Farha Ikramuddin, MD, MPH, is no stranger to medical complexity.
The chief of the M Health Fairview rehabilitation services, she oversees programs that help people recover from cancer treatment, heart surgeries, and other major health issues. But when COVID-19 patients began entering rehabilitation programs earlier this year, Ikramuddin and other care providers found themselves in uncharted territory.
“We’re not just looking at a disease that behaves like the common cold,” said Ikramuddin, a physiatrist. “We are seeing things that we have never seen before. There are just so many moving pieces to it.”
So Ikramuddin and rehabilitation leaders across M Health Fairview went to work. In April, they formed a multi-disciplinary group of experts to evaluate the recovery needs of each COVID-19 patient leaving hospital care. This assembly of doctors, nurses, specialists, and therapists – called the Post-Acute Centralized Referral Group – convenes for 30 minutes every day to discuss cases and create a rehabilitation “playbook” for each person.
“We had to move quickly to understand the patients and their unique rehabilitation needs,” said Liz Larsen, an occupational therapist and the director of the M Health Fairview Acute Rehabilitation Center. “In my lifetime, I haven’t had a population of patients for whom the landscape is changing so quickly.”
Many people with severe COVID-19 infections face neurological after-effects; significant muscle loss; lingering lung function issues; and damage to the kidneys, liver, and other organs. Some of these issues are due to the prolonged sedation and ventilator care that some COVID-19 patients require. But Ikramuddin compares the after-effects of the disease itself to another often-deadly infection: sepsis.
“Sepsis has a similar mortality rate which involves infection and injury to many tissues in the body,” Ikramuddin said. Emerging research demonstrates that certain proteins in the kidney, liver, and brain seem to attract the virus, Ikramuddin said, which may explain why those organs seem particularly vulnerable in severe cases.
To complicate matters, some COVID-19 patients continue testing positive for the virus 30, 40, or 50 days after the initial infection. This means rehabilitation staff must take many of the same infection prevention precautions as frontline intensive care unit (ICU) teams.
“We don’t really know whether they’re still infectious or not,” said Larsen. “You have to treat them like they are.”
Low lung function is a challenge for patients in recovery, too. Something as simple as brushing your teeth can leave some COVID-19 survivors short of breath, Larsen said.
To make sure each person gets the care they need, rehabilitation specialists begin evaluating patients while they’re still in the hospital. Once they are discharged, patients are referred to one of four different programs. People with significant ongoing medical needs are directed to a Long-Term Acute Care Hospital (LTACH) unit set up at M Health Fairview St. Joseph’s Hospital. Others who still require 24/7 care but have fewer intensive needs are transferred to the inpatient Acute Rehabilitation Center. Patients who don’t need as much medical management enter a COVID-19 transitional care unit (TCU) created at Ebenezer Ridges. Finally, those with the least substantial needs are able to enter M Health Fairview Home Care.
Triaging recovering COVID-19 patients to these different care models falls to the Central Referral Group, spearheaded by Mary Jo Huppert, system director of inpatient care management. What rehabilitation services a patient needs is not always clear-cut, Huppert said, but it’s the role of the group to make an informed decision based on their collective expertise to make sure patients transition to the right level of care.
The end goal is a set of best-practice standards for COVID-19 patient rehabilitation – something that did not exist at the beginning of 2020. This framework will be crucial in the months ahead, as researchers learn more about the long-term health effects of COVID-19.
“How can we be prepared for that as an organization?” Ikramuddin said. “We’re learning it takes a village to manage it.”