224 - The Little Unit that Could: Did Multidisciplinary Rehabilitation Help Patients During an ICU Bed and Ventilator Crisis?

Objectives: To evaluate acute rehabilitation interventions for COVID-19 patients who required prolonged mechanical ventilation. A temporary “Acute Ventilator Recovery Unit” opened in the early days of the COVID-19 pandemic at a community hospital in a state where long-term acute care hospitals are not a disposition option. The retrospective chart analysis looked at whether 3 hours per day of physical occupational, and speech therapy could help patients recover their independent respiratory function and make progress based on traditional rehab functional measures.

Design: Over 92 days, the AVRU accepted 19 COVID-19 patients from one hospital ICU all of whom had failed attempts at ventilator weaning but were otherwise stable for transfer to a medical floor. De-identified data from medical records dated May 27 to July 31, 2020 were collected and analyzed. Primary outcomes: weaning from mechanical ventilation, Functional Independence Measures for mobility, decannulation of tracheostomy, resolution of dysphagia, and disposition setting.

Results: Mean length of time in ICU was 45 days. Mean length of AVRU stay was 26 days during which time 100% of patients were successfully weaned off ventilation (mean time on ventilator = 60 days). While in the AVRU, 12 patients (63.2%) had tracheostomies decannulated. Mean FIM score for bed mobility increased from 1.53 at AVRU admission to 2.94 at discharge (total assist  moderate assist). All patients were NPO at admission; four patients were on regular diets and thin liquids at discharge. Fourteen of 19 patients were discharged to acute inpatient rehab units; 2 went to sub-acute rehabilitation facilities and 2 patients returned to acute care.

Conclusions: During a time of critical need, an AVRU successfully transitioned patients out of the ICU into a less acute setting where functional rehabilitation and weaning from mechanical ventilation were simultaneous goals of care. Other critically ill patients could similarly benefit from intensive rehab interventions.

Scientific Paper Best Paper Award Abstract: Title: The Little Unit that Could: Did Multidisciplinary Rehabilitation Help Patients Regain Function During an ICU Bed and Ventilator Crisis?

Research

Objectives: The purpose of this clinical, descriptive retrospective study was to evaluate the impact of acute rehabilitation interventions for COVID-19 patients who required prolonged mechanical ventilation (PMV), often due to underlying critical illness polyneuropathy and/or myopathy. A temporary “Acute Ventilator Recovery Unit” opened in the early months of the COVID-19 pandemic at a community hospital in a state where long-term acute care hospitals (LTACHs) are not a disposition option for ventilator-dependent patients. Prior studies have shown that patients who underwent a targeted, multimodal rehabilitation program after discharge to an LTACH for PMV demonstrated greater improvements in function and experienced higher rates of weaning success than those who did not receive rehabilitation. This retrospective analysis looked at whether 3 hours per day for an average of 5 days per week of multidisciplinary rehabilitation (physical occupational, and speech therapy with physiatry oversight) — along with coordinated care from pulmonary specialists and respiratory therapists – could help patients recover their independent respiratory function. Determinants of progress were based on traditional rehabilitation functional measures.

Design: Over 92 days, the AVRU accepted 19 COVID-19 patients from one hospital Intensive Care Unit who had failed one or more weaning trials from mechanical ventilators. Patients in the study group were otherwise stable for transfer to a medical floor except for the need for mechanical ventilation. After obtaining IRB approval, de-identified data were extracted from electronic health records of all post-COVID patients admitted to the AVRU between May 27 and July 31, 2020. No patients were excluded. Primary outcomes for determining success of rehabilitation intervention were 1) weaning from mechanical ventilation, 2) Functional Independence Measure scores for mobility, 3) setting for decannulation of tracheostomies, 4) resolution of dysphagia, and 5) discharge setting.

Results: The COVID-19 patients (N=19) were treated during the study period. Most of the patients were male (13 male, 6 female). They ranged in age from 24 to 80 (mean 61 years, SD 12.95). Length of ICU stay ranged from 23 to 72 days (mean 45.63, SD 12.28) within a total acute care stay of 26 to 87 days (mean 53.89, SD 13.53) prior to transfer to the AVRU.

All study patients had tracheostomies placed prior to their transfer to AVRU between hospitalization day 15 and 63 (mean 39.79, SD 12.9). All patients were NPO at time of their admission to AVRU and were receiving tube feeds via percutaneous gastrostomy. Seventeen of 19 patients (89.4%) arrived in the AVRU with at least 1 pressure ulcer; 53.7% of patients included the study had 2 or more pressure ulcers, and 10.5% had 5 or more pressure ulcers.

During AVRU stay, 100% of patients were successfully weaned off ventilation. Time on mechanical ventilation was 24 to 110 days (mean 59.44, SD 24.2). While in the AVRU, 12 patients (63.2%) had tracheostomies decannulated. Mean FIM score for bed mobility increased from 1.53 at AVRU admission to 2.94 at discharge (equivalent of progression from total assistance to moderate assistance). From NPO status with tube feedings, four of 19 patients (21.1%) progressed to regular diets and thin liquids at time of AVRU discharge. Fourteen patients (73.7%) were ultimately discharged to acute inpatient rehab units; 2 patients (10.5%) went to sub-acute rehabilitation facilities and 2 patients (10.5%) returned to acute care due to medical complications.

Conclusion: During a time of critical need during the COVD-19 pandemic, an AVRU successfully transitioned patients out of the ICU into a less acute setting where functional rehabilitation and weaning from mechanical ventilation were simultaneous goals of care. It is important to assess the long-term outcomes and cost-effectiveness of the AVRU to determine its sustained impact on patient health as well as healthcare resource utilization. While the ventilator crisis has since abated, there remains the potential for other novel respiratory viruses to stress healthcare system resources. The benefits of the temporary AVRU should not be forgotten. Non-COVID patients whose rehab courses are delayed due to difficulty weaning from mechanical ventilation could benefit with quicker recovery of independent respiratory function if they, too, received intensive rehab interventions that were offered in the temporary AVRU.