Advances in Rehabilitation Medicine

Dr. Leroy R. Lindsay

Throughout the pandemic, physicians in the Department of Rehabilitation at NewYork-Presbyterian/Weill Cornell Medical Center continued to learn more about the recovery of critically ill patients who had COVID-19. These patients shared many of the physical, psychological, and cognitive challenges typical of recovering critical care patients, including generalized deconditioning, pulmonary dysfunction, loss of mobility, and difficulty with activities of daily living. To address their post ICU/post-intubation recovery, the Department created a 30-bed COVID-19 Recovery Unit, previously an inpatient behavioral health service, to provide a multidisciplinary, comprehensive treatment model emphasizing the medicine, rehabilitation, and neuro-psychological needs of patients.

“The COVID-19 Recovery Unit was a unique and collaborative effort undertaken primarily by the Department of Rehabilitation Medicine and the Department of Internal Medicine with the primary focus on managing the medical condition of these patients, and at the same time, providing the appropriate level of rehabilitation services. That was our initial premise,” says Leroy R. Lindsay, MD, Director of Rehabilitation Medicine Consult Services at Weill Cornell. “Beyond that, we wanted to create programming and a pathway for patients to meet their needs as we learned more about how COVID would affect each individual. We were hoping to start to see a pattern where people might need additional focus or attention medically, socially, or disposition wise. Those are the things we thought about in the formation of this unit and as it evolved.”

A team of physicians from hospital medicine, neurology, nephrology, pulmonology, physical medicine and rehabilitation, psychiatry, psychology, and integrative health – along with partners from nursing, nutrition, social work, and care coordination, conceptualized the acute care unit that would integrate needed medical care with early rehabilitative therapy and extra support for psychosocial complications.

Understanding the COVID-19 Phenotype

Initially, Dr. Lindsay and his colleagues assumed the unit would be targeted toward a respiratory or pulmonary type of rehabilitation and considered using the model of pulmonary or cardiac rehabilitation. “But we started to see that there were a number of other organ systems that were affected, and it was not always that the patients were going to be in high oxygen need,” explains Dr. Lindsay. “Some had very minimal oxygen requirements and others had more neurologic conditions – neuropathy of different types, unclear etiology of weakness, or a combination therein. So, we examined each patient to find out what those specific deficits would be, how they would manifest, and how they might only present once we attempted to mobilize and move the patient through the spectrum of care.”

“It took a bit of work to figure out how we were going to balance the medicine and rehab portions of their care because when these patients arrived at the unit, they were still very sick,” says Kaile Eison, DO, then chief resident, Department of Rehabilitation Medicine at Weill Cornell, who volunteered to be assigned to the new unit. “Some patients were on high levels of oxygen, some were delirious, and others were on dialysis. There was a lot of medical complexity.”

Dr. Lindsay describes the range of clinical presentations as a COVID-19 phenotype in that some individuals exhibited a ferocious response to the virus and in an attempt to clear the infection, they would suffer secondary injury to different systems. “In reviewing data, we were typically seeing the pulmonary patient who needed supplemental oxygen and patients with neurologic deficit, whether it be brachial plexus injury or foot drop and the need for bracing,” he says. “There were patients who had kidney failure, clotting, stroke, or needed amputations, and patients who underwent all of the above. There were also those who had cognitive impairment but unclear if it related to a true central nervous system condition, some inflammatory process, or from being intubated, sedated, and isolated for a protracted period of time. It depended on how aggressively the body responded to the amount of inflammation that was happening and whether or not the patient was going to have minimal morbidity or more serious consequences.”

Filling the Vacuum of Community

Dr. Lindsay notes that what was quite surprising and, indeed alarming, was the amount of psychological and psychiatric conditions they observed. “A number of patients would describe being alone for a prolonged period of time in the ICU,” he says. “As patients became more aware of what was going on, they wanted to be around people, to hear the human voice, so when they arrived on our unit, one of our early initiatives was how could we get them out of their room and engage with people? How could we get them talking about some of their experiences that were still very real?”

As Dr. Lindsay explains, devoid of family support and whisked away to a hospital and possibly transferred to another hospital, these gravely ill patients were left with little information about what was happening to them. “So very commonly, there was a vacuum of communication and a vacuum of community,” he says.

On the COVID-19 Recovery Unit, patients experienced stability as the unit was created exclusively for them. “From the outset, it was designed to be an open space or at least as accessible as possible for the spectrum of care,” says Dr. Lindsay, who notes that there was a mix of patients who were still PCR positive and some who were now PCR negative. “We found it to be very therapeutic with roommates who could say, ‘Hey, when I came in, I couldn’t do what you’re doing right now either, so be encouraged.’ There was a therapeutic benefit to creating this space which allowed patients to speak and get feedback and have specific point people to contact with questions.”

The clinical team created programming that included a cognitive rehabilitation workshop led by a neuropsychologist, meditation, yoga – activities that would be considered extracurricular from the traditional rehabilitation model. “We thought this would be greatly appreciated by a population that had been alone and already survived something that many had not, giving them a forum to escape to or not, to share or not, and to just allow them to know that we were listening and that we cared,” says Dr. Lindsay.

“We also assembled a gym on the unit for the higher-functioning patients who were able to participate a little bit more in therapy services,” says Dr. Eison, who helped to create a similar COVID-19 recovery unit at NewYork-Presbyterian/Columbia University Irving Medical Center.

While the COVID recovery team focused on patients’ specific needs, every day featured a set of uniform activities:

• Structured group and individual therapy opportunities
• Rest and mealtimes
• Unstructured socialization opportunities
• Activities to support community reintegration
• Bed-to-chair focus

“Our hope is that this structure provided some comfort to patients, especially in the midst of so much uncertainty,” says Dr. Lindsay.

Dr. Lindsay and his Weill Cornell colleagues described the creation of the unit, their observations, and lessons learned in an article published in the May 29, 2020 issue of NEJM Catalyst: Innovations in Care Delivery.

On August 20, 2020, the COVID-19 Recovery Unit discharged its last patient before closing. “The emotional, psychological component cannot be ignored, and the constraints that we’ve put in place to limit communication and to limit PPE use, while functional, have their own secondary costs and should be reevaluated constantly,” says Dr. Lindsay. “This pandemic created an environment where we realized we needed to keep each other informed and to encourage and assist. The collaborative opportunities were invaluable. Those are some of the lessons that I’ve taken from this experience and that inform how we care for patients going forward.”