COVID-19 has affected the care of persons with spinal cord injury throughout the world. In August 2020, spinl cord injury professionals from many different regions were asked how COVID-19 has affected care in their local areas. This is what they had to say...
USA- New York
In New York City, at the peak of the COVID-19 pandemic, most of the acute rehabilitation facilities stopped admitting persons with acute spinal cord injury. At Mount Sinai, the inpatient rehabilitation units were converted to medical/surgical units, which only cared for persons with COVID-19. All outpatient therapies were stopped and all outpatient physician visits were converted to video visits. Since then, as the number of new COVID-19 cases has dropped dramatically, the rehabilitation facilities are now accepting those with acute SCI. Outpatient therapies have restarted and outpatient physician visits are now a mixture of in person and video visits. Differences in care from the time before COVID-19, included perhaps less ordering of screening bladder/kidney ultrasounds and neurological examinations due to the fear of COVID-19 by persons who have increased risk when they leave home. One positive thing from this has been the explosion of online virtual support groups and exercise groups which seem to be reaching people who were unable to participate before as travel to the SCI centers was difficult.
In Rochester, Minnesota, in the North Central United States, due to the COVID-19 pandemic in mid-March, outpatient clinic visits were halted and all but the most emergent/essential procedures were deferred as government mandated business closures went into effect. Telephone and video visits were rapidly implemented which allowed the resumption of some patient services remotely. Inpatient rehabilitation continued throughout the duration of wide social distancing measures. Spinal cord injury admissions were unaffected, and inpatient rehabilitation services continued without interruption. For several weeks, the inpatient rehabilitation unit had the highest census of any unit in the hospital. Because most outpatient therapy services were unavailable, and admissions to skilled nursing units were limited, discharges from inpatient rehabilitation were occasionally delayed. To limit the risk of virus transmission inside the medical center, strict visitor policies were implemented. While necessary for the safety of patients and staff, these restrictions have been difficult for everyone. In recent weeks, the implementation of strict hospital wide masking, social distancing, visitor restrictions, and screening has allowed the resumption of outpatient and procedural care without a significant surge in COVID-19 case numbers. Perhaps due to the reductions in road traffic, business closures, etc, trauma related inpatient rehabilitation admissions appear to be reduced compared to a typical summer.
At the Spinal Cord Injury Service at Veterans Affairs (VA) medical center in Seattle, Washington, USA, our first known occurrence of COVID-19 infection in an outpatient Veteran with SCI occurred in early March 2020. It seems like so long ago: no distancing, no masks, and the outpatient Veteran was in the same therapy gym as our inpatients just a few days before he became symptomatic with COVID-19 infection. Fortunately, none of our inpatients or staff contracted infection from this potential exposure. To date, four Veterans with SCI from western Washington are known to have had COVID-19, three of whom required hospitalization.
To reduce the chance of a unit-wide outbreak of infection amongst inpatients and staff, we adopted measures similar to other sites reporting here, with similar negative effects on the inpatient population receiving rehabilitation. We allowed visitors under limited circumstances, primarily to provide necessary hands-on caregiver training so the patient could discharge from the hospital. We perform COVID-19 testing prior to admission and at the time of admission, and newly admitted patients are provided with a private bedroom for the first two weeks of hospitalization. All staff have their temperature checked daily prior to entering the inpatient unit. Elective admissions remain on hold, and already admitted inpatients have continued to receive their initial rehabilitation for new SCI. Medical center leadership has required us to maintain a maximum inpatient census that is reduced by one third from our usual census. We haven’t observed a drop in the incidence of new SCI, and fortunately the new processes have not significantly impacted Veteran access to initial SCI rehabilitation.
VA provides a secure telehealth application (VA Video Connect) that many staff and patients were using prior to the pandemic, so it was relatively easy to expand virtual care, which now includes annual SCI evaluations previously offered only as face-to-face care. We completed outreach calls to Veterans with SCI in our catchment area to identify needs and get patients set up for using the telehealth application. Our face-to-face appointments with providers, physical therapists, and occupational therapists remained greatly restricted, and our other allied health professionals provided only virtual care.
In the United States, as of June 30, 2020, 140 Veterans from 63 VA medical centers were known to have had COVID-19, and 26 had died. ( https://www.nature.com/articles/s41393-020-0529-0.pdf ) The observed case fatality rate was 2.4 times the rate reported for the non-SCI US Veteran population. This finding validates the national guidelines requiring VA medical centers to treat inpatient SCI units similar to the nursing home units located on medical center campuses (Community Living Centers), as both locations treat Veterans who may be at greater risk for infection severity and fatality. Visitors are restricted to a greater degree than the overall medical center, and patients are asked to remain on the inpatient unit at all times. All inpatients and staff periodically undergo surveillance screening for COVID-19. It appears that these strategies are working, as there have been no large-scale outbreaks of COVID-19 involving patients and staff on VA SCI Units.
Spinal Cord Rehabilitation Program, University Health Network –
Since the onset of the COVID-19 pandemic, the Toronto Rehabilitation Institute has put in place many measures to prevent the spread of COVID-19 while continuing clinical operations. Screening stations have been established at all entrances and all individuals entering the building are provided masks. Initially, only essential personnel were allowed entry and outpatient assessments were limited to those requiring hands-on care. The inability of family and friends to visit and provide support to inpatients has been difficult. Recreational programming has been increased in the evenings and on weekends. Therapy services have also been extended to weekends to keep inpatients occupied and provide ongoing professional opportunities for staff reassigned from the outpatient department. Patients have embraced this.
In the span of 1 – 2 weeks, all outpatient appointments were converted to phone calls or video. Outpatient clinics (physiatry, urology, seating, skin and wound, etc.) have slowly ramped back up; however, many clinical interactions still occur by phone or video. Prior to COVID-19, telehealth services were minimal and there was a dearth of reimbursement mechanisms. This has been completely transformed and will have long-term ramifications to our models of care. A positive has been increased access to services for individuals who cannot easily travel to the centre.
Due to the close physical interactions and potential intermingling with inpatients, outpatient therapies have and continue to be on hold. This has been a hardship for individuals who recently transitioned back to the community. In the community, physiotherapy and occupational therapy clinics were also closed, and have justly recently reopened. Virtual services have not been an adequate substitution. There has been much discussion regarding how outpatient therapies can be resumed safely.
Inpatient services have continued unabated at full census. This has been essential. As the only spinal cord rehabilitation program in the Toronto metropolitan area, the program is a central part of the care continuum and facilitates the flow of patients from acute care to community reintegration. Fortunately, there has been no inpatient COVID-19 transmission. Inpatients are tested prior to admission and weekly during admission. Staff are offered regular voluntary testing. Clinical staff for all face-to-face interactions are wearing face shields, in addition to masks.
Anthony S. Burns
In the Spinal Cord Injury Center Heidelberg (Germany), we were confronted with an outbreak of COVID19 on the wards in the first weeks after the beginning of the pandemic in Germany. Quick and systematic identification of infection chains among staff and patients along with strict hygienic measures, such as mandatory mask-wearing in all clinic facilities or rapid establishment of dedicated wards for COVID-19, helped us to get the outbreak under control within a few weeks. Ever since we have been spared from further infections with COVID-19 among patients. Most challenging for inpatients were very probably the strict regulations regarding social distancing among patients and even between clinical staff and patients. Temporarily, telephone/virtual counseling had to be established to ensure psychological care for patients. After elective inpatient admissions were completely stopped and outpatient treatment was limited to emergencies at the peak of the pandemic in Germany, we have now gradually returned to a state of routine. Simplified administrative regulations concerning both the approval of rehabilitation programs and the regulations for discharges of inpatients have facilitated the clinical management during the pandemic. However, we also made the experience that a few of the patients in need of treatment did not show up for appointments because they were afraid of infection with COVID-19. Remaining restrictions regarding visitors during inpatient treatment and screening tests for new admissions have become part of the clinical routine. Steps are increasingly being taken to make virtual outpatient presentations possible, which reduces the travel burden for spinal cord injured patients with easy-to-address issues and will lead to fewer time constraints in more challenging cases in the outpatient department. Medical diagnostics have been continued to be ordered without change.
In Rome COVID-19 pandemic had both a “positive” and a negative effect on SCI. Because of the strict lock-down measures adopted by the Italian government there has been a reduction of spinal traumas and spinal cord injuries. In our hospital we continued to admit patients, with the exception of a three weeks period of quarantine due to the fact that we had some COVID-19 cases in other wards of the hospital. For more than two months we closed all the outpatient activities (visits and rehabilitation) and we tried to use telemedicine to keep in contact with SCI individuals. The most severe difficulties were experienced by inpatients: during the lockdown period, because of the need of maintaining a strict social distancing we stopped all the visits of relatives to the patients. After the lock down we continued to apply a close restriction of the visits. In our opinion, this distance, although clearly very necessary, had a negative impact on our inpatients who showed higher levels of depression and reduced compliance to the rehabilitation protocols. I Don't know exactly what happened in the rest of Italy, but I am sure that the same measures (or almost the same) have been taken in all Italian spinal units. Some unit had a reduction of the number of beds because they have been transformed in COVID-19 beds.
South Africa and greater Africa
In South Africa the early strict lock down meant that there were less incidents of traumatic SCI. Patients in rehab unit are discharged much quicker and rehab units have instituted strict COVID-19 admission criteria. As no visitors are allowed on the units has there has been a negative impact on care giver trainer and family involvement.
From the rest of Africa, including South Africa AFSCIN received reports that virtual outreach is taking places but is only reaching those that have the finances to access it. The lock down in various countries is leading to an inability to access supplies or medical assistance as public transport is not available. There are problems with the supply chain in health facilities and items such as catheters are not ordered and received. In situations where a paid helper is used in the community, a lack of public transport had made continued care as helpers have difficulty getting to work. For those relying on a family member to provide care, there are concernes about the consequence if their family member gets ill and thee individual is left to fend for themselves. As only two countries in Africa have some form of social security, reports have been received that some SCI consumers have been unable to engage in any form of work and food security has become a problem. Social distancing is often not kept for a variety of reasons, while a lack of access to running water in a dwelling or yard can add to the inability of the household to practice good hand hygiene practices. Finally, as in other parts of the world, people with SCI on the continent are fearful that their needs will not be met should they be admitted to a COVID-19 ward and SCI consumers are fearful of going to the clinics and hospitals as they might be exposed to the virus at the health facility.
“It’s funny watching you guys (staff) get so anxious about this. COVID will pass, my spinal cord injury won’t…..” the perspective of an in-patient on one of the early days of the COVID-19 outbreak when a decision was taken to temporarily suspend all visiting and patients’ weekend leave.
In Dublin, we have had no cases of COVID-19 affecting our in-patients in the National Rehabilitation Hospital (NRH) but the pandemic has had a substantial impact on how we deliver rehabilitation. All visiting and therapeutic weekend leave were discontinued. In an effort to combat this, there were more recreational activities over the weekends, provided by staff from all departments on a voluntary basis. It was observed that because of having no visitors, there were large captive audiences for the evening education sessions. There have been no peer support or peer education sessions for several weeks now. In-patients have been unable to practice community participation skills such as outdoor wheelchair skills in public places, accessing public transport and extended activities of daily living such as shopping.
Like all health-care facilities, we were affected by staff absenteeism due to illness and the need for self-isolation and COVID testing. As a result, there was much re-deployment of clinical staff to different departments. This also resulted in some services being temporarily suspended e.g. vocational assessments. To reduce the risk of introducing COVID-19 infection to the NRH, newly admitted patients were quarantined for 2 weeks, which impacted negatively on the rate of admissions. For some patients, discharge was delayed during the pandemic. There were a number of reasons for this. As manufacturing of equipment such as shower chairs and wheelchairs slowed, it was a challenge to have all necessary equipment for discharge. In some regions, recruitment of carers in the community became a challenge as care staff were re-deployed to various settings such as community hospitals, to help deal with staff absenteeism.
For the patients for whom we have been able to proceed with discharge, family and carer training posed a challenge as we could not bring large numbers of people into the wards for training. This resulted in one of the most positive developments to emanate from the pandemic. Our Discharge Liaison Occupational Therapy (DLOT) service, historically only funded to aid discharge planning in a small region in the East of the country, became national. A member of DLOT and at least one other member of staff (usually liaison nursing and/or physiotherapy) have transported patients to their homes on the day of discharge where they met with and trained family and carers. Reports from patients and families, of this service, have been very positive. Out-patient clinics were cancelled and there was a move to tele-health. The children and teenagers in our paediatric SCI clinic seemed most receptive to this, not surprisingly!
In India, most of the acute outpatient rehabilitation facilities had been stopped due to the nationwide lockdown which extended from 22nd March 2020 till end May 2020. However, inpatient rehabilitation services continued at many places during this period. Initially only patients with health emergencies were admitted during this period. All outpatient physician visits were encouraged to be converted to telemedicine consultations. Tele- rehabilitation and Tele- nursing were encouraged. Since rehabilitation therapists have to work in close contact with patients, screening for COVID-19 was given special importance before therapy sessions were initiated. In fact all patients visiting the hospital were screened and all patients and their attendants were tested for COVID-19. The hospital was demarcated into COVID-19 positive, COVID-19 negative and COVID-19 suspect zones and precautions taken accordingly. Special precautions were taken during cardiorespiratory rehabilitation of patients with neurological deficits. Psychosocial rehabilitation of the patients, family members, and caregivers was given an important role since many of them were stressed out because of the pandemic. As the realisation sank in that the pandemic was going to last for a significant period, the services were gradually opened up taking all precautions and this was hastened with staged unlocking starting from June 2020. The reopening was also initiated to start to overcome the financial hardships posed due to the pandemic. Outpatient therapies have restarted, and outpatient physician visits now include both telemedicine consultation as well as in-person visits. In-patient facilities have been opened up fully. The pandemic has stressed the importance of telemedicine and online education and training, particularly for individuals with difficulty in mobilization or transport.
Argentina- Buenos Aires
A number of measures were implemented at the Santa Catalina Neurorehabilitation Clinic, an important neurological center in the region. There was the installation of booths with aerosolized disinfectant liquid for the entry of personnel to the headquarters and adoption of personal protective measures for both patients and healthcare personnel. Individuals were isolated for the first 14 days after admission and COVID-19 testing was performed on the first day. Family visits were stopped at the hospital except for those at end-of-life. Communication between patients and their family members was through video calls. Inpatient schedules and therapy shifts were modified and all outpatient therapies, group therapies, and workshops were suspended. Use of virtual visits was begun for some therapies for outpatients and for monitoring of continuing care.
In Honduras, the specialized centre en PMR from the Social Security Honduran Institute in San Pedro Sula, which has a 10 bed Day Hospital available for management of subacute SCI patients was temporarily closed due to the COVID-19 pandemic, but it was reopened in June, for 8 patients for 2 days a week only, due to the fact that a good number of staff were working with COVID-19 patients creating a staffing shortage.
In Costa Rica, the National Rehabilitation Center, which has 88 beds available for in patients and is one of the 5 national hospitals run by a State institution called Caja Costaricense de Seguro Social (CCSS), was initially converted into a COVID center to care for not very severe patients, however the situation changed and a 20 beds have were allocated for patients on artificial ventilation. As the CCSS runs the health system and all hospitals in the country, besides the private ones, any decisions in relation to the changes or bed allocation caused for the COVID-19 pandemic, can be easily taken and implemented. As such, rehabilitation personnel were moved to work to a nearby facility and the consultations were carried out mostly by video, phone calls and other communication options. For newly injured people with SCI, or those with complications, the situation has not been easy and sometimes dramatic, as there became no option for in-patient rehabilitation available. The situation of converting rehabilitation facilities into facilities for treating COVID-19 patients has been also taken place in other countries of Latin America. Some of the rehabilitation facilities that were converted to COVID-19 facilities have gradually returned to their previous activities at this time however.
In Jordan, the COVID-19 pandemic surge was slowed by the very early nationwide lockdown from 18th of March till 6th of June. The only dedicated SCI Unit in Jordan located at Hussein Medical Centre has a 31 bed capacity. Measures considered to prevent COVID-19 transmission were managed by the infection control unit. Screening stations were established at all entrances and all individuals entering the building were provided masks and gloves. Hand washing was encouraged before and after any procedure or patient contact. The Outpatient rehabilitation facilities and clinic were closed and inpatient admissions were limited to urgent cases.
Royal Medical Services (RMS), the Jordanian PMR association, in-collaboration with the higher council for the affairs of people with disabilities, and the Jordanian charitable society for spinal cord injury care provided medical advice to patients over the phone to minimize hospital visits. They also handed out monthly medications to patients at their homes eliminating the need to visit the hospital in person, provided patients with pressure injury care and home dressings through volunteer doctors if needed. These volunteers also expanded knowledge and answered questions about COVID-19 through phone calls and social media posts.
Beginning on June 7th, services were gradually reopened and now all inpatients, outpatient clinics and rehabilitation facilities are fully operational.
In Australia, we have been very fortunate that the strategies put in place by State and Federal Governments have prevented COVID-19 from been much worse. Our cases are much lower than many other countries. So far, as far as I am aware, there have been no people with spinal cord injury/dysfunction admitted with COVID-19 to our acute service. To date there has not been a requirement for COVID-19 testing of patients prior to admission, from either the major acute hospital associated with our service, or if the patient comes from another hospital (most of our patients come from other organisations). I believe, however, that routine screening of some sort may be starting in the future. There have, however, been major changes in service delivery and model of care….
As the first wave of cases was building here in mid-late March the hospital management decided to close the 3 rehabilitation wards and relocate the patients, including those in the spinal rehabilitation service, to a ward that was previously a geriatric patient ward. It was decided that the rehab nursing staff with the spinal expertise would be relocated to other duties elsewhere, with only 2 or 3 nursing staff with spinal cord rehabilitation expertise came across with the patients. The nurse unit manager and the majority of nursing staff had no prior expertise with these patients. It was very challenging to try and upskill these staff, especially regarding management of bladder, bowel and autonomic dysreflexia. The ISCoS eLearning modules were handy, along with educational presentations to the nursing staff – with these also transmitted via online software and recorded for loading on the staff education portal.
There has been a major impact on physiotherapy. The hydrotherapy pool was closed, as too was the gym. No plinths were available or ceiling track systems. Therapy occured in the patients’ rooms with limited equipment or in a small room on the ward that is a designated therapy area with parallel bars. The room needed to be cleaned after every patient session. We have been able to negotiate the transfer of a tilt-table from the gym to a patients room who has significant postural hypotension in order to allow therapy to progress efforts to mobilise the patient. Occupational therapy and other disciplines have been able to manage therapy on the ward with less disruption.
Team discussions occur with many staff using remote access via the software platforms. We are fortunate that the health Network transitioned to an electronic record system 18 months ago, so it is possible to review the medical record, patient observations and results remotely. When a nurse who worked on the ward was diagnosed as COVID-19-positive, I have stopped visiting the ward for 2 weeks and performed ward rounds and team meetings via phone and remote access using the software/technology available.
Discharge planning has been challenging. Most home visits were replaced by families taking measurements and photos/video’s – as approval from senior hospital management was required for actual home visits. Discharge equipment sourcing has also been done remotely/online. Almost all community rehabilitation services were suspended and transitioned to a virtual platform. Some services were seeing patients face-face after the first wave settled and restrictions eased in June-July, but we experienced a second wave of COVID-19 leading to a 4 lock-down, and all face-face therapy was again stopped.
Our outpatient clinic is virtual, except for patients needing intrathecal pump refills. I have continued to see patient who need botulinum toxin injections into lower limbs for safety reasons, but deferred all patients with upper limb spasticity.