When Physical Medicine and Rehabilitation Became Medicine-Life in the Time of Coronavirus Disease of 2019.

To the Editor:

The first coronavirus disease of 2019 (COVID-19) infection was reported in New York State on March 1, 2020; the first person died from COVID-19 infection in New York City on March 14, 2020. The number of COVID-19+ cases in New York City was increasing, and on March 12, a total of 358 cases were reported. It soon became clear that most of our hospitals would be devoted to care of COVID-19 patients. To ensure that adequate acute care beds would be available for the surge in patients, we made the decision to stop accepting referrals to our 20-bed acute inpatient rehabilitation unit and discharge the remaining patients as safely and quickly as possible. On March 12, we admitted the last patient for acute rehabilitation to our unit. Daily COVID-19 admissions to New York City hospitals quickly escalated (https://www1.nyc.gov/site/doh/covid/covid-19-data.page): on March 12, NYC hospitals admitted 75 patients. On March 19, hospitals admitted 512 patients and by March 24 daily admissions had increased to 1045. Admissions continued to increase and on March 30 had reached a new daily high of 1565.

Initially, the plan was for internal medicine and other services to admit and care for non-COVID positive patients on our unit. However, with the rapid influx of patients and critical need for physicians, we were asked by hospital administration to consider running a medical unit on our floor; we agreed and our acute rehabilitation unit was transitioned to a medical unit.

The initial plan was to transfer non-COVID+ patients who were medically stable to our unit for postdischarge planning. Leveraging and using our experience and infrastructure on matters related to disposition, we were able to efficiently and quickly discharge these patients. However, as the hospital began to exceed capacity and additional intensive care units (ICUs) were opened, the medical service began transferring patients requiring active medical management to our unit where we assumed their care. We also started accepting low-acuity admissions—of both COVID negative and positive patients—directly from the emergency department as requested. Along with the patients we were covering on our floor, other available rooms in the rehab unit started to be filled with COVID+ patients who were being taken care of by medicine services. As the need for medical residents and staff became greater in the ICUs, we began caring for COVID+ patients with less severe symptoms.

As the hospital’s needs continued to evolve, we were asked to accept critically ill patients from our ICUs, on ventilators. All of these patients had been seen by our palliative care team before transfer and goals of care were clearly delineated. These were patients who were not expected to survive and no longer required the interventions only available in an intensive care setting. Palliative continued to consult on all these patients and were instrumental in the care plans. An advantage for these patients was the ability to allow visitation by loved ones before death. Visitors were limited to one at a time, and they had to be healthy as well as wear masks and other appropriate protective gear. Visitors could not be allowed in our ICUs because of the sheer volume of critical work by staff and the high likelihood of COVID-19 exposure.

In addition to managing medical patients on our unit and covering a busy in-house physical medicine and rehabilitation (PM&R) consult service, some PM&R residents volunteered to work on the medicine wards or ICU with COVID+ patients. PM&R residents and attendings also staffed the COVID screening annex of our hospital’s emergency department. PM&R resident work hours were adjusted and coordinated with medicine so as to stay well within Accreditation Council for Graduate Medical Education duty hour guidelines. Despite busy and ever-changing clinical demands and varying schedules, we have been able to continue our PM&R didactics by shifting to guided independent study.

Some lessons and points we would like to share with other PM&R departments during this pandemic are as follows: it is crucial to establish a formal and robust procurement process for personal protective equipment for physiatrists who are working with COVID+ patients. Close communication with internal medicine, their subspecialties, and other services such as palliative care has been key to the successful transfer of patients from the medical services to the care of the PM&R services. The transfer protocol included a detailed handoff with a clearly delineated plan of care before transfer or admission of medical patients to a physiatry service. Patients with higher medical acuity should remain under the care of the medical service, and therefore, appropriate triaging is critical. The spirit of teamwork within physiatry is of great benefit when taking care of any patient, but especially so for medical patients. Interestingly, we have also found that a thorough physiatric history and physical examination, assessment, and plan are extremely effective tools and resources even when applied to the care of nonrehabilitation medical patients.

As of April 15, there seems to be a plateau in COVID admissions in New York City hospitals including ours. However, as with everything else about this novel human coronavirus, there is uncertainty about the future and we have not yet made plans to transition back to running an acute inpatient rehabilitation unit.