– Response to the COVID-19 Pandemic Among Posthospital Brain Injury Rehabilitation Providers

Abstract

Rehabilitation after significant acquired brain injury (ABI) to address complex independent activities of daily living and return to family and community life is offered primarily after initial hospitalization in outpatient day treatment, group home, skilled nursing, and residential settings and in the home and community of the person served. The coronavirus 2019 pandemic threatened access to care and the health and safety of staff, persons served, and families in these settings. This article describes steps taken to contain this threat by 7 leading posthospital ABI rehabilitation organizations. Outpatient and day treatment facilities were temporarily suspended. In other settings, procedures for isolation, transportation, cleaning, exposure control, infection control, and use of personal protective equipment (PPE) were reinforced with staff. Visitation and community activities were restricted. Staff and others required to enter facilities were screened with symptom checklists and temperature checks. Individuals showing symptoms of infection were quarantined and tested, as possible. New admissions were carefully screened for infection and often initially quarantined. Telehealth played a major role in reducing direct interpersonal contact while continuing to provide services both to outpatients and within facilities. Salary, benefits, training, and managerial support were enhanced for staff. Despite early outbreaks, these procedures were generally effective, with preliminary initial infections rates of only 1.1% for persons served and 2.1% for staff. Reductions in admissions, services, and unanticipated expenses (eg, PPE, more frequent and thorough cleaning) had a major negative financial effect. Providers continue to be challenged to adapt rehabilitative approaches and to reopen services.

List of abbreviations:

ABI (acquired brain injury), CDC (Centers for Disease Control and Prevention), COVID-19 (coronavirus disease 2019), PPE (personal protective equipment), SO (significant other)

The novel 2019 coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, can present with a wide array of symptoms and coronavirus disease syndromes. Since the pandemic onset, the wealth of articles and case descriptions present a picture of disease that can affect nearly all major organ systems. There is increasing attention to neuroinvasive presentations as well that include a continuum of vague neurologic symptoms to discrete neurologic syndromes.¹^,²^,³Mao et al ⁴detailed subgroups of COVID-19 neurologic manifestations centered around central nervous system, peripheral nervous system, and skeletal muscular injury. Estimates suggest that from a quarter to one-third of individuals hospitalized with COVID-19 may develop neurologic symptoms, with neuroinvasive presentations being linked to more severe COVID-19 cases. ¹^,⁴The preferential effect on neuroanatomic structures may include brain stem regions linked to regulatory functions, such as respiration and cardiac function, possibly exacerbating the disease course. ⁵^,⁶More discrete neurologic complications can include stroke, even in persons with few if any risks factors, and seizures. ¹^,²Additionally, the potential for residual encephalopathy syndromes, long-term hypoxic/anoxic effects and post–intensive care unit syndrome raises concerns that the number of individuals with more severe forms of COVID-19 could have significant rehabilitation needs during the subacute recovery stage and even across the lifespan. ²^,⁷Thus the COVID-19 pandemic challenges rehabilitation providers both to manage the spread of the disease among the people that they presently serve and to consider the potential future rehabilitation needs of those who have recovered from severe forms of the infection.

Over the last several decades, the duration of both acute medical and inpatient rehabilitation hospital stays after significant acquired brain injury (ABI) have declined markedly. In most cases, inpatient rehabilitation extends for only 2-3 weeks, with a focus on addressing basic self-care and equipping the patient and family to transition out of the hospital either to home or to a less medically intensive care facility. Rehabilitation to address limitations in more complex instrumental activities of daily living, cognition, behavior, and other barriers to return to participation in family and community life is currently offered by specialty posthospital rehabilitation organizations. These organizations provide rehabilitation in a range of settings including residential, skilled nursing, group home, outpatient, and day treatment facilities, as well as home and community in which services are provided in the personal residence of the person served. Services range from intensive rehabilitative and behavioral interventions with a goal of significantly improving the functional status of the person served to assistive services designed to maintain gains made previously in more intensive rehabilitation and the current level of community participation. Braunling-McMorrow et al ⁸provide further detail about current practice in posthospital ABI rehabilitation.

Predicting the extent of potential rehabilitation needs stemming from the COVID-19 pandemic is challenging. Nonetheless, consideration of potential treatment options and providers to manage the complexity of the neurologic and rehabilitation needs of individuals with ABI who contract COVID-19 appears warranted. Given the limited length of stay for inpatient rehabilitation, it is likely that any additional needs for intensive rehabilitation for these individuals will be met by posthospital rehabilitation organizations.

The COVID-19 pandemic challenged these organizations to develop innovative methods for continuing to provide services while protecting the health and safety of persons served, their families, and staff and managing financial budgets based on prepandemic planning. Individuals with ABI are particularly vulnerable to infection by COVID-19 because of cognitive and behavioral limitations that could compromise their ability to comply with precautionary measures to decrease risk of infection. Many are also more vulnerable to the effects of infection because of multiple comorbidities associated with ABI. ⁹

Because the reality of the pandemic dawned suddenly, posthospital ABI rehabilitation organizations were compelled to make major modifications to their procedures in a very short period of time. Although these organizations have experience in infection control, the high contagion rate and insidious nature (ie, asymptomatic carriers) make COVID-19 control particularly challenging. Organizations contributing to this article addressed the challenges posed by the pandemic independently with variable guidance from federal and state public health authorities. However, across organizations, considerable consistency and consensus emerged. This article summarizes the consensus of leading posthospital ABI rehabilitation organizations regarding suggested and recommended practices in response to the COVID-19 and similar future pandemics. At the time this article is being published, many of the practices described in this article have been widely adopted throughout health care. Nonetheless, these procedures and their effectiveness in postacute ABI rehabilitation have not been previously presented in the professional literature and are offered here as a potential guide for postacute facilities in regions not yet extensively affected by COVID-19, for reference in the event of future similar health crises, and to document their effectiveness.

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