In this issue, we talked to Dr. Pablo Celnik at Johns Hopkins University in Baltimore, MD. Dr. Celnik works at the university as the Department Director of Rehabilitation. During the initial outbreak, Dr. Celnik worked with his department on redeploying staff and reorganizing the care management process for acute and inpatient rehabilitation of patients with COVID-19. The following article is based on his experience as of October 2020.
Pablo Celnik, MD, FAAPMR
Director, Dept. of Physical Medicine and
Rehabilitation, Johns Hopkins Medicine
Physiatrist-in-Chief, The Johns Hopkins Hospital
Co-Director, Sheikh Khalifa Stroke Institute
Rehabilitation traditionally has been thought of as a process that starts after the acute medical illness is taken care of. After the acute medical situation dwindles, rehab kicks in. We at Johns Hopkins are a strong proponent that we should move rehabilitation interventions earlier in the process. As Department Director of the Department of Rehabilitation, this meant that a lot of my work during the initial surge of the COVID-19 pandemic was reorganizing the department and ensuring that patients got the proper care that they needed early on, without waiting for an admission to the rehabilitation facility.
In Maryland, like the rest of the country, we had a significant first wave of COVID-19. It wasn't as crazy as others and we were not reaching the point of being overwhelmed the way that New York, New Jersey, Massachusetts, etc., were. We captured patients with COVID-19 through all five different hospitals in the Johns Hopkins network, including transfers from neighboring states when their own hospitals were maxing out the number of patients.
Johns Hopkins is known for its ICU rehabilitation programs, which was crucial as the number of our MICUs grew from one to six to keep up with the number of patients we were seeing. This brought with it a number of challenges. Other than having to figure out how we would provide the same level of ICU rehabilitation for COVID-19 patients, we also needed to redeploy our specialists to follow in the medical units those patients debilitated after being discharged from the ICUs. This reorganization led PM&R to follow approximately 70% of all COVID-19 patients admitted to Johns Hopkins Hospital.
In the acute hospital, we categorized patients depending on the level of function. Those people who came with a baseline low level of function (e.g., from nursing homes) received typical care; whereas those patients who lost function due to COVID-19 were put on an aggressive, high intensity rehabilitation program delivered by a physiatrist, together with therapists and psychologists due to the confusion and cognitive abnormalities we were seeing. We really beefed up our rehabilitation services here!
At the same time, we created our COVID-19 inpatient rehabilitation units. As long as the patients were cleared from COVID-19, we were able to admit them in our regular inpatient units, since managing these patients did not require a HEPA filter or negative pressure. Those patients that were ready for rehab but remained positive for COVID-19 were managed in a negative pressure unit. For this group, we took our inpatient rehab team to a specialty unit to do what we call "extended ACIR." In this way, we were able to provide rehabilitation care for all patients - those with COVID-19 who were in the ICU, in the medical unit, those people who were ready for inpatient rehabilitation but required negative pressure units, as well as for those who needed the traditional "bread and butter" inpatient rehabilitation.
To complete the spectrum of care, we created what we called the PACT or Post-Acute COVID Team clinic. This team uses telemedicine to follow all the patients discharged from Hopkins with COVID-19. Standard procedure was to monitor all patients within a week of discharge via a telehealth visit. This is run by a physiatrist and a critical care medicine doctor to ensure safe transfer home, symptoms, etc.
The reorganization in the acute hospital and its continuity clinic put rehab on steroids. We became an extremely prominent team where, typically, the acute management in the acute hospital was by pulmonary folks or critical care medicine doctors or internal medicine docs. Our rehab team was working parallel with them.
Overlapping the two teams provided all the care for these patients. On the other hand, from a specialty standpoint, it was a very exciting opportunity for us to demonstrate all the things rehabilitation can do in the hospital. Our COVID-specific teams got to show off what PM&R does - and the response was fantastic. The ICUs knew us because of our history with ICU rehab, but in the Department of Internal Medicine, as we were transferring people in the unit, they discovered the role of rehabilitation in a way that they did not fully comprehend before this experience. You know, what we can provide for these patients. It was enlightening for them and super engaging for us.
What we've done, ultimately, is grown our rehab team, demonstrated the value of the physiatrist and expanded through the entire continuum from the hyperacute stage in the ICU all the way to the inpatient rehab unit. In that way, COVID-19, terrible as it is, provided an incredible opportunity for rehabilitation. And it isn't one that is limited to our hospital.
Changing the equation in the care continuum process is necessary. Physiatrists need to engage earlier, assess the patient, work together with the primary team, work together with therapists and so on to start rehab activities early in the acute hospitalization. We bring significant value to the rest of the medical community, for instance reducing deconditioning and functional decline. Sure, some of my colleagues may say maybe we are reducing the need for patients to go to the rehabilitation units if we deploy rehabilitation earlier. But if we are doing rehabilitation, we're doing rehabilitation, the business will not dry up.
In fact, I think what we are doing is enlarging the pie by now taking care of many patients in the acute hospital. And there will always be some patients that need to go to the inpatient unit. So, I don't think we are threatening our business. By engaging earlier, we are bringing up the value of the rehabilitation professional. In this way, we help the patients and we are helping the other teams.
Why rehab doctors and not somebody else? I'm going to tell you something that became very evident for us in the context of COVID-19 patients. Patients would be admitted to the ICU and transferred to the MICU unit, then they would go through the other intermediate levels of care or rehab floor. There were different teams and different doctors when we were involved. One thing that the primary team doctors would appreciate is that we were the same rehab doctor following the patient longitudinally through the continuum.
Physiatrists bring a different level of connectivity across the entire hospitalization for the patient and for the other medical teams and therapy teams. That is unique to what we do. For those patients who were sick and debilitated, we became the glue across the many different levels of their care.
People have made a lot of comparisons between COVID-19 to the flu of 1918, but there in the flu either you die or you leave. We don't talk about the people in the middle.
In my opinion this pandemic is much more interesting to be compared to the polio pandemic of the 1930s. This is where some people die, but many more became disabled. That's where the rehabilitation field started. In addition to wars, amputees and spinal cord injury, the epidemic of polio was what triggered many of the disciplines around rehabilitation because people were disabled, we needed a specialist to take care of them.
I see a tremendous opportunity for rehabilitation physicians to grow into a similar space. There's a portion of patients who have significant needs for the longer run with reduced endurance, weakness and other abnormalities, even long after being discharged from the hospital. This is the "bread and butter" of what a rehabilitation professional can handle.