To determine the ability of the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" assessments of mobility and activity to predict key clinical outcomes in patients hospitalized with ...coronavirus disease 2019 (COVID-19).
Retrospective cohort study.
An academic health system in the United States consisting of 5 inpatient hospitals.
Adult patients (N=1486) urgently or emergently admitted who tested positive for COVID-19 and had at least 1 AM-PAC assessment.
Not applicable.
Discharge destination, hospital length of stay, in-hospital mortality, and readmission.
A total of 1486 admission records were included in the analysis. After controlling for covariates, initial and final mobility (odds ratio, 0.867 and 0.833, respectively) and activity scores (odds ratio, 0.892 and 0.862, respectively) were both independent predictors of discharge destination with a high accuracy of prediction (area under the curve AUC=0.819-0.847). Using a threshold score of 17.5, sensitivity ranged from 0.72-0.79, whereas specificity ranged from 0.74-0.83. Both initial AM-PAC mobility and activity scores were independent predictors of mortality (odds ratio, 0.885 and 0.877, respectively). Initial mobility, but not activity, scores were predictive of prolonged length of stay (odds ratio, 0.957 and 0.980, respectively). However, the accuracy of prediction for both outcomes was weak (AUC=0.659-0.679). AM-PAC scores did not predict rehospitalization.
Functional status as measured by the AM-PAC "6-Clicks" mobility and activity scores are independent predictors of key clinical outcomes individual hospitalized with COVID-19.
Abstract
Objective
The purpose of this case report is to describe the acute rehabilitation of an individual with severe COVID-19 complicated by myocarditis, focusing on both facility-wide and ...patient-specific strategies.
Methods
A 50-year-old male presented to the emergency department with progressive dyspnea and confirmed COVID-19. He developed hypoxic respiratory failure and heart failure requiring prolonged mechanical ventilation. Mobility was limited by severe impairments in strength, endurance, balance, and cognition. The referral, screening, and rehabilitation of this patient were guided by a COVID-19 Service Delivery Plan designed to maximize the effectiveness and efficiency of care delivery while minimizing staff exposure to the virus. Coordinated physical and occupational therapy sessions focused on progressive mobility and cognitive retraining. Progress was monitored using a series of standardized outcome measures, including the Activity Measure for Post-Acute Care, Timed Up and Go test, and the Saint Louis University Mental Status examination.
Results
Rehabilitation was initiated on day 18, and the patient participated in 19 treatment sessions, each approximately 30 minutes, over the remaining 30 days of his hospital stay. His Activity Measure for Post-Acute Care mobility and function scores both improved from 100% to 0% disability, he experienced substantial improvements in both Timed Up and Go (Δ = 4.2 seconds) and Saint Louis University Mental Status (discharge score = 25). There were no adverse events. He was discharged to home with his family and home rehabilitation services.
Conclusion
COVID-19 contributed to severe declines in mobility and function in this middle-aged man. He experienced substantial gains in his function, mobility, and cognition during his in-hospital rehabilitation, which was guided by a facility-wide plan to prevent virus transmission.
Impact
The rehabilitation of individuals with severe COVID-19 presents significant challenges, both at the level of the individual patient and the whole facility. This report describes clinical decision-making required to manage these individuals in the setting of a global pandemic.
The goal of this case report is to describe the process, challenges, and opportunities of implementing rehabilitation for individuals who were critically ill and required both mechanical ventilation ...(MV) and extracorporeal membrane oxygenation (ECMO) support following a coronavirus 2019 (COVID-19) infection in an academic medical center.
This administrative case report is set in a heart and vascular intensive care unit, a 35-bed critical care unit that provides services for patients with various complex cardiovascular surgical interventions, including transplantation. Patients were admitted to the heart and vascular intensive care unit with either COVID-19 acute respiratory distress syndrome or pulmonary fibrosis for consideration of bilateral orthotropic lung transplantation. The authors describe the process of establishing rehabilitation criteria for patients who, by previously established guidelines, would be considered too ill to engage in rehabilitation.
The rehabilitation team, in coordination with an interprofessional team of critical care providers including physicians, respiratory care providers, perfusionists, and registered nurses, collaborated to implement a rehabilitation program for patients with critical COVID-19 being considered for bilateral orthotropic lung transplantation. This was accomplished by (1) reviewing previously published guidelines and practices; (2) developing an interdisciplinary framework for the consideration of rehabilitation treatment; and (3) implementing the framework for patients in our heart and vascular intensive care unit.
In response to the growing volume of patients admitted with critical COVID-19, the team initiated and developed an interprofessional framework and successfully provided rehabilitation services to patients who were critically ill. While resource-intensive, the process demonstrates that rehabilitation can be implemented on a case-by-case basis for select patients receiving extracorporeal membrane oxygenation and MV, who would previously have been considered too critically ill for rehabilitation services.
Rehabilitating patients with end-stage pulmonary disease on extracorporeal membrane oxygenation and MV support is challenging but feasible with appropriate interprofessional collaboration and knowledge sharing.
Introduction
Frailty at listing for lung transplant has been associated with waitlist and post‐transplant mortality. Frailty trajectories following transplant, however, have been less well ...characterized, including whether recipient frailty improves. The objective of this study was to identify prevalence and risk factors for frailty at discharge and to evaluate changes in frail recipients enrolled in an outpatient physical therapy program.
Methods
This was a single‐center prospective cohort study of lung transplant recipients. Enrollees completed a short physical performance battery (SPPB) to assess frailty at listing and at initial hospital discharge.
Results
Of the 111 enrolled recipients, none were frail at listing and 18 (16.2%) were prefrail. At discharge, however, 60 (54.1%) patients were frail. Discharge frailty was associated with prefrailty at listing, acute kidney injury post‐transplant, and longer intensive care unit stay. Among the 35 patients who were frail at discharge and who were enrolled in an outpatient PT program, the median improvement in SPPB was 6 points (IQR = 5‐7 points), and 85.7% became not frail over a median of 6 weeks.
Conclusion
Discharge frailty is common following lung transplantation. In most frail patients, an intensive outpatient physical therapy program is associated with improvement in frailty, as assessed by the SPPB.
Abstract
Objective
Severe coronavirus disease 2019 (COVID-19) can result in irreversible lung damage, with some individuals requiring lung transplantation. The purpose of this case series is to ...describe the initial experience with the rehabilitation and functional outcomes of 9 patients receiving a lung transplant for COVID-19.
Methods
Nine individuals, ranging in age from 37 to 68 years, received bilateral orthotopic lung transplantation (BOLT) for COVID-19 between December 2020 and July 2021. Rehabilitation was provided before and after the transplant, including in-hospital rehabilitation, postacute care inpatient rehabilitation, and outpatient rehabilitation.
Results
Progress with mobility was limited in the pretransplant phase despite rehabilitation efforts. Following transplantation, 2 individuals expired before resuming rehabilitation, and 2 others had complications that delayed their progress. The remaining 5 experienced clinically important improvements in mobility and walking capacities.
Conclusion
Considerable rehabilitation resources are required to care for individuals both before and after BOLT for COVID-19. Rehabilitation can have a profound impact on both functional and clinical outcomes for this unique patient population.
Impact
There is limited literature on the rehabilitation efforts and outcomes for patients who received BOLT for COVID-19. Occupational therapists and physical therapists play an important role during the pretransplant and posttransplant recovery process for this novel patient population.
Lay Summary
Patients with a bilateral orthotopic lung transplant due to COVID-19 require a unique rehabilitation process. They have significant difficulties with activities of daily living and functional mobility across the pretransplant and posttransplant continuum of care, but progressive gains in functional performance may be possible with a comprehensive multidisciplinary rehabilitation program.
Existing measures of frailty developed in community dwelling older adults may misclassify frailty in lung transplant candidates. We aimed to develop a novel frailty scale for lung transplantation ...with improved performance characteristics.
We measured the short physical performance battery (SPPB), fried frailty phenotype (FFP), Body Composition, and serum Biomarkers representative of putative frailty mechanisms. We applied a 4-step established approach (identify frailty domain variable bivariate associations with the outcome of waitlist delisting or death; build models sequentially incorporating variables from each frailty domain cluster; retain variables that improved model performance ability by c-statistic or AIC) to develop 3 candidate "Lung Transplant Frailty Scale (LT-FS)" measures: 1 incorporating readily available clinical data; 1 adding muscle mass, and 1 adding muscle mass and research-grade Biomarkers. We compared construct and predictive validity of LT-FS models to the SPPB and FFP by ANOVA, ANCOVA, and Cox proportional-hazard modeling.
In 342 lung transplant candidates, LT-FS models exhibited superior construct and predictive validity compared to the SPPB and FFP. The addition of muscle mass and Biomarkers improved model performance. Frailty by all measures was associated with waitlist disability, poorer HRQL, and waitlist delisting/death. LT-FS models exhibited stronger associations with waitlist delisting/death than SPPB or FFP (C-statistic range: 0.73-0.78 vs. 0.57 and 0.55 for SPPB and FFP, respectively). Compared to SPPB and FFP, LT-FS models were generally more strongly associated with delisting/death and improved delisting/death net reclassification, with greater improvements with increasing LT-FS model complexity (range: 0.11-0.34). For example, LT-FS-Body Composition hazard ratio for delisting/death: 6.0 (95%CI: 2.5, 14.2), SPPB HR: 2.5 (95%CI: 1.1, 5.8), FFP HR: 4.3 (95%CI: 1.8, 10.1). Pre-transplant LT-FS frailty, but not SPPB or FFP, was associated with mortality after transplant.
The LT-FS is a disease-specific physical frailty measure with face and construct validity that has superior predictive validity over established measures.
We evaluated the feasibility, safety, and efficacy of a mHealth‐supported physical rehabilitation intervention to treat frailty in a pilot study of 18 lung transplant recipients. Frail recipients ...were defined by a short physical performance battery (SPPB score ≤7). The primary intervention modality was Aidcube, a customizable rehabilitation mHealth platform. Our primary aims included tolerability, feasibility, and acceptability of use of the platform, and secondary outcomes were changes in SPPB and in scores of physical activity, and disability measured using the Duke Activity Status Index (DASI) and Lung Transplant‐Value Life Activities (LT‐VLA). Notably, no adverse events were reported. Subjects reported the app was easy to use, usability improved over time, and the app enhanced motivation to engage in rehabilitation. Comments highlighted the complexities of immediate post‐transplant rehabilitation, including functional decline, pain, tremor, and fatigue. At the end of the intervention, SPPB scores improved a median of 5 points from a baseline of 4. Physical activity and patient‐reported disability also improved. The DASI improved from 4.5 to 19.8 and LT‐VLA score improved from 2 to 0.59 at closeout. Overall, utilization of a mHealth rehabilitation platform was safe and well received. Remote rehabilitation was associated with improvements in frailty, physical activity and disability. Future studies should evaluate mHealth treatment modalities in larger‐scale randomized trials of lung transplant recipients.
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