The initial COVID-19 infection control response during the first inpatient outbreaks in this community geriatric rehabilitation hospital (Royal Victoria Hospital) was to transfer PCR-positive patients across to the main secondary care hospital (Ninewells Hospital) for cohorting.
As outbreak numbers increased across both sites, it was necessary to establish a COVID-19 ward within the rehabilitation geriatric hospital. The rationale for this was multiple-fold: to reduce burden on ambulance services to transfer a growing number of patients across sites, alleviate rapidly expanding bed pressures for COVID-19 positive admissions from the community, as well as to reduce patient distress from rapid transfers to unfamiliar clinical environments.
Other changes made by the multidisciplinary team at RVH included reducing the number of beds per bay to allow for adequate 2 m social distancing, and the delivery of rehabilitation activities within the COVID-19 ward itself as well as utilising separate rehabilitation equipment to reduce risk of patient-to-patient transmission in the shared gym.
Patients admitted to this COVID-19 rehabilitation ward were PCR positive on admission and underwent regular surveillance COVID-19 testing. When they were found to be COVID-19 negative, the patient was transferred to a non-COVID-19 rehabilitation ward to carry on rehabilitation and discharge planning. While there were varying policies in test of cures during 3 months of the outbreak, x2 negative swabs was mandatory for all care home discharges due to serious clinical risk posed to the existing residents. Patients who have reached their full rehabilitation potential and were fit for discharge home but remained COVID-19 positive on PCR could be discharged directly from the COVID-19 ward with self-isolating instructions for 14days. In such cases, family and carers were informed about the patient’s COVID-19 status prior to discharge for appropriate precaution taking.
More than half of patients admitted to this COVID-19 rehabilitation ward were from various COVID-19 outbreaks onsite, which suggests that geriatric patients within a rehabilitation hospital setting are at significant risk of COVID-19 infection. Increased care requirements by this patient demographic often necessitate allied health professionals and ward staff to be in proximity with patients to assist with activities of daily living. This is challenging for effective social distancing to occur in such clinical environments, which perpetuates risk of infection spread despite diligent use of face masks and PPE.
It is interesting to note that a significant portion of patients who were COVID-19 positive on PCR were asymptomatic at detection. This suggests that a high clinical suspicion for COVID-19 should remain as patients can be widely asymptomatic even when positive. Blood result trends such as lymphopenia and raised CRP seen in this patient cohort was in line with current literature. Unfortunately, there was inconsistent requesting of coagulation profiles at presentation for accurate data collection and meaningful comparison with current literature about COVID-19 coagulopathy.
Ward staff had noticed that stroke patients in this cohort who developed COVID-19 suffered a higher mortality rate and length of hospital stay, and this was statistically significant on univariate analysis. A suggested explanation to this is that patients who have stroke often present with other organ system co-morbidities contributing to overall pre-COVID-19 frailty and increased rehabilitation requirements. A prolonged hospital stay could also predispose these patients to prolonged exposure risks to hospital acquired infections resulting increased mortality.
It is clear from current literature that COVID-19 disproportionally affects older patients due to diminished immune function and multi-morbidities. This patient group is most likely to require hospital admission, and most likely to die from COVID-19 infection. Significant physical functional decline is a recognised outcome in the surviving geriatric COVID-19 population and our study demonstrated this though quantifiable deterioration in mobility, increase in care status and increased frailty post-COVID infection. This supports our theory that COVID-19 survivors require more time to rehabilitate to a new functional baseline safe for hospital discharge, as demonstrated by the statistically significant increased length of hospital stay in our surviving cohort. This further reiterates the importance of a COVID-19 rehabilitation unit inpatient service for COVID-19 positive patients to engage in rehabilitation activities as tolerated while remaining PCR positive, to maximise recovery.
In this study, we observed an increase in Clinical Frailty Scores (CFS) in the surviving population post COVID-19 infection. This data was collected retrospectively, however there is potential for rehabilitation hospitals to utilise the CFS assessment in conjunction with the Comprehensive Geriatric Assessment (CGAs) patient co-morbidities at point of admission as tools to rationalise treatment goals and patient outcomes.
Such use of CFS in patient care in COVID-19 has been recommended by NICE Guidelines to guide clinical decision making, for example, the NICE critical care algorithm suggests that COVID-19 positive patients with a CFS ≥ 5 would not benefit from admission to ICU. Our paper did not find a statistical significance in survival rates in patients with a lower clinical frailty score at COVID-19 presentation, which suggests that CFS should not be used in isolation to guide clinical decision making. Instead, as Hubbard et al suggested, the CFS should be considered as an important component of a holistic patient-centred approach to assessment taking into consideration biomedical factors such as existing co-morbidities and severity of acute COVID-19 infection.
A small sample size of such a unique patient cohort described in our study makes it difficult to accurately extrapolate data for application to the wider Scottish population. Strong multi-disciplinary team involvement (physiotherapy, occupational therapy, social work, nursing) should be considered in the early stages of COVID-19 research planning to adopt a holistic problem-solving approach towards the various challenges in COVID-19 rehabilitation.
Although not directly addressed through this study, it is important to explore the emotional and mental health challenges faced by geriatric patients through prolonged COVID-19 related hospital admission. One of the unique struggles of the COVID-19 patient journey is the emotional challenges of prolonged social isolation through stringent “restricted visitation” hospital infection control policies. This highlights the complexities in balancing public health concerns of pandemic control, while remaining patient-centred by ongoing reflection on how we can improve patient journeys for our population’s most vulnerable.