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First Edition: 2020

COVID-19 Guideline for Physical and Occupational Therapists in the Acute Care

Setting at Mayo Clinic

Authors Jenna Schmid, PT, DPT

Ashley Bella-Klepps, PT, DPT

Whitney Kortuem, OTR/L

Editors Selen Courtney, PT, DPT, OCS

Tina Sauber, OTD, OTR/L, BCPR

Brandon Yancey, OTD, OTR/L

Revised May 2020.

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DISCLAIMER: This document was adapted for generalized use among our Academy of Acute Care membership. Many of the elements specific to a single facility have been removed as this may vary. The AACPT wants to thank Mayo Clinic for their efforts in developing a guideline to share amongst their rehabilitation colleagues.

According to the Center for Disease Control and Prevention (CDC) SARS-CoV-2 has been identified as a highly contagious respiratory illness spread through droplets and physical contact with contaminated environments.

As of February 11, 2020, the International Committee on Taxonomy of Viruses (ICTV) announced names for the virus responsible for COVID-19 (previously known as “2019 novel coronavirus”) and the disease it causes.1

The official names are:Disease coronavirus disease (COVID-19)

Virus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

Due to the high risk of spreading the illness it is prudent that clinicians avoid becoming vectors by limiting contact with infected individuals to essential rehabilitative interventions. Close communication with the referring provider service will ensure the right care is provided to the right patients at the right time. This evidence informed care pathway is provided to guide decision making but not replace individualized decision making in collaboration with the interdisciplinary team.

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Purpose

Educate rehabilitation professionals treating patients diagnosed with COVID-19 in the acute care setting about pathology, common tests/images administered, medical management, and to provide a guideline for therapists’ role and workflow when assessing and treating this patient population.

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Pathophysiology

What is COVID-19? ● Coronavirus disease 2019 (COVID-19) is caused by a new coronavirus called

severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Coronavirusesare common in people and many different species of animals, including camels,cattle, bats and cats. In rare cases, animal coronavirus can cross species barriersand can infect and then spread between people; this occurred with SARS-CoV,MERS-CoV, and now with COVID-19. Although they are part of the same family,and likely all have their origin in bats, there are differences in the geneticsequence identity, and therefore COVID-19 has been classified by the WorldHealth Organization as a new beta-coronavirus that infects humans. 2,3,4

What is the disease process?

● COVID-19 primarily affects the respiratory system as the virus binds to ACE-2receptors that are expressed on the alveoli epithelial cells. The ACE-2 receptors onthe alveolar cells are where the virus attaches via “spikes” and then enters the hostcells. The virus has a typical incubation period of 2-14 days. Within this time, thevirus slowly triggers a response within the lungs, specifically within the alveoli. 4,5

● Once within the alveolar cells, the virus causes a breakdown of the capillary at thealveolar-capillary site, causing increased vascular permeability. This “leakiness”results in interstitial edema, pulmonary edema, alveolar injury and possible alveolarcollapse. This primarily impacts the periphery and bases of the lungs, leading todyspnea, impaired oxygenation, resulting in hypoxemia. 5,6

● Alveolar cell damage initiates an immune and inflammatory response. In asubgroup of patients, the immune and inflammatory responses that are deployedto protect the body from viruses can lead to a “cytokine storm.” A “cytokine storm”is an overproduction of and an increase in activated immune cells into the lungswhich increases fluid buildup, tissue damage, and respiratory distress. Adysregulated T-cell response and elevated inflammatory markers cause severedamage to the alveoli and structural damage to the lungs. The lung tissue damageresults in worsening hypoxemia. Specifically, an increase in erythrocytesedimentation rate (ESR) and ferritin are markers for increased mortality rates.3,5, 6

● C-reactive proteins (CRP) play an important role in early defense against infections.CRP will rise between days 3-5 and peak on day 14 with a significant dropthereafter. Lymphocytes are decreased throughout the first 14 days. Around day10-14, patients may begin to decline due to the immune mediated responsedescribed above. By day 14, people may be at their most inflamed state with theirlowest store of lymphocytes, increasing their difficulty in fighting the virus. Recentcase studies show that ICU admissions are typically occur around day 12 andintubation occurs around day 14.6

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● COVID-19 causes diffuse, peripheral inflammation in the lungs, ranging in spectrumfrom mild to severe. The accumulation of fluid in the lungs, damaged alveoli,ventilation-perfusion mismatch, bronchoconstriction caused by inflammatorymediators, and hypoxemia can lead to acute respiratory distress syndrome (ARDS).ARDS is the leading cause of mortality in COVID-19 patients. An estimated rangefrom 3-30% of people who are hospitalized with COVID-19 develop ARDS,increasing the risk of mortality.5, 6

Cardiac Issues ● COVID-19 can also affect the heart as ACE-2 receptors are found on

cardiomyocytes. As the virus binds with ACE-2 receptors, there may be an increasein troponins in patients with acute respiratory distress. According to the AmericanCollege of Cardiology, clinicians are advised to only measure the troponin if thediagnosis of acute myocardial infarction is being considered because an increase introponin may not be evidence of an acute myocardial infarction but may indicatemyocardial inflammation in this patient population. Highly sensitive troponin hasbeen found significantly elevated in more than half of patients who have died.Therefore, troponin rise, in addition to elevated BNP and p-BNP in patients withARDS may indicate a heart dysfunction, or it may indicate a patient with COVID-19who is more critically ill and is at an increased risk of mortality.6

● Patients with evidence of an acute myocardial infarction (elevated troponinsaccompanied by other symptoms of heart failure, including arrhythmias and ECGchanges), evidence of myocarditis, have a history of cardiovascular disease orangina, or are at a high risk for cardiovascular disease will be treated by medicalteam as appropriate. Therapy is advised to await for a decrease in troponins andother enzymes, await hemodynamic stability, and closely monitor hemodynamicsand symptoms with all activities.6

Neurological Effects ● Up to 40% of patients diagnosed with COVID-19 demonstrate neurologic

manifestations and rates of altered mental status, including delirium, are high(7.5-65%).7,8 Experience from prior coronavirus infections and emergingresearch of COVID-19 suggest that neurologic involvement is more common inpatients with severe infections. Direct central nervous system (CNS) injury dueto the virus is rare.7,8 Elderly patients with a history of cardiovascular risk factorsthat are diagnosed with COVID-19 are more likely to develop newcerebrovascular disease when compared to younger, healthier patientsdiagnosed with COVID-19.9

● Possible mechanisms of insult to the neurological system by COVID-19 includedirect infection injury to the CNS via the blood circulation pathway or the

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neuronal pathway, hypoxic injury, immune injury related to systemic inflammatory response syndrome, or the binding of SARS-CoV-2 to ACE 2 receptors on capillary endothelium.10 COVID-19 can also provoke states that increase the risk of neurological disease due to metabolic derangements, medications, or hemodynamic instability experienced by patients during critical illness.9● Direct insult to the neurological system may result in anosmia, headache, encephalitisand myelitis. Other potential neurological effects of COVID-19 are stroke, seizure, alteredmental status, neuromuscular disorders, and critical illness polyneuropathy andmyopathy.8 The increase in inflammatory markers, CRP and D-Dimer, increases thepotential for accelerated atherosclerosis and thrombosis, which increases the risk forperipheral clot formation and stroke.10

● Altered mental status in patients diagnosed with COVID-19 may be caused bysystemic infection, hypoxemia, hypercarbia, metabolic derangements (renal or hepaticdysfunction), medication effects, or primary CNS dysfunction. Critical illness, prolongedmechanical ventilation, and isolation related to COVID-19 all increase the risk for thedevelopment of delirium.7,8 It is vital to reduce the risk for delirium in hospitalized patients,as the neurologic and cognitive effects of delirium can impact a patient’s quality of life andability to return to their baseline long after their hospitalization.

What are the symptoms?

• Symptoms may appear anywhere from 2-14 days after exposure to the virus and symptoms may range from mild to severe. The viral load is very heavy in the initial10-12 days after exposure, resulting in possible symptoms of fever and dry coughs. The inflammatory process in the lung parenchyma stimulates nerve endings that are responsible for initiating the cough reflex, leading to a dry cough. In more severe cases, patients may present with high fevers, hemoptysis, and multiorgan dysfunction.6 People may also be asymptomatic, showing no signs or symptoms of infection.

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Common Labs Lab Value Reference Range** Meaning Trends with COVID-196

*CRP (C-ReactiveProtein)

<8.0 mg/L Elevated values are consistent with an acute

11 inflammatory process.

Increases (days 3-5; peaks day 14).

*Ferritin 11 – 307 mcg/L A blood protein that contains iron – an increase indicates a condition that causes your body to store too much iron; it may also indicate rheumatoid arthritis, liver disease, or other inflammatory

12 conditions.

Increases (indicating increased inflammation).

Lymphocytes 0.95 – 3.07 x10(9)/L White blood cells that help fight off diseases. 13

Decreases throughout first 14 days; lowest at day 14 and critical at this point.

Platelets 157 – 371 x 10(9)/L Blood cells that help body form clots to stop

14 bleeding.

Decreases

BUN(Blood urea nitrogen)

6.0 – 21.0 mg/dL Determines how well kidneys and liver are working – measures amount of urea nitrogen that’s in the blood – increase in levels may indicate

15 kidney injury.

Increases

Cr (Creatinine) 0.59 – 1.04 mg/dL Is a chemical waste product that’s produced by your muscle metabolism – an increase level of creatinine in the blood indicates your kidneys aren’t functioning properly. 16

Increases

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*LFTs (LiverFunction Test) 1.AST (aspartateaminotransferas)2.ALT (alanineminotransferas)3.Total bilirubin

1. 8-43 U/L2. 7-45 U/L3. <1.2 mg/dL

LFTs: blood tests used to help diagnose and monitor liver disease or damage.

1. Enzyme that helpsmetabolize aminoacids – increase mayindicate liver damage,disease or muscledamage2. Enzyme found inthe liver that helpsconvert proteins intoenergy for liver cells.Increases with liverdamage3. Substance producedduring normalbreakdown of bloodcells – it passesthrough the liver andexcreted through stool– increase may indicateliver damage/ disease

17 or types of anemia.

Increases

ESR (erythrocyte sedimentation rate)

0 to 22 mm/hr for Men.

0 to 29 mm/hr for 14

Women.

A blood test that can reveal inflammatory activity in the body – not a standalone tool, but can help diagnose or monitor the progress of an inflammatory

18 disease.

Increases in over 50% of patients.

*D-dimer < 500 mg/mL FEU A blood test that can be used to help rule out the presence of a

19 serious blood clot.

Increases

*LD or LDH(LactateDehydrogenase)

122-222 U/L A test that looks for signs of damage in body tissues higher LD means more damage.20

Increases

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Procalcitonin (ProCT)

< 0.08 ng/mL Helps identify sepsis and bacterial infections - therefore, low levels may indicate low risk of developing sepsis and may indicate symptoms are due to another cause such

21 as a viral infection.

Decreases

*IL-6 (Interleukin 6) 17 < 1.8 pg/mL Useful to evaluate

patients with suspected systemic infection; elevation may indicate an ongoing inflammatory response and could be consistent with systemic or localized infection or chronic inflammatory disease.22

Increases

Troponin < 10 ng/L Protein in the blood - released when the heart muscle has been damaged such as a heart attack. The more damage the greater amount of troponin in the

23 blood.

If elevated, look into other signs of cardiac injury.

NT-Pro BNP (brain natriuretic peptide)

<202pg/mL BNP is a peptide secreted by the heart that regulates blood pressure and fluid balance; aids in the diagnosis for congestive heart

24 failure.

If elevated, look into other signs of cardiac injury.

*the lab values frequently reviewed in some ICUs.

**While lab value range references may vary, the reference ranges listed in this table were taken from Epic electronic health records system for a particular institution for consistency. Please refer to the reference ranges for your practice location.

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Common Imaging

Chest X-Ray (CXR)

• Typically demonstrate bilateral lower zone consolidation, which peaked at 10-12 days from symptom onset.25

• Patients may have normal chest radiographs early in the disease.6

Computed tomography scan (CT) of the Lungs • The known imaging features of initial CT include bilateral, multi-lobar ground glass

opacities (GGO) with a peripheral or posterior distribution (or both), mainly in the lower lobes and less frequently within the right middle lobe. 26

Less common and in later stages: Septal thickening, bronchiectasis, pleural thickening, and subpleural involvement. 26

• Uncommon, but possible findings seen with disease progression: Pleural effusion, pericardial effusion, lymphadenopathy, cavitation, CT halo sign, and pneumothorax.26

• Follow-up CT in the intermediate stages: Increase in the number and size of GGO into multi- focal consolidation, septal thickening, and development of a crazy paving pattern. 26

• The greatest severity of CT findings was visible around day 10 after symptom onset33

• Imaging signs associated with clinical improvement usually occur after week 2 and include gradual resolution of consolidative opacities and decrease in the number of lesions and involved lobes.26

Medical Management Common Medications • Azithromycin: Used to treat certain bacterial infections, such as bronchitis and

pneumonia.• Hydroxychloroquine/Plaquenil: Prevents and treats acute attacks of malaria. Also

used to treat discoid or SLE and RA.28 Both Azithromyocin and Hydroxychloroquine can cause cardiac side effects (QTc prolongation and cardiac arrhymias). 29

• Lenzilumab: New medication used to reduce or prevent the cytokine storm that can lead to acute respiratory distress syndrome. Recently approved by the FDA for a multicenter, Phase III, double-blinded, controlled clinical trial and for the administration to COVID-19 patients under individual patient emergency investigational new drug applications.30

• Tocilizumab: Biologic medication approved to treat adults with moderately to severely active RA and adults with giant cell arteritis. Tocilizumab blocks the inflammatory protein IL-6.31 Serum IL-6 level is significantly increased in severely ill patients with COVID-19. Clinical studies from China have shown that Tocilizumab is effective in treating severely ill patients with extensive bilateral lung lesions, who have elevated IL-6 levels.32

• Zinc: Helps the immune system fight off invading bacteria and viruses.33 Research has shown it also improves immune responses and suppresses viral replication.34

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Oxygen Delivery DevicesRecommendation: SpO2 92-96% (regardless of spectrum of disease).6

• Nasal cannula (up to 6 LPM)• Hi-Flow Nasal Cannula (HFNC)• Non-invasive positive pressure ventilation (NIPPV)37

o If HFNC is not available and there is no urgent need for intubation, NIPPV is suggested with close monitoring and short-interval assessment for worsening of respiratory failure.

o For NIPPV or HFNC, close monitoring for worsening of respiratory status, and early intubation in a controlled setting if worsening occurs is recommended.

• Mechanical ventilation6

o Recommendation: Patients should be managed with lung-protective strategies to minimize ventilator injury.

o Ventilation:▪ Tidal volume: 4-6 ml/kg predicted body weight (at times can increase

to 8 if not tolerating settings);▪ Plateau pressures (Pplat) <30 cm H2O (make sure pt doesn’t have

ventilator injury or barotrauma);▪ Respiratory rate (RR) should be maintained 16-24 (If patient is very

symptomatic and severe acidosis is present, can increase to 35);▪ Volume control *AC/VC (can control tidal volume for every breath the

vent delivers).o Oxygenation: What drives oxygenation is PEEP and FiO2

▪ PEEP moderate to high levels as needed▪ FiO2 100% on intubation, rapidly wean to SpO2 92-96%

Prone Positioning6

• Optimizes gas exchange/improves oxygenation.• Current recommendation is 16-18 hours per day.• Recommended in ventilated and non-ventilated patients.• Aerosols can be generated.• Sedation may be required.• Intubated, tenuous ETT needs to be protected.

Extracorporeal Membrane Oxygenation (ECMO) 37

• In mechanically ventilated patients with COVID-19 and refractory hypoxemia despiteoptimizing ventilation, use of rescue therapies, and proning, it is suggested usingvenovenous (VV) ECMO.

• Convalescent plasma (CP): is collected from COVID-19 recovered individuals who are eligible for blood donation.35 CP contains a large amount of neutralizing antibodies capable of neutralizing COVID-19 and eradicating the pathogens from blood circulation and pulmonary tissues.36

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Role of Physical and Occupational Therapy Decision Tree It is critical for the therapist to understand the disease process before evaluating and treating the patient who is positive for COVID-19. Use of the decision tree (see Appendix A) will help determine appropriateness for rehabilitation needs. • Decision tree specific to ICU• Decision tree specific to medical/surgical unit

Clinical reasoning will change depending on where the patient is in his/her disease process.

InTouch Technology, Inc or Comparable Electronic Device with HIPPA Protection To minimize exposure and use of PPE, each patient who is diagnosed with COVID-19, should have a device in their room to be able to see and speak with the patient without entering the room. It is recommended that each therapist should have a personal login to connect from the designated desktop at the nurses’ station. As recommended in the attached decision tree, speak with the bedside nurse and utilize InTouch Inc. or comparable device such as electronic device with HIPPA protection or facility provided phone, to help determine the patient’s need for therapy evaluation and intervention prior to entering the room.38

Personal Protective Equipment (PPE)

Appropriate donning/doffing of PPE is crucial for preventing infection transmission.6 It is important to note that after an aerosolized procedure (see Appendix B) the therapist may not access the room for 60 minutes.

Therapeutic Interventions

Patients that have been diagnosed with COVID-19 have impaired recovery ability,6 therefore, require close monitoring of patient’s activity tolerance and how much supplemental O2 the patient requires to maintain SpO2 92%, etc. to prescribe appropriate dosing of exercises and activities. Therapists are encouraged to employ clinical judgment for when to terminate the session based on the patient’s signs and symptoms for tolerance to activity.

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Educational Handout Material for RNs and Caregivers There is an additional education handout available in Appendix C that includes: • Functional mobility and activities• Strategies to decrease delirium

Consider compiling a folder/packet with different handouts for the RN to give to the patient.

Issuing DME The Centers for Medicare and Medicaid Services (CMS) is waiving signature requirements during this time. While this Public Health Emergency remains in effect, it is important that the suppliers carefully document the delivery date of all Durable Medical Equipment (DME) and state that the signature was unable to be obtained due to COVID-19.39

Workflow For a patient with a pending COVID-19 rule-out, the therapist should closely communicate with the referring provider team to determine the urgency of the rehabilitation needs of the patient. Results should be available in 24 hours. Based on rehabilitation needs, patients with pending test results may be deferred to minimize use of PPE and undue exposure.

The primary objective is to provide the right care to the right patient at the right time.

In an effort to minimize movement of teams between patients who are diagnosed with COVID-19 and non-infectious patients, therapists/teams will be identified on a daily/weekly basis who will provide the rehabilitation services. Primary therapists will be chosen daily, including:

• One physical therapist, one occupational therapist and one technician in theICU• One physical therapist, one occupational therapist and one technician on the medical

units.

While our therapy census of patients with COVID-19 is low, therapists assigned to these patients will schedule them at the end of the day and then leave from there in order to prevent cross contamination.

In the case of a surge or higher volume of patients diagnosed with COVID-19, supervisors will schedule therapists in accordance to patient volumes.

Literature suggests that exposure to patients who have been diagnosed with COVID-19 should be avoided for staff who are at increased risk of susceptibility to developing serious illness resulting from COVID-19 exposure. “This includes staff who:

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● Are pregnant● Have significant chronic respiratory i llnesses● Are immunosuppressed● Are older (eg, >60)● Have severe chronic health conditions such as heart disease, lung

disease,diabetes● Have immunodeficiencies, such as neutropenia, disseminated malignancy and

conditionsor treatments that produce immunodeficiency”.40

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References: 1. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. How to

Protect Yourself and Others. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html. Updated April 13, 2020. Accessed April 14, 2020.

2. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19): SituationSummary. https://www.cdc.gov/ coronavirus/2019-ncov/cases-updates/summary.html. PublishedMarch 2020. Accessed April 9, 2020.

3. Cascella M, Rajnick M, Cuomo A, Dulebohn S, Di Napoli R. Features, evaluation and treatmentof coronavirus (COVID-19). In:StatPearls. Treasure Island (FL): StatPearls Publishing; 2020.https://www.ncbi.nlm.nih.gov/books/NBK554776/#_NBK554776_pubdet. Accessed April 9,2020.

4. Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease(COVID-19) outbreak [published online ahead of print February 26, 2020]. J Autoimmun. 2020;109. DOI: 10.1016/j.jaut.2020.102433

5. Hasudungan, A. COVID-10 (SARS Coronavirus 2): Timeline, pathophysiology (ARDS),coronavirus life cycle, treatment [video].YouTube.https://www.youtube.com/watch?v=DD_wdvwN9rg. Published April 6, 2020. Accessed April 9,2020.

6. Campbell, A., Engel, H., Hillegass, E., Perme, C., Ramsey, S. COVID-19: Clinical Best Practices in PhysicalTherapy Management [Webinar]. March 28 2020. Retrieved fromhttps://register.gotowebinar.com/recording/7342833725268746509. Accessed April 6, 2020.

7. Kumble S, Lopker M, Verma A. Physical Therapy Considerations of Neurologic Presentations in COVID-19[Webinar]. April 25, 2020. Retrieved fromhttps://register.gotowebinar.com/recording/recordingView?webinarKey=998243714740537359&registrantEmail=bella-klepps.ashley%40mayo.edu. Accessed April 28, 2020.

8. McEntire C, Misra A, O’Hare M, Srikanth P, Williams E, Yau W. COVID-19 Protocols: Neurology. Brigham andWomen’s Health. https://covidprotocols.org/protocols/11-neurology/?highlight=rehab. Updated April 24, 2020.Accessed May 3, 2020.

9. Cervantes A, Greer D. COVID-19 Neurology Protocols. Boston Medical Center. https://covidneurology.org/1-introduction. Accessed May 3, 2020.

10. Wu Y, Xu X, Chen Z, et al. Nervous system involvement after infection with COVID-19 and othercoronaviruses [published online ahead of print March 30, 2020]. J Brain BehavImmun. 2020. doi:10.1016/j.bbi.2020.03.031.

11. Test ID: CRP C-Reactive Protein (CRP), Serum. Mayo Clinic Laboratories.https://www.mayocliniclabs.com/test-catalog/Clinical+and+Interpretive/9731. Accessed April 9, 2020.

12. Mayo Clinic Staff. Ferritin Test. Mayo Clinic.https://www.mayoclinic.org/tests- procedures/ferritin-test/about/pac-20384928. Updated November 28, 2019. Accessed April 9, 2020.

13. Mayo Clinic Staff. Lymphocytosis. Mayo Clinic.https://www.mayoclinic.org/symptoms/lymphocytosis/basics/definition/sym-20050660. Updated July 12,2019. Accessed April 9, 2020.

14. Mayo Clinic Staff. Thrombocytopenia (low platelet count). Mayo Clinic.https://www.mayoclinic.org/diseases-conditions/thrombocytopenia/symptoms-causes/syc-20378293.Updated April 8, 2020. Accessed April 9, 2020.

15. Mayo Clinic Staff. Blood urea nitrogen (BUN) test. Mayo Clinic.https://www.mayoclinic.org/tests-procedures/blood-urea-nitrogen/about/pac-20384821. Updated July 2,2019. Accessed April 13, 2020.

16. Mayo Clinic Staff. Creatinine Test. Mayo Clinic.https://www.mayoclinic.org/tests- procedures/creatinine-test/about/pac-

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20384646. Updated December 22, 2018. Accessed April 9, 2020. 17. Mayo Clinic Staff. Liver function tests. Mayo Clinic. https://www.mayoclinic.org/tests-

procedures/liver-function-tests/about/ pac-20394595. Updated June 13, 2019. Accessed April 9,2020.

18. Mayo Clinic Staff. Sed rate (erythrocyte sedimentation rate). Mayo Clinic.https://www.mayoclinic.org/tests-procedures/sed-rate/about/pac-20384797. Updated August 3, 2019.Accessed April 13, 2020.

19. What does a D-Dimer test do? WebMD. https://www.webmd.com/dvt/qa/what-does-a-ddimer-test-do.Updated November 18, 2018. Accessed April 10, 2020.

20. What Is a Lactate Dehydrogenase (LDH) Test? WebMD. https://www.webmd.com/a-to-z-guides/lactic-acid-dehydrogenase-test#1.

21. Accessed May, 10, 2020Procalcitonin. Lab Tests Online. https://labtestsonline.org/tests/procalcitonin.Updated September 23, 2019. Accessed April 10, 2020.

22. Test ID: IL 6 (Interleukin 6, Plasma). Mayo Clinic Laboratories.https://www.mayocliniclabs.com/test-catalog/Clinical+and+Interpretive/63020. Accessed April 10, 2020.

23. Troponin test. University of California San Francisco Health.https://www.ucsfhealth.org/medical-tests/007452. Updated October 17, 2017. Accessed April 13, 2020.

24. Test ID: PBNP (NT-Pro B-Type Natriuretic Peptide, Serum). Mayo Clinic Laboratories.https://www.mayocliniclabs.com/test-catalog/ Clinical+and+Interpretive/84291. Accessed 13, 2020.

25. Wong H, Lam H, Fong A, et al. Frequency and distribution of chest radiographic findings in COVID-19positive patients[published online ahead of print March 27, 2020]. Radiology. 2020. doi:10.1148/radiol.2020201160.

26. Salehi S, Abedi A, Balakrishnan S, Gholamrezanezhad A. Coronavirus disease 2019 (COVID-19): asystematic review of imaging findings in 919 patients [published online ahead of print February 29, 2020]. Amer Jour of Roentgenology. 2020; 215. Doi: 10.2214/ AJR.20.23034.

27. Azithromycin. Medline Plus. https://medlineplus.gov/druginfo/meds/a697037.html. Updated March 16,2020. Accessed April 13, 2020.

28. Hydroxychloroquine. Medline Plus. https://medlineplus.gov/druginfo/meds/a601240.html Updated March16, 2020. Accessed April 13, 2020.

29. Mercuro NJ, Yen CF, Shim DJ, et al. Risk of QT interval prolongation associated with use ofhydroxychloroquine with or without concomitant Azithromycin among hospitalized patients testingpositive for coronavirus disease 2019 (COVID-19). JAMA Cardiology (2020),doi:10.1001/jamacardio.2020.1834

30. FDA approves emergency IND use of humanigen's lenzilumab for compassionate use in COVID-19patients. Bloomberg. https:// www.bloomberg.com/press-releases/2020-04-02/fda-approves-emergency-ind-use-of-humanigen-s-lenzilumab-for-compassionate- use-in-covid-19-patients. UpdatedApril 2, 2020. Accessed April 14, 2020.

31. Tocilizumab (actemra). American College of Rheumatology. https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Treatments/ Tocilizumab-Actemra. Updated March 2019. Accessed 4/13/2020.

32. Ye Q, Wang B, and Mao J. The pathogenesis and treatment of the ‘Cytokine Storm’ in COVID-19. Journal ofInfection (2020), https://doi.org/10.1016/j.jinf.2020.03.037

33. Zinc. National institutes of Health: Office of Dietary Supplements.https://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/. Updated March 2, 2020.Accessed 4/13/2020.

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35. Vijayvargiya P, Garrigos ZE, Castillo Almeida NE, Gurram PR, Stevens RW,Razonable RR, TreatmentConsiderations for COVID-19: A Critical Review of the Evidence (or LackThereof), Mayo Clinic Proceedings(2020), doi:https://doi.org/10.1016/mayocp.2020.04.027.

36. Duan K, Liu B, Li C, et al. Effectiveness of convalescent plasma therapy in severe COVID-19 patients.

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PNAS.2020;117(17):9490-9496 37. Alhazzani W, Moller MH, Arabi YM, et al. Surviving sepsis campaign: guidelines on the management of

critically ill adults with Coronavirus Disease 2019 (COVID-19). Society of Critical Care Medicine.https://sccm.org/getattachment/Disaster/SSC- COVID19-Critical-Care-Guidelines.pdf?lang=en-US.Accessed April 13, 2020.

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40. Thomas P, Baldwin C, Bissett B, et al. Physiotherapy management for COVID-19 in the acute hospitalsetting: Recommendations to guide clinical practice. Journal of Physiotherapy. 2020;1-31.

41. Delirium Tool Box. Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center. https://uploads-ssl.webflow.com/5b0849daec50243a0a1e5e0c/5e7b98c0de1ee43dd63b0244_CIBS-Delirium-Toolbox-Rack-Card.pdf. Accessed April 13, 2020

FLOOR

DECISION TREE

FOR PT/OT

LAB VALUE TRENDS'

.-Rise in CRP (days 3-5; peaks day 14}

• -neaeased lymphocytes (lhr�

fir.II 14 days; lowest at day 14; aitical atthis point)

• Deaeased lllatelelselncrease BON/Cr elncrease LFTs (AST/ALTfTolal bilirubin)e Increase ESR in over 50% of patienlse Increase d-dmer e Increase fenilin• Deaease procalcitoninelncrease IL�

IMAGING TRENDS8

• CXR may be normal; if abnormal, will seeblateral peripheral opacities

• CT progress!!)" over time:o Early stage (0-4 days): ground glass

opacities (GOO)o l'ro!,essive stage (5-8 days): more

lilliise GGO, aazy JHMng, early consolidation

o Peak stage (9-13 days): peakinvolvement with dense consoldation;GOO and aazy paving

oAbsorplion stage(>/= 14 days): improvement in consoldalion and aazy paving; GOO improved, but may persist beyond 26 days

Step 1. Is the diagnosis of COVID-19

less than 10-14 days?

----------------No Yes

-------

lf �er lhan 14 days, consider Step 2. dimcal status. At. this point, patient Is the patient able to consistently follow

may be� better or much worse. commands and is STABLE from a Then go to Step 2. hemodynamic and cardiac standpoint? (see

Box 1)

----------------------No Yes---------

Defer PT/OT consult. Consider using In Touch to educate RN on

PROM/exercises, positioning, deaease delirium, etc.

SteR 3. Is the patient ST ABLE from a respiratory

standpoint? ( see Box 2)

----=----

'---

-N-o�- • ._______

Defer PT/OT consult. Consider using In Touch to educate RN onPROM/exercises, positioning,

deaease delirium, etc.

Step 4. Has the patient gotten up with

nursing yet?

----------------No Yes�

BOX16

If elevations in troponin, BNP or pro BNP look for other documentation of cardiac injury (i.e. ECG symptoms, arrhymm,as, E:CHO). If evidence of true acute Ml (symptoms, ECG, troponins) or evidence of myocarclitis and also has a history of CVD, treat like Ml: await decreases in troponins and other enzymes, awa� hemodynamic stability and then MONITOR hemodynamics wtih all actimiies

BOX26

Consider dinical status and progression of the disease process. See Lab Value and Imaging Trends boxes.

Is the patient on room air or nasal cannula? Has the patient maintained 92-96% Sp02 saturations? Has the patient been consistently requiring more supplemental 02'? Has the patient been stable or able to recover 02 saturations �h activity?

Have the RN assess basic mobiity {bed mobility, transfers, toileting, ambulation in the room, basic self cares in sitting). Then go to Step 5.

Step 5. Is the patient a one person

assist?

Inquire further. Does the patient reqLire evaluations from BOTH

disciplines?

---------------� Yes No�

Inquire further about patient's mobility and assess from outside the room using In Touch

technology while RN performs mobility assessment. Make recommendations or

evaluate the patient as appropriate.

One cliscipine saeens the patient (possibly have the other cliscillline PT/OT co-evaluation

readly available if needed)

Appendix A

ICU

DECISION TREE

FOR PT/OT

LAB VALUE TRENos8

•-Rise in CRP {days 3-5; pealcs day 14)

.-Decreased t,u11iplkh!:,tes (lhroughout tnt 14 days; - al day 14; alical al this poill)

• Deaeased plalelels• lnaease BUNICro lnaease LFTs (AST/AL T/Tolal blinm,)o lnaease ESR in ...,.. 50% of patienlse lnaease d-dmere lnaease fenili1 • Decrease nll"m_..,..,., .... in olnaease ll�

IMAGING TRENos8

• CXR may be nonnal; if allnonnal, wll seeblaleral ptoipl""al opaclies

• CT progression over time:o Eady stage (0-4 days� ground glass

opac:iles (GGOJo Prngressive slage (5-3 days): more

dilbe GOO, aazy paving, eady--on

o Peale stage (9-13 dayst. .--will dense --n· GGO and aazy paving

oAbovijAiti,I stage (>I= 14 days):i1 .. uveme11II in consoldalion and crazy paving; GOO improved, but may persist beyond 26 days

Step 1. Is the patient OFF mechanical

ventilation or high flow nasal cannula yet?

____ .....;;:;;;.....__ ... __________ y� Co-where in Ille disease process 1he patient is: is the patienl's respiralory -· worsening or improving? I worsening, defer

S1ep2. Is the patient consistentty following

commands? PT/OT. If improving, then go lo Step 2.

-----""""'"'--

--

N•___________

_ Yes

------..

S1ep3. Defer PT/OT coosul. Con_, using lnTooch to educale RN oo

PROMlexercises, positiollillg, deaease delrium, elc.

Is the patient STABLE from a hemodynamic standpoint?

(Stable MAP at rest and recovers to baseline MAP after movement/I.urning)

�No---------Ye'--------

Defer PT/OT consult. Cons­

using lnTouch lo ecu:ale RN on PROM/exen:ises, positioning,

decrease delrium, elc.

Slep 4. Is the patient STABLE from a respiratory

standpoint? (Able lo maintain Sp02 92-96% al rest6)

------------

-----"""'�----

--

·N_

•�

Yes-------..

Defer PT/OT coosul. Con-r using lnTooch to educale RN oo PROM/exen:ises, posiloning,

decrease-. etc.

Slep 5. Has the patient gotten up with

nursing yet?

S1ep6. Have the RN assess basic mobility (bed mobilily, transfers, toileting,

ambulation in the room, basic self cares in -g). Then go to Step 6.

Is the patient a one person assist?

Inquire fl.wlher. Does Ille patient require evaluations from BOTH

disciplines?

No�Yes

----- --._,,,_

Inquire further. Observe RN mobilize patient, utiize In T ooch technology

and make recommendations or evaluate the patient as approp<iate.

One discipline screens the patient (possibly have the other discipine

readily avaiable H needed) PT/OT c.-aluation

(RN available H needed)

Appendix A

Inpatient Suspected or Confirmed COVID 19Stable O2 < 15 lpm Unstable O2 > 15 lpm

Negative Pressure (AIIR)

Modified Droplet Contact

Negative Pressure (AIIR)

Modified Droplet Contact

Aerosol Generating Procedures *

AIIR + Airborne with N95/PAPR

• Intubation/Extubation• Mechanical ventilation with anticipated circuit

disconnection (Does not include: transport,diagnostic interventions)

• Bronchoscopy• NIPPV (acute and home routine)• EzPAP• Metaneb• Small Volume Nebulizer• High Flow Nasal Cannula, High Flow Tracheostomy• Sputum Induction• Suctioning (nasotracheal and open tracheal)• NG Tube placement• GI Endoscopy• Transesophageal echocardiogram• ENT procedures on the upper airway

Intermittent Procedures

Wear 95 or CAPR during and 1 hour after procedure

Place sign on door with time indicated to return to Modified Droplet

Appendix B38

Appendix C Additional Activities and Ways to Decrease Delirium

Progression of Activity:

• Rolling in bed with patient engagement using bedrails• Chair position in bed - engage patient in bed level exercises and self-care tasks (face, arm,

chest washing, oral care, hair brushing/washing with shower cap). Encourage them to complete what he/she is able

• Edge of bed/Chair - engage patient in seated exercises and self-care tasks (face washing, sponge bath, oral care, hair brushing/washing with shower cap). Encourage them to participate in what he/she is able

• Standing activity - marching in place - stand pivot to bedside chair or commode for toileting-engage patient to participate in toileting task

• Walk within room to/from chair, bathroom, and sink for self-care (if unsteady reach out to therapist regarding use of walker)

• Exercise handouts available for patients include:o Arm Active Range of Motion Exerciseso Elbow Strengthening Exercises Using an Elastic Bando Shoulder Strengthening Exercises Using an Elastic Band (Seated)o Exercises for the Legs (Lying)o Exercises for the Legs (Sitting)o Exercises for the Legs (standing)o Lower Extremity Home Exercise Programo General Lower Extremity Exercises

Decrease Delirium:

• Reorientationo Remind patient what day it is, where he/she is, the current situation, time of day, who

you are as a staff membero Direct them to the white board where this information is written and clock for time of

dayo Consider having the patient use a journal to keep track of what is happening; staff is

encouraged to contribute information to the journal to assist patients and families in keeping track with the patient’s plan of care and progress

o Offer patient to call or FaceTime family memberso Write information regarding patient’s interest on white board for staff members to ask

patient about to engage them in meaningful conversation

• Sensory improvement30

o Hearing aids in with charged batterieso Clean glasses on (including readers when needed)

• Environment modifications41

o Lights on and shades open during the dayo Lights off and shades closed at nighto TV okay to be on during the day only if patient is able to ask for it or able to

control it him/herselfo Music on during the day/off at night

• Allow only short naps during the day• “Normalize” routine and engage patient in morning/night cares• Engage patient in leisure activities as able (coloring, magazines, books, puzzles)

• Sleep promotion41

o Eye maskso Ear plugso Dark quiet roomo Relaxation TV channelo Essential oils