By Brian Peers, VP Clinical Services and Provider Management, MedRisk
About 50 percent of patients who survive treatment in an intensive care unit–think COVID-19 patients on ventilators–will experience some form of post-intensive care syndrome or PICS, according to the American Thoracic Society.
The term PICS refers to “new or worsening impairments in physical, cognitive, or mental health status arising after critical illness that continue after acute care hospitalization,” according to a Home and Community-Based Physical Therapy Management of Adults with Post-Intensive Care Syndrome study.
The study’s authors were already examining how physical therapy could address some PICS symptoms before COVID-19 struck. They quickly pivoted to tailor the study to reflect COVID-19 survivors. The Physical Therapy Journal fast-tracked their paper and published it in April 2020.
The majority of adults with PICS, including those who are young or middle aged, struggle with slow-to-resolve physical problems. Not restricted to COVID-19 patients, these can happen with anyone who is hospitalized for more than five days, especially those who land in intensive care. Some COVID-19 patients remain on ventilators for 10 to 23 days. Being on a ventilator magnifies the symptoms and leaves the lungs in poor condition.
The after-effects of COVID-19 are on a wide spectrum. People recovering from a mild case may feel sluggish and experience some breathing difficulty. Those who suffered a severe case may be too weak to get out of bed without aid. Patients experiencing periods of prolonged ventilation may have lung damage, respiratory and cardiovascular issues, and neurological problems.
The Essential Role of Home- and Community-Based Physical Therapists During the COVID-19 Pandemic article, also in PTJ’s April issue, stressed that the pandemic’s increased strain on short-term, post-acute care facilities means that more patients will be discharged directly from hospitals to their homes and could have a high risk of readmission. “Two robust risk factors for hospital readmission are impaired physical function and unmet need for activities of daily living,” it said. Physical therapy and occupational therapy can mitigate those risks.
The longer a patient is immobile, the more prone they are to deconditioning, defined as a general deficit of strength and endurance. Muscle wasting and weakness, pain, and fatigue along with difficulty breathing, balance, and walking are common. In severe cases, patients cannot shower or get dressed by themselves or perform other activities of daily living.
Mental health symptoms associated with PICS range from mild anxiety and irritability to severe depression and post-traumatic stress syndrome. Memory, problem-solving, and organizational abilities have been affected in some cases.
An issue particularly pertinent to workers’ compensation is PICS’ effect on return to work. The home- and community-based physical therapy study said, “The influence of PICS and ongoing healthcare utilization can impact joblessness and associated lost earnings.”
Those researchers examined a multi-site, prospective study of patients who survived acute respiratory distress syndrome (ARDS), which is associated with severe COVID-19 cases. Approximately one-third of ARDS survivors were not able to drive or return to work within 12 months.
The study’s authors calculated the jobless rate among previously employed ARDS patients at 67 percent three months after they left the hospital. Jobless rates were 40 percent at the one-year mark and 33 percent at 60 months post discharge.
Many of those who did return to work faced subsequent job losses, decreased work hours, or changes in in occupation. The paper suggested that the inability to return to work might result from cognitive or mental health changes associated with the illness and called for appropriate screening.
It’s important to identify all claims with lengthy hospital stays and determine if the patients were treated in ICU and have them evaluated by a physical therapist (PT). PTs assess the person’s physical condition, probing for deficits in strength, mobility, endurance, functionality, and general movement. They compare the patient’s current capabilities to those required by the job description, which hopefully outlines the physical demands and frequency of routine tasks. Depending on the case, a Functional Capacity Evaluation may be requested.
Then, the PT designs and implements a comprehensive rehabilitation program to restore functionality and strength so the patient can safely perform their job duties. Additionally, a pre-treatment consultation with a PT who is trained to detect psychosocial issues can help the claims representative prevent return-to-work delays. Keep in mind that both COVID-19 and PICS are associated with cognitive and mental health issues.
The treatment team may include an occupational therapist (OT) to help the patient regain the ability to perform activities of daily living and improve their quality of life. If the patient cannot return to the original job, OTs help them learn new job skills.
In some cases, patients may start with a PT and progress to an OT. For example, someone with PICS might work with a PT to build back muscle strength and mobility. Later they could see an OT to practice basic skills impaired by the illness and immobility, such as, bathing, dressing, eating, and driving.
Naturally, the exercise-based rehabilitation program should be individualized to the patient’s condition and position in the workplace. A postal carrier who walks 10 miles a day needs a different program than an accountant who sits at a desk most of the time or a warehouse worker who lifts heavy boxes overhead. As the patient recovers, this comprehensive, person-centric program can equip the employee to safely resume their specific job duties.
That said, most programs include cardiovascular exercise and strength training with weights and machines. Prescriptive cardiovascular training with the PT monitoring blood pressure, heart rate and oxygen levels while the patient uses a bike or treadmill gradually and safely builds endurance, strength, and aerobic capacity.
Leg exercises will be employed to restore strength to leg muscles to reduce the demand on the heart and lungs. It’s possible for some patients to take advantage of telerehab for part of the physical therapy.
Ideally, the patient will receive treatment for any cognitive or mental health issues during this period of physical rehabilitation. Accelerating the recovery of PICS patients calls for coordinated care management and an interprofessional team of providers, including the treating physician, PT, OT, other medical specialists, and any mental health provider.
Workers’ compensation does not typically cover community-spread illnesses like a cold or flu because they cannot be causally linked to exposure in the workplace. With COVID-19, though, multiple states have created presumptive laws and regulations. This means people holding certain positions, usually first responders and healthcare workers, do not have to prove they contracted the virus at work. A few states, including Illinois and Kentucky also included workers from grocery stores, laundries, banks, hardware stores, childcare centers, and domestic violence shelters under COVID-19 presumptions.
Health Strategy Associates’ second survey on the impact of COVID-19 on workers’ compensation showed that the 24 payers surveyed had accepted 6,600 COVID-19 claims – roughly one-fifth of those filed – as of May 28, 2020. The World Health Organization predicts that 80 percent of COVID-19 cases will be mild, but 15 percent will require hospitalization. The Respiratory Pathophysiology of Mechanically Ventilated Patients with COVID-19: A Cohort study, accepted for publication by the American Thoracic Society Journal, indicates that five to 20 percent of hospitalized patients will end up in the ICU.
This aligns with results of Health Strategy Associates’ survey, where respondents indicated most coronavirus claims’ costs were relatively low, but a few have incurred costs of more than $200,000 because of ICU and ventilator treatment. It is too soon to report the total medical costs of most of the severe cases because treatment is ongoing.
The virus continues to infect people and some of them will become critically ill, hospitalized, and possibly ventilated. Payers and providers should prepare to see an increased need for specialized care, including physical and occupational therapy, to manage PICs.
About Brian Peers
Brian Peers is a licensed physical therapist and serves as MedRisk’s Vice President of clinical services and provider management. He is responsible for overseeing and ensuring the quality of MedRisk’s centralized telerehabilitation services, as well as MedRisk’s platinum grade clinical review and peer-to peer provider coaching program. He is board certified as an orthopedic clinical specialist and is recognized as an expert in rehabilitation of the injured worker. Prior to joining MedRisk, Dr. Peers was the owner and operator of an interdisciplinary rehab practice and has held faculty appointments at multiple physical therapy education programs. He has also served as an injury prevention consultant for multiple large corporations and the United States Department of Defense. Dr. Peers holds Bachelor’s and Master’s degrees from St. Francis University, an additional Master’s degree from Louisiana State University and a Doctorate from the University of St. Augustine.
Based in King of Prussia, Pennsylvania, MedRisk is the largest managed care organization dedicated to the physical rehabilitation of injured workers. One of the Inc. 5,000 fastest growing privately held companies for 13 consecutive years, MedRisk counts over 272,000 providers in its network and serves almost 550,000 injured workers every year.
It holds direct contracts with more than 90 percent of the nation’s top workers’ compensation insurers and third-party administrators.
MedRisk, which has successfully completed a SSAE 18 SOC Type 1 and 2 examination, ensures high quality care and delivers outstanding customer service. To that end, all customer service professionals, healthcare advocates and physical therapists are based in the U.S. For more information, visit www.medrisknet.com or call 800-225-9675.
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