Abstract
This case report examines the role of occupational therapy in the recovery of a client who became critically ill with severe acute respiratory syndrome coronavirus 2. In it, we describe evaluation and treatment methods, functional impairments, and special considerations when working with a client with severe coronavirus disease 2019 infection. The client was a 43-yr-old Hispanic man treated in a long-term acute-care hospital. Client-centered treatment sessions focused on activities of daily living (ADLs), self-feeding, medication management, and leisure and were implemented in 30- to 45-min sessions 3 times per week for 5 wk. The Activity Measure for Post Acute Care Daily Activities Short Form was used to measure basic mobility, daily activities, and applied cognition in the acute setting. A manual dynamometer was used to measure grip strength, and the Nine-Hole Peg Test was used to measure digit dexterity. Both were used in the context of occupational engagement. Data were collected at evaluation, every 2 wk, and at discharge. The client achieved his goals and demonstrated marked improvement in independence with basic ADLs, leisure activities, bilateral grip strength, and manual dexterity.
Postacute care occupational therapy plays a key role in functional recovery for a client with acute hypoxemic respiratory failure resulting from COVID-19 infection.
Coronavirus disease 2019 (COVID-19) is a new disease caused by the severe acute respiratory syndrome coronavirus 2 virus, first discovered in December 2019, that spread rapidly across the globe and was declared a pandemic by the World Health Organization in January 2020. Severity ranges from no symptoms or mild coldlike symptoms to severe disease requiring significantly increased health care resources (Centers for Disease Control and Prevention, 2021). Health care workers, public health experts, and scientists have rapidly gathered information to determine the best treatment courses to maximize positive outcomes. Occupational therapy practitioners have been on the frontlines and have been identified as playing an integral role in client recovery and pandemic response (Margetis et al., 2020; World Federation of Occupational Therapy, 2020). In this case report, we examine the rehabilitative course of one client, Enrique, in the long-term acute-care hospital (LTACH) setting. 1
Enrique
Enrique is a 43-yr-old man with no past medical history who in March 2020 was diagnosed with COVID-19 at a community health clinic. Enrique is from El Salvador and is more comfortable communicating in Spanish, although he has some fluency in English, primarily as it relates to his work as a landscaper. He was managing well at home until 9 days after his diagnosis, when he began experiencing shortness of breath and went to the emergency department. He was initially placed on 2 liters per minute (LPM) nasal cannula (NC) supplemental oxygen. A few hours later, he was transitioned to 50 LPM, 50% fraction of inspired oxygen via high-flow nasal cannula and admitted to the intensive care unit (ICU), where he was ultimately intubated because of hypoxemic respiratory failure.
Enrique remained hospitalized for 42 days and required mechanical ventilation, proning, and sedation for the first 27 days. Despite maximal medical intervention, Enrique needed to be placed on femorally cannulated venous–venous extracorporeal membrane oxygenation as a result of refractory hypoxemia.
On hospital Day 35, Enrique underwent surgical tracheostomy and placement of a percutaneous endoscopic gastrostomy (PEG) tube. After weaning of sedation, his neurological exam was notable for diffuse weakness, with his right side more affected than his left. He was diagnosed with myopathy and unspecified cerebrovascular disease resulting from COVID-19 infection. He received occupational therapy and physical therapy services twice per week during the last 15 days of his hospitalization. He continued to require a high level of medical care and was transferred to a long-term acute care hospital (LTACH)1 for medical management and rehabilitation.
Evaluation
The physician ordered occupational therapy, physical therapy, and speech-language pathology (SLP) evaluations. Enrique had the following precautions for therapy consideration: contact and isolation precautions because of respiratory infection, Stage 2 occipital wound, heart rate parameter <150 beats per minute (BPM), oxygen (O2) saturation parameter ≥90%, and multiple lines (i.e., tracheostomy, PEG, peripherally inserted central catheter in his right upper extremity, rectal tube, indwelling urinary catheter, cardiac telemetry, and peripheral O2 monitoring). Enrique’s occupational therapy evaluation consisted of an occupational profile, standardized testing, and assessment of functional self-care routines (American Occupational Therapy Association [AOTA], 2021). A video-based Spanish interpreter was used for the evaluation via an iPad provided by the LTACH.
Occupational Profile
Enrique lives in the city of Boston with his mother and two brothers in a single-level apartment with two flights of stairs to enter. They had no previous experience using durable medical equipment. Enrique emigrated to the United States from El Salvador approximately 20 yr ago. He works as a landscaper 5–6 days per week. He has an active role in his community church, and prayer is a strong source of spiritual strength. Enrique enjoys exercising, spending time outside, and playing the violin. He was independent in all basic activities of daily living (ADLs) and instrumental activities of daily living (IADLs) before admission. Enrique’s family was very involved and willing to provide as much assistance as Enrique needed; however, Enrique stated that he was not comfortable with family assistance for personal care.
Analysis of Occupational Performance and Related Impairments
During the occupational therapy evaluation, Enrique was alert and oriented to person, place, and month and year and grossly oriented to situation. He was tearful and verbalized feeling anxious about the transition out of the hospital. He performed grooming and upper body ADL tasks at bed level with maximal assistance and required total assistance for all other ADLs. Because of the aspiration risk, he was unable to eat anything by mouth and received all of his nutritional needs via PEG tube. He tolerated sitting at the edge of the bed with one person assisting; however, his heart rate elevated to 152 BPM, and he was significantly fatigued afterward, requiring return to supine.
The occupational therapist completed the Activity Measure for Post Acute Care Daily Activities Short Form (Haley et al., 2004), hand strength assessment via manual dynamometer (Massy-Westropp et al., 2011), and the Nine-Hole Peg Test (Mathiowetz et al., 1985). These assessments were chosen on the basis of Enrique’s desire to return to independent function and to have full hand strength and coordination for playing the violin and working as a landscaper. The results of these assessments (Table 1) suggested impaired ability to perform self-care activities, decreased hand strength, and decreased fine motor control compared with age-matched norms.
Evaluation and Discharge Standardized Outcomes
Note. AM-PAC = Activity Measure for Post Acute Care; LUE = left upper extremity; RUE = right upper extremity.
Primary barriers to performance that were identified during the evaluation included strict isolation precautions; tracheostomy; impaired hemodynamic response to activity; language barrier; pressure wound to occiput; impaired body functions (Table 2); fluctuating anxiety; and the psychosocial effects of prolonged hospitalization, sedation, and isolation.
Occupational Therapy Interventions for Enrique
Note. ADLs = activities of daily living; AOTA = American Occupational Therapy Association.
Treatment Plan and Goals
The occupational therapist collaborated with Enrique and established client-centered goals with strong consideration of Enrique’s supporting and inhibiting factors; his values, roles, and routines; and his estimated length of stay. The occupational therapist also used standardized assessment scores for enhanced objectivity and measurability when formulating the following goals:
Perform ADL routines independently
Demonstrate improved hand strength and fine motor control for self-feeding and simulated violin playing
Complete medication management with minimal assistance from family.
The occupational therapist requested physician confirmation of orders for occupational therapy treatment twice daily, as needed for splint checks and endurance-related impairments, 3 times per week. International Classification of Diseases, 10th Revision (ICD–10; World Health Organization, 1990) codes were identified for diagnoses, and Current Procedural Terminology ® (CPT ®) codes were identified for treatment procedures (Table 3).
Medical, Treatment, and CPT ® Codes
Note. CPT ® = Current Procedural Terminology ®. CPT ® is a registered trademark of the American Medical Association. All rights reserved. COVID-19 = coronavirus disease 2019.
Theoretical Framework
Occupational therapy practitioners apply multiple theoretical frameworks and models of practice to guide and support intervention. In this case, the Person–Environment–Occupation model was used to identify interactions among Enrique, his environment, and his desired occupations, resulting in his overall occupational performance (Law et al., 1996). The Model of Human Occupation provides a top-down and holistic view that helps to understand how occupations are incorporated into daily life through volition, habituation, and performance (Forsyth et al., 2014). Enrique expressed high motivation and benefited from initiation of routines to promote return to his prior level of function. The Dynamic Interactional Model of Cognitive Rehabilitation explores the relationship among individual, task, and environment, with components of metacognition, personal characteristics, and information processing. The model suggests that a multicontext approach maximizes learning potential (Toglia, 1992).
Compensatory techniques were used to support Enrique’s progress and maximize his independence via adaptive equipment and graded approaches to completing tasks. Biomechanical techniques were used during therapeutic exercise to target range of motion (ROM), strength, and endurance to promote maximal functional abilities. Occupation-based activities were used throughout sessions.
At the time, research on COVID-19–associated respiratory failure and occupational therapy was limited; however, occupational therapy has been shown to be effective for clients recovering from critical illness, including acute respiratory distress syndrome, and in pulmonary rehabilitation (Adler & Malone, 2012; Dinglas et al., 2013). Principles and intervention techniques from previous research were extrapolated to this case.
Intervention
Enrique participated in 1:1, in-person, occupational therapy treatment sessions 3 days/wk for 5 wk. Initially, Enrique reported feeling anxious in the setting of continued isolation precautions, visitor restrictions, and residual psychosocial effects of critical illness. For all intervention sessions, the occupational therapist used a video interpreter via the facility-issued iPad. Enrique’s family participated in emotional support and caregiver training sessions via Facetime on Enrique’s personal phone. Time was allotted at the end of sessions for Enrique to ask questions and verbalize his needs. All treatment sessions were done in Enrique’s room until he was no longer COVID-19 positive. Sessions were then held in the gym while wearing surgical masks when no other clients were present. Activity modification, close monitoring of hemodynamic response to activity, use of compensatory treatment strategies, and client–staff education were integral. Throughout the LTACH course, Enrique and his family participated in multimodal education on critical illness survivorship, post–intensive care syndrome, and associated cognitive and emotional regulation.
Activities of Daily Living
The initial phase of Enrique’s intervention was focused on improving independence with ADL routines, including grooming, bathing, dressing, and toileting. With increased time out of bed, Enrique’s vital signs stabilized, and his cardiopulmonary endurance improved, resulting in increased ability to participate in seated ADL routines. Enrique progressed to transfers using the rolling walker for toileting and was able to complete bathing and dressing while seated. Blocked practice for grooming, bathing, and dressing, as well as overall activity tolerance exercises, energy conservation strategies, and positioning, were incorporated to ensure Enrique’s success in completing tasks (see Table 2). Enrique progressed to modified independent ADL routines and was able to safely discharge home.
Self-Feeding
Enrique had bilateral upper extremity (BUE) weakness, with his proximal joints being weaker than his distal joints, resulting in difficulty with self-feeding. He was cleared by the speech-language pathologist to begin drinking nectar-thick liquids and eating soft foods, such as mashed potatoes, ripe bananas, or diced bread or pasta, with 1:1 assistance on rehab Day 9. The occupational therapist provided Enrique with proximal stabilization at his elbows, a right-wrist cockup splint, built-up spoon, and scoop dish. Using these compensatory techniques, Enrique was able to feed himself 20% of his meal with increased time and moderate assist. The occupational therapist also incorporated targeted active-assisted ROM and active ROM BUE exercises as part of his treatment plan, with a focus on staff training to assist with the exercises outside of occupational therapy sessions. The occupational therapist reassessed Enrique’s BUE strength biweekly with manual muscle testing and a manual dynamometer to ensure appropriate gradation of exercises. As his strength and skills improved, Enrique was able to feed himself at a modified independent level by rehab Day 22 and perform self-feeding without adaptations by rehab Day 32.
Medication Management
The occupational therapist educated Enrique on types of medication management systems to compensate for his ongoing short-term memory impairments. Enrique verbalized his preference to use his smartphone. Enrique’s occupational therapist consulted AOTA’s (n.d.) list of smartphone and tablet applications for medication management and trialed Medisafe Medication Management and Recorder (Medisafe Inc., 2020). Enrique was able to use the app to track and manage his medication without making errors. With Enrique’s permission, the occupational therapist contacted Enrique’s brother and provided him with education on the app and with recommendations for supporting Enrique’s safe medication management upon discharge.
Outcomes
Enrique participated in 5 wk of inpatient occupational therapy, physical therapy, and speech therapy. Enrique demonstrated improvement on all outcome measures (see Table 1) and met his stated long-term goals. At discharge, he was able to complete basic ADLs at a modified independent level and used a rolling walker for functional transfers. He was able to self-feed all meals independently and simulate playing the violin at a seated level for up to 5 min. His family verbalized understanding of adaptive equipment recommendations, rationale for IADL assistance, and plan of care for community reentry. On rehab Day 36 he was discharged home with orders for Visiting Nurse Association services, including occupational therapy, physical therapy, and speech therapy with a plan to transition to telehealth occupational therapy.
Considerations for Occupational Therapy in the Long-Term Acute-Care Hospital Setting
COVID-Related Regulations
Pandemic-related precautions included personal protective equipment (PPE) for clients and staff, reduced client use of communal areas, and social distancing. Occupational therapy practitioners needed to allot extended time for treatments because of increased PPE requirements and coordination with the interdisciplinary team to ensure consistency across the continuum of care.
Adjustment to Illness and Related Functional Impairments
Clients with critical illness experience a wide variety of physical, psychological, and cognitive effects that are debilitating and unfamiliar (Topçu et al., 2017). Occupational therapy practitioners should be sensitive to the potential novelty of these effects when working with clients, family, and caregivers affected by COVID-19–associated critical illness. Younger clients may be more modest during ADLs when working with similarly aged therapists, and psychosocial support is vital (Margetis et al., 2020). At the LTACH level, clients have multiple medical considerations and are significantly deconditioned, requiring increased time and attention by the occupational therapy practitioner to ensure safety and best practice.
Documentation
Many facilities require occupational therapy practitioners to document which PPE items were used during the client interaction. The use of new ICD–10 codes; documentation of respiratory status, recovery, and associated vital signs; and documentation of psychosocial goals can be a newer process for occupational therapy practitioners. It may take increased time and consideration to accurately reflect client status.
Implications for Occupational Therapy Practice
The results of this case report have the following implications for occupational therapy and occupational therapy practitioners:
Occupational therapy practitioners play a key role in facilitating family involvement and addressing psychosocial areas of rehabilitation during increased social isolation in the context of the pandemic.
Existing occupational therapy theoretical frameworks can successfully be applied to the multidimensional sequelae associated with COVID-19.
Addressing meaningful engagement in desired activities is a valuable motivator for clients with critical illness.
Occupational therapy practitioners use their distinct knowledge and skills to address the rehabilitation needs of clients in new and creative ways.
Conclusion
This case report provides an example of how to apply evidence-based occupational therapy services with clients recovering from critical illness resulting from the novel coronavirus disease in the long-term acute care setting. Enrique met his goals and was able to discharge to his home with family support for IADL routines. Special considerations regarding the unique role of occupational therapy include psychosocial impairments, isolation precautions, documentation of new ICD–10 codes, recommended outcome measures, client adjustment to illness and disability, and use of video communication for family participation and language services. Occupational therapy practitioners can use their distinct skill set to address the varied rehabilitation needs of clients recovering from the sequela of COVID-19.
Footnotes
An LTACH is a certified extended-care hospital that provides 24/7 nursing care and daily physician care for clients who are medically stable enough to leave the hospital but have continued elevated care needs.
Acknowledgments
We acknowledge Julie Malloy for her continuous support and guidance throughout this process.