One way to get patients back on their feet after COVID19 infection

Coronavirus disease 2019 (COVID-19) has dramatically affected global society and it is unclear when its effects will subside. There have been over 500,000 deaths and 13.5 million documented infections as of the 15^th July. The UK has seen over 45,000 deaths and over 291,000 documented cases (1). Although a large number of cases have a self-limiting illness, a significant proportion become critically ill, with 13,132 patients admitted to UK critical care units as of 10^th July. Of these 5,985 have been discharged alive, with a subsequent surge in demand for rehabilitation projected to follow.  Following a critical care admission, individuals frequently suffer from deconditioning, psychological symptoms and have a reduced functional status that can take significant time to recover (2).

Current post ITU rehabilitation standards and barriers

The National Institute of Health and Care Excellence recommends that patients who have a critical care admission greater than four days, receive information about rehabilitation at discharge, arrangements for ongoing rehabilitation and follow up at 2-3 months, to identify and address ongoing recovery needs (3). The need for holistic rehabilitation of COVID-19 survivors has been identified as a major challenge facing heath care providers (2). There have also been suggestions of increased multi-disciplinary working including Respiratory and Sports and Exercise Medicine specialties to help individuals recover from COVID-19 (4).

Ordinarily, physical rehabilitation might take place through community physiotherapy and involve face to face contact. However, clinical services across the UK have been forced to limit the amount of face to face work they perform due to the Government’s social distancing measures. This may present a barrier to rehabilitation in this group of patients and a strain on rehabilitation services.

The wearable based COVID19 remote rehabilitation MDT

In an attempt to overcome these barriers, the Critical Care department at Worthing Hospital (UK), along with The University of Brighton are piloting the use of smartwatches (FitBit) given to patients at discharge to augment rehabilitation. At discharge, physical assessments and baseline characteristics are assessed to guide delivery of an individualised exercise plan. Patients are provided with information about the smartwatch and how to increment activity. Data from the smartwatches are then monitored remotely and reviewed monthly by a team, with the following members;

• Respiratory and Critical Care Physiotherapists
• Respiratory Medicine Consultants
• Critical Care Doctors
• GPs with interest in Sports and Exercise Medicine
• Exercise Physiologists

For each patient the following areas are reviewed;

• Daily sedentary time
• Daily time at low, medium and high exercise intensities
• Daily step count
• Daily resting heart rate
• Clinical progress including symptoms or reported barriers

Following this, a plan for the next month is formulated for each patient that might including continuing their current plan, a phone call to review or alter exercise plans or a review in a face to face clinic if required. This process has allowed socially distant reviews using real time daily data from patients and has proved to be time efficient.

Further applications and conclusions

• The efficacy of this process is being compared to standard care in other local hospitals and the experience of patients, carers and professionals is being evaluated as part of a research study which is aiming to produce reports at 3 and 12 months.
• If it is found to be effective, we hope it could form a model for rehabilitation following ITU admission and may have applications in pulmonary and cardiac rehabilitation.

Authors:

Daniel Fitzpatrick; University of Brighton, St Georges University Hospitals NHS Foundation Trust

Ana-Carolina Gonçalves; Worthing Hospital, Worthing

Alexander Hunter Worthing Hospital, Worthing

Alan Richardson University of Brighton

Christina Koulouglioti Worthing Hospital, Worthing

Benjamin Hardy Worthing Hospital, Worthing

Todd Leckie Worthing Hospital, Worthing

Luke Hodgson Worthing Hospital, Worthing

Competing interests

This study has received funding from the British Association of Sports and Exercise Medicine and the University of Brighton. FitBit UK provided several FitBit Devices for the study.

References

1. Intensive Care National Audit and Research Centre. ICNARC report on COVID-19 in critical care [Internet]. 2020.
2. Barker-Davies RM, O’Sullivan O, Senaratne KPP, Baker P, Cranley M, Dharm-Datta S, et al. The Stanford Hall consensus statement for post-COVID-19 rehabilitation. Br J Sports Med. 2020 May 31;0:bjsports-2020-102596.
3. Overview | Rehabilitation after critical illness in adults | Guidance | NICE [Internet].
4. Faghy MA, Ashton RE, Maden-Wilkinson TM, Copeland RJ, Bewick T, Smith A, et al. Integrated sports and respiratory medicine in the aftermath of COVID-19. Lancet Respir Med. 2020 Jul 9;0(0).