Abstract
The coronavirus disease 2019 (COVID-19) pandemic has presented unique challenges for occupational therapy practitioners working in acute and critical care settings. Using the best available evidence, this case report overviews a prototypical COVID-19 disease course and discusses key aspects of clinical reasoning for practitioners working with this novel population. Following a single patient admitted to a tertiary academic medical center, the authors review the occupational profile and medical history, common impairments, the intervention plan, and strategies to align the occupational therapy and medical goals of care.
This case report describes a prototypical COVID-19 disease course and discusses key aspects of clinical reasoning for practitioners working with this novel population.
The novel coronavirus disease 2019 (COVID-19) pandemic has forced hospital-based occupational therapy practitioners to adapt to a rapidly evolving health care landscape. With little evidence specifically addressing pandemics and infectious diseases, clinicians have relied on existing literature on critical care, cardiovascular, and pulmonary rehabilitation to meet the needs of patients hospitalized with COVID-19 (Devlin et al., 2018; Hodgson et al., 2014; Margetis et al., 2021). This case report presents a single prototypical patient’s experience of an acute COVID-19 infection requiring hospitalization, intensive care, step-down care, and finally postacute rehabilitation. The case report includes a brief review of clinical reasoning components relevant to the case. The clinicians used multiple frames of reference, including biomedical, rehabilitative, adaptive, and compensatory. Unique aspects of each level of acute care are reviewed to highlight the myriad challenges patients recovering from COVID-19 have faced throughout the pandemic.
Occupational Profile
Jeffrey is a 74-yr-old, White, cisgender man who works as a middle school science teacher in Los Angeles. Jeffrey is originally from Chicago and an avid Chicago sports fan. He has a big family and loves to spend time with his wife, children, and five grandchildren. When not spending time with his family, Jeffrey likes to hike on the weekends.
When Los Angeles County began its first quarantine period, Jeffrey adhered to public health guidance to remain at home, wear a mask, and wash hands. However, Jeffrey and his large family gathered for the winter holidays just as Los Angeles County became the national epicenter for COVID-19 cases. Jeffrey and his family are well educated and present with a high level of health literacy. The COVID-19 pandemic has not affected Jeffrey’s finances.
Medical History and Hospital Admission
Jeffrey has a complicated medical history including nonischemic cardiomyopathy and atrial fibrillation. On New Year’s Eve, he presented to the emergency department after 5 days of worsening fatigue, fever, shortness of breath, and low peripheral oxygen saturation (SpO2) on his home pulse oximeter. He was placed on 2 liters per minute (LPM) of supplemental oxygen and admitted to the hospital COVID unit. Occupational therapy was consulted on admission per standard hospital protocol. In addition, the physician provider prescribed oxygen therapy to maintain Jeffrey’s SpO2 above 92% and allowed the occupational therapy team to adjust oxygen delivery on the basis of Jeffrey’s fluctuating needs during activity. Jeffrey’s evaluation is summarized in Table 1, Telemetry column. In short, Jeffrey demonstrated full strength and was previously independent with activities of daily living (ADLs) and mobility; however, he had limited activity tolerance, as evidenced by exertional desaturation and an excessive heart rate response to activity. Over the first several days at the hospital, Jeffrey’s oxygen requirements increased from 2 LPM on admission to 50 LPM, 50% fraction of inspired oxygen (FiO2) via high-flow nasal cannula, to maintain his SpO2 above 92%.
Key Data Points Across the Care Continuum
Note. AM-PAC = Activity Measure for Post-Acute Care; CAM–ICU = Confusion Assessment Method for the Intensive Care Unit; EOB = edge of bed; FiO2 = fraction of inspired oxygen; HFNC = high-flow nasal cannula; ICU = intensive care unit; LPM = liters per minute; MRC–SS = Medical Research Council Scale for Muscle Strength; O2 = oxygen; RASS = Richmond Agitation–Sedation Scale; SpO2 = peripheral oxygen saturation.
On Days 9 to 22, occupational therapy services were paused because of the use of paralytic medication.
Balancing Occupational Performance With Fragile Physiology
A key aspect of Jeffrey’s occupational therapy plan of care was determining where he was in his COVID disease progression. Evidence suggests the median time from symptom onset to acute respiratory distress syndrome is 8 to 12 days (Yang et al., 2020). With Jeffrey’s symptoms having begun 5 days before admission, he remained at high risk for clinical deterioration. As a result, the occupational therapy intervention plan centered on energy conservation training to support his basic self-care needs, an activity prescription, strategies to promote self-proning adherence, and psychosocial interventions to support his coping.
Activity Prescription
When Jeffrey ambulated to the bathroom during the initial evaluation, he experienced significant tachycardia, tachypnea, and rapid desaturation despite a preemptive increase in supplemental oxygen to 5 LPM (see Table 1, Admission column). These abnormal physiologic responses to light activity were evidence of Jeffrey’s fragile respiratory reserve and risk for clinical deterioration. As a result, the occupational therapy team provided a toileting activity prescription. Activity prescriptions are “tailored, task-specific recommendations that facilitate successful participation and accommodate performance-related physiologic responses” (Wilcox et al., 2021, p. 17). The occupational therapist instructed Jeffrey and the interprofessional team to limit his out-of-bed activity and recommended he use a bedside commode with increased supplemental oxygen. By avoiding ambulation to the bathroom, the activity prescription aligned with the medical team’s goals of preventing refractory hypoxia and sustained tachycardia, which could cause deterioration of Jeffrey’s condition.
Self-Proning
Another occupational therapy treatment strategy was education on the importance of self-proning, also called awake proning. Self-proning is a body-positioning intervention that requires a patient to lie on their stomach for hours at a time to improve systemic oxygenation and prevent potential clinical deterioration in the setting of COVID-19–related respiratory failure. Given data supporting the safety and efficacy of self-proning, Jeffrey was instructed to lie in the prone position (Caputo et al., 2020). Occupational therapy practitioners, with their holistic lens, were able to identify potential barriers to self-proning adherence and provide solutions to promote occupational engagement. For example, Jeffrey’s bed was repositioned in his room to keep the television in sight, and a clear bag was taped to Jeffrey’s bedrail to hold his phone within reach while he self-proned.
Coping
On admission, Jeffrey reported feelings of loneliness stemming from his isolation from his family in the hospital and guilt about his decision to break public health ordinances during the holidays. As Jeffrey’s breathing became increasingly labored, he grew worried about his condition. At the occupational therapy practitioner’s recommendation, Jeffrey’s family delivered his iPad to the hospital and set up video calls to support his coping and mitigate his loneliness. His sterile hospital walls were adorned with pictures of his loved ones, and a calendar and clock were placed visibly at his bedside to support his orientation during the prolonged hospitalization.
Escalation to Critical Care
On Day 8 of Jeffrey’s hospitalization, his respiratory status acutely declined, prompting transfer to the critical care unit. Despite maximum noninvasive oxygen support and prone positioning, Jeffrey remained severely hypoxemic, with an arterial blood gas measuring his partial pressure of oxygen (PaO2) at 44 mm Hg (normal range 75–100 mm Hg; Weinberger et al., 2017). At this point in his clinical course, Jeffrey’s fragile respiratory reserve precluded any functional activity beyond his work of breathing while resting in bed. Because the risks associated with occupational therapy intervention outweighed the potential benefits, occupational therapy services were paused. The nursing staff took over maintenance of joint and skin integrity interventions (e.g., passive range of motion, positioning). Within 12 hr of intensive care unit (ICU) admission, the physicians transitioned Jeffrey to a mechanical ventilator and initiated continuous sedation.
For 2 wk, the intensivists focused on stabilizing Jeffrey’s hemodynamics and oxygenation using continuous infusions and mechanical ventilation. While heavily sedated and paralyzed, Jeffrey spent 18 hr/day in the prone position, requiring four interprofessional team members to manually turn his body 3 times daily. After 13 days in critical care, Jeffrey’s oxygenation and hemodynamic stability sufficiently improved to allow the discontinuation of paralytics and manual proning. Notably, Jeffrey’s other vital organs escaped injury, and after a meeting with the critical care team, his family consented to a tracheostomy in anticipation of a prolonged recovery.
Early Rehabilitation
Elements of Jeffrey’s daily care were organized using the ICU Liberation Bundle (A–F), a best-practice guideline shown to improve outcomes among ICU survivors (Devlin et al., 2018).
Because of infection prevention protocols, the staff needed additional time to don personal protective equipment. As a result, patients with COVID-19, including Jeffrey, experienced more liberal physical and chemical restraint use than non-COVID patients (Devlin et al., 2020). The increased restraint use predisposed these patients to higher risk of long-term morbidity, such as post–intensive care syndrome (Devlin et al., 2020). Daily awakening trials, which involved temporary decreases of sedation to improve arousal, allowed intensivists to assess for pain, physiologic stability, ventilator synchrony, spontaneous breathing, and delirium. On Day 15 of Jeffrey’s ICU course, he achieved the readiness criteria for occupational therapy reevaluation:
adequate cardiovascular reserve, defined as mean arterial pressure of ≥60 mm Hg, with stable doses of vasoactive medications (Hodgson et al., 2014)
adequate respiratory reserve, defined as SpO2 of >90% and/or PaO2 of >60 mm Hg, while on mechanical ventilation with FiO2 of <80% (Hodgson et al., 2014)
adequate arousal and cognition to allow for active participation, defined as a Richmond Agitation–Sedation Scale score of –2 to +2 (Sessler et al., 2002)
no other contraindications to progressive mobilization (Hodgson et al., 2014).
Reevaluation
Jeffrey’s reevaluation revealed pronounced ICU-acquired weakness, severe activity intolerance, limited postural control, anxiety, and neurocognitive impairments (see also Table 1, ICU Reevaluation column; Stevens et al., 2009). The occupational therapy intervention plan at this stage included preparatory activities, early engagement in occupation, and early mobilization (e.g., cardiac chair position, sitting upright, transferring). An ICU diary was also initiated during the first week of Jeffrey’s critical care rehabilitation to document his early recovery milestones and serve as a memory aid for the future (Inoue et al., 2019).
Occupational therapy practitioners played a key role in the success of Jeffrey’s awakening trials by using daily interprofessional rounding to coordinate simultaneous therapy sessions. In doing so, occupational therapy practitioners increased the time Jeffrey spent on “sedation vacations” and reduced the amount of time he spent physically restrained and sedated. Early interventions focused on delirium management using cognitive reorientation, modulation of sensory input to facilitate optimal arousal, environmental modification to promote awareness and interaction with surroundings, engagement in familiar activities, and initiation of progressive mobilization (Schweickert et al., 2009).
Interprofessional Communication
Interprofessional communication was critical to the success of occupational therapy in the ICU. Before each session, the occupational therapy practitioners coordinated with the bedside nurse and provider to prepare Jeffrey for therapy participation. For example, he initially needed less sedation, increased ventilatory support, and increased vasopressor support to facilitate successful mobilization into upright body position. While the nurse, respiratory therapist, and ICU provider coordinated these aspects of Jeffrey’s care, the occupational therapy practitioner simultaneously modified Jeffrey’s sensory environment by opening the blinds, playing emotionally salient music, placing Jeffrey’s glasses on his face, and using a warm washcloth to awaken him. As Jeffrey attained the requisite level of arousal to participate, he engaged in bed-level warm-up exercises and gradually transitioned into upright cardiac chair position.
After confirmation of stable vital signs in supported sitting, Jeffrey’s mental status was assessed, which included a screening for delirium using the Confusion Assessment Method for the ICU (CAM–ICU). The CAM–ICU is a standardized screening tool for which a positive result indicates the presence of delirium, an acute change in mental status of unknown etiology and a common complication for patients admitted to the ICU (Miranda et al., 2018). Before mobilization to the edge of the bed (EOB), the occupational therapy team set up the environment to allow Jeffrey to move freely while protecting the integrity of invasive lines and devices. Environmental preparation included careful consideration of Jeffrey’s route back to bed, access to emergency equipment and monitors, and the clinicians’ body mechanics.
Early Engagement in Occupation and Mobility
An early goal of Jeffrey’s critical care rehabilitation was to improve his hemodynamic tolerance to upright positioning, a prerequisite for mobilization out of bed. Initially, Jeffrey required total assistance from his occupational therapy clinician and a rehabilitation aide to transition to the EOB, relying on the aide for postural support. During the first week of mobilization, Jeffrey experienced an excessive heart rate response, often increasing by more than 40 beats per minute (see Table 1, ICU EOB column). During these early therapy sessions, Jeffrey had significant anxiety that limited his ability to engage in any additional tasks other than sitting and breathing on the ventilator. The occupational therapy practitioner used multiple strategies to support Jeffrey’s coping and decrease his anxiety, including playing his favorite music, engaging him in guided imagery, storytelling from his ICU diary, and later guiding self-care training tasks. Jeffrey initially tolerated 10 min of sitting before his fatigue and breathlessness overtook his attention, leading to anxiety and pleas to return to bed. After 6 days of working on upright sitting tolerance at the EOB, Jeffrey’s occupational therapy practitioner surprised him with a video call to his son and grandchildren for the first time. Jeffrey was so motivated by the sight of his family that he sat upright for the entire 20-min call.
Unable to speak while intubated, Jeffrey initially used a functional communication board. As his strength improved, he communicated with more nuance, mouthing words, gesturing, and using facial expressions to convey his thoughts. Although he continued to experience intermittent periods of delirium, the severity and duration diminished over time as his sleep–wake cycle normalized.
In the final week of intensive care, Jeffrey transferred daily to a chair for up to 2 hr with maximal assistance from the occupational therapy practitioner. Six weeks after being intubated, Jeffrey trialed breathing on his own. He successfully weaned from the ventilator to a tracheostomy mask before moving to the COVID step-down unit to continue his recovery.
Step-Down Unit
Jeffrey was transferred to the COVID step-down unit, where he was reevaluated by an occupational therapist (see Table 1, Step-Down Unit column). Despite clinicians’ efforts to maintain Jeffrey’s strength and endurance while in critical care, he had severe ICU-acquired weakness, cardiopulmonary deconditioning, postural muscle weakness, and dysphagia. The occupational therapy intervention plan addressed activity tolerance, activity prescription, energy conservation, and ADL and mobility retraining, with the goal of safely challenging Jeffrey’s cardiopulmonary and muscular endurance.
To promote self-monitoring and management of his limited functional endurance, Jeffrey received education on use of the Modified Borg Dyspnea Scale (mBorg; Borg et al., 2010). The mBorg consists of a scale from 0 (no breathing difficulty at all) to 10 (maximal breathing difficulty) and is used to subjectively rate and monitor breathlessness. Additionally, Jeffrey was educated on the use of a pulse oximeter to monitor SpO2 and pulse rate during exertion. To prevent desaturation and improve overall activity tolerance, occupational therapy practitioners stressed the importance of self-pacing and taking breaks when his mBorg rating reached 6/10. This initial education enabled Jeffrey to avoid overexhaustion and facilitated his gradually increased participation in daily self-care tasks. In tandem, Jeffrey was educated on the safe integration of supplemental oxygen during ADLs to maintain his SpO2 above 92%. Throughout his step-down care and in preparation for discharge, clinicians challenged his activity endurance by incorporating the speaking valve to normalize his respiratory mechanics during task performance.
Outcomes
By discharge, Jeffrey demonstrated significant gains in strength, endurance, mobility, and self-care capacity (see Table 1, Discharge column). Jeffrey was sitting in a chair for most of the day and tolerating 5 min of standing grooming activities with intermittent seated rest breaks. Jeffrey was transferred to inpatient rehabilitation with the diagnosis of critical illness myopathy secondary to COVID-19 (International Classification of Diseases, 10th Revision; World Health Organization, 1990). Jeffrey was eventually discharged home with improved functional independence and subsequently continued his recovery using outpatient telerehabilitation services.
Implications for Occupational Therapy Practice
This case study has broad implications for occupational therapy practice:
Occupational therapy clinicians providing critical care rehabilitation can effect positive long-term survivorship after severe cases of COVID-19.
Interprofessional collaboration plays a key role in managing the medical aspects of occupational performance in critical care settings.
Occupational therapy’s broad perspective on physical, psychosocial, and emotional health during COVID-19 pandemic hospitalization offers distinct contributions to the interprofessional care team.
Conclusion
Jeffrey’s successful critical care recovery highlights the comprehensive, quality care he received throughout his illness. At every point in Jeffrey’s COVID-19 disease course, occupational therapy played a key role, optimizing his functional independence and occupational engagement within the constraints of impaired physiologic reserve. Successful critical care rehabilitation required a collaborative interprofessional approach to care delivery, as outlined in the ICU Liberation Bundle (Devlin et al., 2018). In addition, occupational therapy practitioners working with the critically ill COVID-19 population had advanced clinical training and education to ensure safety. To align the functional and medical goals of care, the practitioners thoughtfully considered the disease course, Jeffrey’s medical status, and the risks associated with occupational therapy interventions. These practitioners demonstrated their distinct value by providing client-centered interventions that supported Jeffrey’s transition from critical illness to long-term survivorship.