian or Minority Ethnic (46%), in employment (79%), functionally independent pre-admission (93%).
Median critical care length of stay was 37 days (23.5 IQR) and median length of stay on OPU of 12 days (12.25 IQR).
Following OPU rehabilitation more patients were able to mobilise (89% on discharge vs 36% on admission), mean CPAX scores improved (42/50 [10.0 SD] vs 30/50 [8.4 SD]), gait speed increased (0.40m/s [0.17 SD] vs 0.31m/s [0.24 SD]). Symptomatic breathlessness reduced (48% vs 57%), conversely, reports of fatigue increased (59% vs 25%). The majority of patients demonstrated an improvement in mean grip strength (17Kg vs 11kg) however all patients remained below age-matched peers.
On discharge 68% of patients had enduring physical impairments, including foot drop (23%) and focal shoulder weakness (19%),most patients had ongoing rehabilitation needs (89%) and required formal care or support from family (77%).
Median critical care length of stay was 37 days (23.5 IQR) and median length of stay on OPU of 12 days (12.25 IQR).
Following OPU rehabilitation more patients were able to mobilise (89% on discharge vs 36% on admission), mean CPAX scores improved (42/50 [10.0 SD] vs 30/50 [8.4 SD]), gait speed increased (0.40m/s [0.17 SD] vs 0.31m/s [0.24 SD]). Symptomatic breathlessness reduced (48% vs 57%), conversely, reports of fatigue increased (59% vs 25%). The majority of patients demonstrated an improvement in mean grip strength (17Kg vs 11kg) however all patients remained below age-matched peers.
On discharge 68% of patients had enduring physical impairments, including foot drop (23%) and focal shoulder weakness (19%),most patients had ongoing rehabilitation needs (89%) and required formal care or support from family (77%).
Conclusion(s): COVID-19 ICU admission results in significant patient symptom burden at step down to wards. Physical and functional impairments improved during stay on the rehabilitation unit with physiotherapy input, however, most patients were discharged with a level of dependency and with ongoing rehabilitation needs. Limitations included breathlessness, fatigue and focal shoulder/ankle weakness. Observed impairments are likely caused by a combination of disease pathology and iatrogenic related factors including prolonged bed rest.
Implications: Physical and functional impairment post-ICU admission results in significant implications for service provision, both immediately post-ICU within the hospital setting, and into the community. Given most patients were functionally independent and working pre-COVID, ongoing rehabilitation is critical.
Furthermore, reviewing dosing of physiotherapy intervention throughout the pathway with rehabilitation trajectories and community outcomes needs to be prioritised, to understand the optimal setting and dosing of physiotherapy.
Presence of persistent focal joint weakness indicates a need for joint monitoring during ICU stays, particularly in relation to prone positioning.
Furthermore, reviewing dosing of physiotherapy intervention throughout the pathway with rehabilitation trajectories and community outcomes needs to be prioritised, to understand the optimal setting and dosing of physiotherapy.
Presence of persistent focal joint weakness indicates a need for joint monitoring during ICU stays, particularly in relation to prone positioning.
Funding, acknowledgements: The authors received no funding to complete this work
Keywords: COVID-19, Physiotherapy, Critical care rehabilitation
Topic: COVID-19
Did this work require ethics approval? Yes
Institution: Guys and St Thomas' NHS Foundation Trust
Committee: Local Trust Governance Process
Ethics number: ID: 11002
All authors, affiliations and abstracts have been published as submitted.
