Occupational Therapy Practice for Post-Acute COVID-19 Inpatients Requiring Rehabilitation

doi:10.21203/rs.3.rs-3439429/v1

Introduction: COVID-19 caused significant occupational disruption to people’s life roles, with some people requiring an inpatient rehabilitation admission. Occupational therapists assessed and treated these patients using previous knowledge of similar conditions due to limited available guidelines to inform practice. The aim of this study was to investigate current practice with Post-Acute COVID-19 (PAC) patients within an inpatient rehabilitation setting in Australia, to better understand the role and impact of occupational therapy.

Methods: A mixed methods study was conducted including electronic medical record audits (October 2021– October 2022), and descriptive patient interviews at a large metropolitan sub-acute service. Descriptive statistics and thematic analysis were used to summarise and interpret data.

Results: A total of 24 patient electronic medical records were audited and 14 patient interviews were completed. Three overarching themes were identified within the 685 occasions of occupational therapy service audited - occupational engagement, education provision and discharge planning. Patients identified the value of occupational therapy by reflecting on their lived experiences of engaging with occupational therapists and associated changes in occupational performance between COVID-19 diagnoses and discharge home.

Conclusion: Occupational therapy possess a unique skillset which directly addresses the occupational needs and priorities of PAC patients. This study adds to the growing body of evidence supporting the contribution of occupational therapy to the management of COVID-19, however further research is needed to develop evidence-based practice resources and advocate for system changes that improve quality of life for COVID-19 patients.

Physical Medicine & Rehab

Occupational Therapy

Inpatient

Rehabilitation

COVID-19

SARS-CoV-2

Occupational therapists provide holistic patient-centred interventions to address PAC needs and preferences.
Occupational therapists maximise occupational engagement to facilitate discharge home, enabling recovery and quality of life.
Patients value the opportunity to practice meaningful occupations to improve their confidence and self-esteem.

The COVID-19 pandemic has posed unprecedented challenges to global healthcare systems. Despite relatively low case numbers initially and high levels of vaccination, Australia has not escaped the profound effects of the pandemic on healthcare. As of 22nd September 2023, Australia had recorded 11,591,525 cases and 22,887 deaths from COVID-19 since the beginning of the pandemic (World Health Organisation, 2023a). While some of these cases are reinfections, these numbers are likely under-estimated given that reporting of polymerase chain reaction (PCR) or rapid antigen test (RAT) results are no longer required.

While most people make a full recovery from their COVID-19 infection, a noticeable minority experienced sustained and significant disability. Long COVID (also known as Post-Acute COVID Condition or PACC) was first identified by patients in May 2020 (Callard & Perego, 2021). The World Health Organisation (WHO) developed a case description of Long COVID as “the continuation or development of new symptoms 3 months after the initial SARS-CoV-2 infection, with these symptoms lasting for at least 2 months with no other explanation” (WHO, 2021, p.1). However, the Centres for Disease Control and Prevention (Centres for Disease Control and Prevention, 2023) recognises Long COVID in people experiencing ongoing symptoms which significantly impact on function and quality of life in the medium term (4 to 12 weeks post infection).

Variations in definitions and a lack of diagnostic criteria for this syndrome is an ongoing challenge for both healthcare providers and patients. In this paper, we use the term Post-Acute COVID-19 (PAC) in recognition that the patients in this study were experiencing difficulties stemming from an acute COVID-19 infection but may or may not have met the criteria for Long COVID.

Rehabilitation needs for PAC patients

The range of sustained symptoms and functional problems reported following COVID-19 infection are strikingly diverse. Commonly reported symptoms include fatigue, breathlessness, smell and taste dysfunction, myalgia and cough (Healey et al., 2022). A cross sectional study from Denmark (Nielsen et al., 2022) described the functional problems experienced by patients (n = 448) attending a Post COVID-19 outpatient clinic. Around three quarters of the sample experienced moderate to severe mental fatigue, and most patients experienced significant difficulties completing productive and leisure activities. Over half of the patients (56%) were also on sick leave from their usual employment. Most recently, a cohort study of over 6 million Americans (Bowe et al., 2023) found Long COVID contributed 80.4 disability adjusted life years per 1,000 persons, indicating a higher level of disability than cancer or heart disease.

Australians recovering from COVID-19 have also described the widespread impact of this syndrome in their daily life, describing recovery as getting back to ‘their normal’ (Hitch et al., 2023a). Over time, it became increasingly evident that many PAC patients require support for rehabilitation and recovery. The final report of an Inquiry into Long COVID by the Federal Parliament of Australia (Parliament of Australia, 2023) highlighted that people experiencing functional impairment following COVID-19 infection needed early access to rehabilitation services tailored to their individual symptoms and participation needs.

An evidence base for rehabilitation for PAC patients is only now emerging and suggests that tailored multidisciplinary rehabilitation programs are an effective approach to maximise both short-and medium-term outcomes (Grishechkina et al., 2023). Studies of the impact of allied health for PAC patients receiving inpatient rehabilitation (Bellinger, Ouellette & Robertson, 2021) and a scoping review of rehabilitation programs for older adults post, PAC hospitalisation (Araya-Quintanilla et al., 2023) both mention occupational therapy as part of the multidisciplinary team approach. The WHO (2023) living guideline for the clinical management of COVID-19 also mentions occupational therapy specific to the care of critically ill patients, decision making around multimorbidity and functional decline, and generally as members of the rehabilitation workforce for PAC patients.

Occupational Therapy for PAC patients

Despite these mentions of occupational therapy in the international literature, the Australian evidence-based clinical guidelines (National Covid-19 Clinical Evidence Taskforce, 2023) do not refer to the profession. Guidelines for the management of PAC patients are limited by a lack of evidence from clinical practice, leading to a lack of detailed guidance on discipline specific assessments and interventions for this patient cohort.

Establishment of an evidence-base about the role of occupational therapy with PAC patients is critical to establishing the profession's presence in the services, systems and policies currently being developed for this growing cohort of patients. A case study from the United States (Wilcox & Frank, 2021) described occupational therapy assessment and intervention with a patient which included functional endurance assessments, time use, occupational balance interventions, education on symptoms self-management and a multi-context approach to functional cognition. An Energy Management Education intervention developed by Swiss occupational therapists (Hersche & Weise, 2022) was perceived as feasible by clinicians, who also noted anxiety and discrepancies between self-concept, self-perception and performance these patients experience. A more recent study of the Stop-Rest-Pace approach (Tanguay et al., 2023) delivered by occupational therapists and physiotherapists found up to two thirds of patients continued to experience post exertional malaise after receiving this intervention.

There have been no Australian studies of the occupational therapy role with PAC patients to date. Local evidence is needed due to the unique context of our geography and healthcare systems, and the impact of national and state-based policy responses to the pandemic. The need for local research is highlighted by a study which found many PAC patients seeing occupational therapists in overseas settings (Christensen et al., 2022; von Zweck et al., 2023) were initially referred for assessment of dysphagia, which is beyond the scope of occupational therapy in Australia.

The aim of this study was to investigate current practice with PAC patients within an inpatient rehabilitation (IPR) setting in Australia to better understand the role and impact of occupational therapy. The research questions were: (i) What are the characteristics of PAC patients requiring inpatient rehabilitation with regards to clinical frailty, length of stay, medical complications, vaccination status, functional outcomes and discharge destination?; (ii) What is current occupational therapy practice for PAC patients in inpatient rehabilitation?; (iii) From the patients perspective, what impact does inpatient rehabilitation occupational therapy have on their recovery?

Study design

This study adopted a mixed-methods approach using a concurrent triangulation design (Creswell, 2014), collecting quantitative and qualitative data simultaneously and completing separate data analysis before comparing and contrasting the findings from each form of data. Retrospective Electronic Medical Record (EMR) audits gathered quantitative data about patient characteristics and qualitative descriptions of occupational therapy interventions using an audit template. Patient interviews also captured qualitative data about patient perceptions of the impact of occupational therapy. The study was approved by Western Health Human Research Ethics Committee (QA.2022.83_91736).).

Study setting

This study was completed on an adult IPR ward at a large metropolitan hospital in Victoria, Australia. The IPR ward consists of 30 beds providing multidisciplinary care to patients presenting with diverse medical conditions. While there were few PAC patients in the first year of the pandemic, the team observed increased admissions to address significant functional decline for this patient cohort during 2021.

Recruitment

File Audits

EMR’s retrospectively selected for admissions to the IPR ward betweenOctober 2021 andOctober 2022, provided a convenience sample of data. Due to the timing of data collection, the study sample reflects COVID-19 infections arising from the Delta and Omicron variants. The inclusion criteria were patients admitted to the IPR ward with a primary diagnosis of COVID-19 pneumonia.

Patient Interviews

Patients meeting the above criteria, were identified by occupational therapists from the IPR ward. Occupational therapists then approached patients to introduce the project and request verbal consent. Consenting patients were interviewed by an occupational therapist 1–2 days before discharged.

Data collection

File Audits

A bespoke audit tool collected the following information using the REDCap database (Vanderbilt University, 2023): (i) patient demographic information (i.e. gender, age, impairments, co-morbidities, primary language); (ii) admission details (i.e. ICU admission required, ventilation requirements, vaccination status, length of stay, discharge destination, discharge follow up); and (iii) type and frequency of occupational therapy invention provided.

The primary outcome measure was the Functional Independence Measure (FIM) which was extracted from the EMR. Additionally, the Clinical Frailty Score (CFS) was calculated using information from the EMR to add to the patient demographic picture.

Functional Independence Measure

The FIM is a standardised outcome measure designed to evaluate the functional abilities and progress of people undergoing rehabilitation (Uniform Data Set for Medical Rehabilitation, 2014). It includes 18 items across two domains: motor tasks (13 items) and cognitive tasks (5 items). These items quantify the person’s level of independence in daily activities, based on the amount of assistance needed to perform the task. The FIM has strong reliability and validity (Cournan, 2011; Gosman-Hedström & Svensson, 2000), and is widely used in rehabilitation services across Australia.

Clinical Frailty Score

The CFS (Rockwood et al., 2005) classifies patients according to nine levels of frailty, based upon activity and participation levels, with frailty defined as any score above 4 (Juma et al., 2016). The CFS was originally developed to measure frailty in outpatient clinical settings, and has been shown to have very good inter-rater reliability, predictive validity and clinician utility (Gregorevic et al., 2016). To enhance reliability in the scale application, an algorithm developed by Chong and colleagues (2019) was provided to all researchers participating in data collection. This algorithm enabled excellent inter-rater agreement and supported the predictive validity of the scale when used in an EMR audit of acute admissions for adults (Chong et al., 2019).

Patient interviews

The interviews were conducted by occupational therapists on the IPR ward. Three specific questions were developed and piloted with similar patients prior to data collection. These questions were:

1. Can you tell me about your experience with doing your daily occupations since being diagnosed with COVID-19?

2. Can you tell me about your experience working with occupational therapy during your rehabilitation stay?

3. You are leaving hospital soon; if you think back to when you first came to the rehabilitation ward and to now the point of leaving, how are you feeling about participating in your daily occupations?

Patient responses were written verbatim by the occupational therapists conducting the interviews, which were then entered into a Microsoft Excel spreadsheet for analysis.

Data Analysis

File Audits

Retrospective EMR audit data was exported from the REDCap (Vanderbilt University, 2023) platform into an Excel spreadsheet for analysis. Simple summary statistics, reported as averages and percentages were applied to describe patient demographics. Occupational therapy intervention types were coded and themes identified.Qualitative data regarding interventions were added to the qualitative data from the patient interviews for thematic analysis.

Patient interviews

A descriptive qualitative approach was used to support the analysis of the patient interviews and EMR data (Liamputtong, 2013). Thematic analysis involves the identification, analysis and reporting of patterns with data, which are known as themes (Braun & Clarke, 2021). The analysis followed these steps: (i) transcription of responses into an Excel spreadsheet; (ii) familiarisation with responses; (iii) coding of data to identify key interpreted concepts within the data set; (iv) preliminary identification of themes; (iv) refining and naming of themes to complete the analysis. Two research team members coded all qualitative data independently and collaboratively identified and refined the themes. There were very few disagreements between the coders and those were resolved through discussion.

File Audits

Characteristics of PAC patients

The EMR’s of 24 inpatient files were audited. Participants ranged from 29–78 years of age (SD = 13.0), and 13 (54.2%) were female. Most patients were unvaccinated (n = 20, 83.3%), with 91.6% requiring an ICU admission. While 21 patients (87.5%) were previously active and independent (as determined by CFS < 2), the PAC patients experienced various physical, cognitive and psychosocial impairments. Functional improvements were observed through an overall FIM change score of 31.09. Most patients were discharged home (n = 23, 95.8%), and 18 (75.0%) patients had ongoing rehabilitation goals requiring referral to outpatient rehabilitation. Participant characteristics are outlined in Table 1.

Place Table 1 about here.

Occupational Therapy Role in Current Practice

A total of 685 occasions of occupational therapy intervention was provided, with an average of 28.5 occasions per patient (SD 19.93, range 3–72). Three overarching themes were identified - occupational engagement (55.2%), education provision (27.7%) and discharge planning (17.1%). For each of these themes, codes were identified that highlighted what interventions were provided and the clinical justification for their use. A summary of the interventions provided to PAC patients is provided in Table 2.

Place Table 2 about here.

Strategies for Occupational Engagement

Patients had disengaged from meaningful occupations during their acute COVID-19 infection, and occupationalretraining was offered for domestic, leisure and community occupations one on one and within a group environment. However, personal care occupations were most often the focus of occupational therapy intervention. Patients experienced significant deconditioning, weakness and shortness of breath, necessitating a graded approach to interventions. Occupational therapists also utilised motivational techniques combined with deep breathing, to assist with building confidence and anxiety management during occupational engagement.

Education Provision

Occupational therapists provided various forms of education to patients, their family members and/or carers. While patients were mostly educated on energy conservation techniques within occupations, occupational therapists also educated patients on management of new oxygen requirements at home and within the community. Other topics of education provision included; falls prevention, use of equipment, pressure care, rehabilitation expectations, graded approach to recovery, sleep hygiene, return to work processes, and external follow up options such as accessing the National Disability Insurance Scheme (NDIS) for co-diagnosis (i.e. Acquired Brain Injury) post COVID-19.

Discharge Planning

With most patients discharged home, common interventions provided by occupational therapists were assessment of the home environment, conducting home assessments and completing environmental interventions to facilitate discharge home. However, COVID-19 restrictions imposed by the health service limited traditional face-to-face home assessments. Occupational therapists instead gathered information via the use of photos, measurements of the home environment taken by family, or from online platforms and by completing virtual home assessments with family members. Other forms of intervention included thesetup and use of equipment, carer training of mobility and transfers within the home environment and organisation ofoutpatient rehabilitation, support services and equipment supply to enable sustainable discharge.

Patient Interviews

Impact on Occupational Engagement and Participation

The three themes identified in this data reflected the topics of the questions posed in the interviews. Findings are presented below using pseudonyms to protect the confidentiality of the patients.

Patients experience of daily occupations post COVID-19

Patients reported experiencing a range of new feelings while completing occupations following their COVID-19 diagnosis. Many reflected on the significant changes in occupational performance experienced due to increased difficulties completing simple occupations: “It’s been a big change…a typical day for me would be working full time, hanging out with my daughter and now I need assistance with all tasks” (Jordan).

Some patients felt severely disabled by their ongoing symptoms and recognised how much assistance they needed to participate in previously taken for granted occupations: “I haven’t been able to do anything really…. I’m flat out just trying to get to the toilet…. It was really debilitating because it was difficult to breath. It was extremely hard… I really needed the help” (Charlie). These changes in function were often experienced as a complete disruption in their occupational lives: “Getting dressed is no comparison; never had to learn how to eat again and now I need to think about everything… how much I can put in my mouth, how long I can brush my hair for… (it’s been) a complete life change” (Peter).

A consistent feature of many descriptions of activity participation was the extra work and effort involved in occupational engagement: “It’s been really hard work, but I am pushing through. I get tired quickly… as doing things is harder. It’s frustrating” (Georgie). These struggles also increased the time required to complete tasks, further exacerbating fatigue: “It’s a disaster; everything just takes so much longer and is more effort”(Ashley). The cumulative impact of functional difficulties was also evident, as describe by ‘Sam’: “Getting out of bed and my mobility were challenges that made everything else slow”.

Feelings of fear, anxiety and being overwhelmed were commonly reported by patients during occupational engagement. ‘Taylor’ described how mental fatigue impacted on emotional responses, which were at odds with their usual approach to life:

“I had a level of fear doing my daily activities, however I’m really tired mentally…I’m a motivated person however initially my daily activities were so overwhelming; you know initially I couldn’t even sit on the edge of the bed without being short of breath” (Taylor)

However, in some cases this started to improve as they began to regain function: “For a long time I needed to use a bed pan instead of going to the toilet. Over the last 3–4 weeks I started to use the toilet and doing things more normally again. It was scary to begin with and more difficult to do things such as attending to my hygiene and going to the toilet”(Chris). Support from family appeared to be a facilitator in changing this mental state as described by ‘Ashley’: “Having my wife allowed to be here has also helped me….do more for myself which I like”.

Patients experience of the impact of Occupational Therapy

When reflecting on experiences of working with occupational therapists during rehabilitation, patients identified various interventions they perceived as helpful. Many of these interventions helped the patient make sense of their overall recovery journey:

“The biggest thing I’ve learnt from OT is to pace myself. It’s okay to sit and rest. It’s a process. It’ll take time and everyday you’ll make small steps (which) really helped me to build my confidence” (Taylor).

Patients received a range of interventions tailored to their specific needs, which included individual, group, face to face and online modalities. ‘Charlie’ explained how the diverse interventions they experienced contributed to their preparations for the future:

“The aids (long handled sponge and pick up stick) were helpful. The support was helpful in the breakfast club and thinking about how I need to be more organised and pace myself. The online group was also helpful to think of different ways to conserve energy. Very helpful in preparation to go home. It was helpful to prepare for what I might encounter and what to expect” (Charlie).

Patients appreciated the support, responsiveness and positivity demonstrated by their occupational therapists; “Always present when needed, encouraging me to get back to doing things on my own. (Therapist) came home with me on the day of discharge to help setup equipment” (Jamie). The positive impact of the interpersonal interactions they had with occupational therapists on their motivation was mentioned by several patients, which supported their confidence to regain independence: “Very helpful and friendly. Motivated me. Showed me that I can do things for myself” (Chris). The motivational support of the occupational therapists included targeted support around specific occupations and symptoms: “Everyday making sure that I was up and dressed. (Therapist) has been so positive and supportive when I’m short of breath… I really appreciated it” (Ashley). A key aspect of these interactions was the professionalism that patients perceived from the occupational therapists, which enhanced their own feelings of confidence and ability: “I had confidence in my OT, that you knew what you were talking about, which helped me improve my confidence to do my activities” (Taylor).

Patients also valued occupational therapy interventions that provided practical tips and strategies they readily applied to daily life. Despite the limitation of the inpatient setting, patients were provided with opportunities to practice various occupations in different forms: “The energy group was great. I learnt a lot of strategies which I then practiced in the kitchen making my birthday cake” (Shannon). The use of both graded and compensatory approaches was frequently described, with these strategies used in a complementary manner: “First sitting then I practiced standing in the shower. Getting down to the toilet was hard, took too long…. now I use a higher seat which makes life easier” (Sam). Occupational therapy was perceived as having a wide-reaching impact on the patient’s quality of life and recovery, as summarised by ‘Max’: “(Therapist) taught me how to do everyday things, like putting my clothes on. It’s been helpful. I didn’t have an OT in acute but it has made such a difference”.

Patients anticipated experience of occupational participation post discharge

A key focus of occupational therapy on IPR is to prepare patients for safe and sustainable discharge. All patients described better confidence and improved occupational independence in the lead up to going home: “I’m feeling good, much better than before. I wasn’t able to do things like put my clothes on but now I’m feeling confident” (Ashley).

While all members of the IPR multidisciplinary team contributed to their recovery and readiness for discharge, occupational therapists were perceived as the profession that focused on outcomes that really matter to patients: “I now know what I need to do, to pace my daily activities, and I’m confident in doing this, despite needing oxygen still. What I learnt through the education and practice of doing things such as showering, going to the toilet, these are meaningful things which I do everyday; a physio (therapist) can’t teach you that” (Taylor).

Many patients recognised that their recovery would be ongoing and desired to continue working with the community rehabilitation service providers that their occupational therapists referred them to: “Overall (I’m) much better but I still need more rehab so I can look at going back to work, cleaning my house and walking the dog” (Jamie). However, the prevailing perception was that discharge was an important and hard-won milestone that provided a benchmark for reflecting on how far they had come: “I never thought that I’d get out of here; such a big hill to climb. It impacted my whole life which changed (from) as always independent. I’ve been reborn and (now I) need to think and breathe” (Peter).

Combined analysis of EMR and interview data

As patients’ occupational needs changed over time, so did the occupational therapy role. The qualitative experiences of PAC patients on IPR reflected most of the findings from the EMR audits, which suggests patients see the role of occupational therapy as providing education and maximising occupational engagement. Many interventions were present in both the EMR and interview data, as shown below in Fig. 1. Firstly, patients reflected on their fatigue, altered breathing and anxiety and how simple occupations were now hard work. Secondly, patients recognised learning about new helpful tips and strategies such as pacing, use of aids/equipment and energy conservation techniques. Thirdly, patients valued the importance of being able to practice their daily occupations to help build their independence and confidence in preparation for discharge.

Insert Fig. 1 about here.

However, patients did not appear to fully recognise the role of occupational therapy in discharge planning. While themes relevant to discharge were identified in the interviews (such as acknowledging the need for further rehabilitation and onward referrals), patients did not explicitly make the link between these activities and returning home. This may be due to most of the discharge planning process occurring without the patient present.

This study found that occupational therapists working in this IPR setting addressed occupational engagement, education provision and discharge planning for PAC patients. The PAC patients were active and independent prior to their COVID-19 infection, and the majority were able to return home, despite a high proportion initially requiring ICU treatment. Muscular fatigue, shortness of breath, anxiety and confusion were the most common presenting symptoms. Patients valued occupational therapy interventions and reflected positively on their lived experience of engaging with occupational therapists and associated changes in occupational performance between COVID-19 diagnoses and discharge home.

This is the first study to specifically investigate occupational therapy practice in the management of PAC patients within an Australian IPR setting. Recently, von Zweck et al. (2023) surveyed occupational therapists globally to describe the delivery and quality of occupational therapy interventions for people with COVID-19 and Post-COVID-19 Conditions (PCC). While Australian occupational therapists were likely included in the sample, international practices differ significantly which highlights the need for local health context research to promote generalisability to practice.

The findings of this study are consistent with a Netherlands study (Nielsen et al., 2022), where most PAC patients receiving IPR were also active and independent prior to the onset of COVID-19, which also caused significant loss in function and profound disruption to their lives. Similarly, inpatient interventions focused on building independence in occupations necessary for discharge home, such as personal care. Interventions that focused on engagement across the full range of meaningful occupations such as employment, was addressed to a lesser extent due to time constraints. Returning to work has been consistently identified as a key aspect of recovery from COVID-19 (Hitch et al., 2023a; Hossain et al., 2023), recognising the potential on the person, their family and also the wider society due to economic factors. The role of occupational therapy with patients with PAC therefore extends far beyond the inpatient setting, particularly given many people with Long COVID were not admitted to hospital in the acute phase of their infection (Malesevic et al., 2023).

Access barriers to occupational therapy services for this cohort is a significant issue worldwide, attributed by limited funding, staff availability and insufficient resources (von Zweck et al., 2023). Many patients in this study did not fit the referral criteria of community rehabilitation services due to significant waitlist pressure where only the most debilitated were prioritised (Parliament of Australia, 2023). Virtual community rehabilitation in the home environment is a feasible and acceptable modality for this patient group (Groenveld et al., 2022) potentially increasing service efficiencies. Further exploration of technology enabled home based rehabilitation and general advocacy around access to occupational therapy is therefore needed, to enable patients to achieve all occupational goals and promote health equity.

Findings of this study confirm that occupational therapists provide a broad range of interventions addressing the diverse symptoms and occupational performance issues experienced by PAC patients. Many of the interventions identified are consistent with international research which describe common occupational therapy interventions of fatigue management, cognition, relaxation, self-management, environmental adaptation and mental health (von Zweck et al., 2023). Patients valued the broad range of interventions provided by occupational therapy which they perceived as addressing their personal needs and preferences. The positive perceptions of these patients suggests occupational therapy aligns with published best practice principles for working with this patient group by understanding the impact of COVID-19 on every part of their lives, tracking recovery and adjusting support accordingly. Additionally, supporting patients to remain connected with their community, minimising the functional impacts, providing integrated health as part of the multidisciplinary team, employing evidence-based interventions, promoting patient education and improving the patient experience (Hitch et al., 2023b; Ladds et al., 2020).

To build on this solid foundation, proactive efforts may be required to ensure occupational research is included in the evolving clinical practice guidelines in this area. The current guidelines include broad advice on topics like person-centred care, management of oxygen requirements and working within a multi-disciplinary team (World Health Organisation, 2023b). However, Australian occupational therapists report existing practice resources as insufficient, lacking specific and detailed guidance, and new resources are needed to inform quality rehabilitation practices for these patients in the community (Van Laake & Hitch, 2023). In the absence of detailed guidelines, occupational therapists have relied on established interventions for similar conditions and presentations (Van Laake & Hitch, 2023). Further research and implementation are urgently needed to consolidate the occupational therapy role and advocate for the unique contribution of the profession to recovery for PAC patients (von Zweck et al., 2023).

Limitations & Future Directions

This study had several limitations. Firstly, it had a small sample size and was conducted at a single site due to ease of accessibility and limitations of COVID-19 restrictions. Further studies should include a larger sample size, with the inclusion of multi-sites to validate these findings. Secondly, the study had no comparison group and patient care was provided by a multi-disciplinary team therefore the outcomes cannot be solely attributed to occupational therapy input. To mitigate these, patient interviews were directly targeted towards occupational therapy input. Thirdly, follow-up after discharge was not performed. Therefore, it is not possible to confirm whether these outcomes persisted after discharge. A follow-up evaluation is beneficial in confirming the long-term effects and further journey of PAC patients. Despite these limitations, the mixed methods approach provided rich data to understand the characteristics of this cohort and the occupational therapy role.

Occupational therapists possess a unique and relevant skill set which addresses a broad range of needs and preferences for PAC patients. Activity analysis and modification, energy conservation, environmental adaptation and motivational guidance are already being applied in practice to increase patient independence, confidence and engagement in meaningful occupations. This comprehensive approach supports patients to return home after discharge, however they may not achieve their community rehabilitation goals and optimal recovery due to systemic barriers to accessing occupational therapy. Further research is urgently needed to strengthen and advocate for the occupational therapy role, in this rapidly changing and developing field.

Authors declaration

All authors meet the criteria for authorship. All authors were involved in the study design, analysis, interpretation of the data, drafting the work for intellectual content and, final approval for publication. All authors acknowledge that the content has been reviewed and take responsibility for the data, analysis, interpretation and the conduct of the research.

Funding statement

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Conflict of interest statement

The authors have no conflict of interest to declare.

Acknowledgements

The authors would like to thank the patients and the occupational therapy team for their contributions in this study.

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Table 1. Patient demographics from the file audits

Characteristics		File audits (n=24)
Age (years)		58 ± 13.0
Gender
	Male	11 (45.8)
	Female	13 (54.2)
Language (English)		19 (79.1)
Unvaccinated		20 (83.3)
ICU admission		22 (91.6)
Intubation		16 (66.6)
Non-invasive ventilation		4 (16.6)
No pre-morbid history		4 (16.6)
Clinical Frailty Scale < 2		21 (87.5)
FIM score on admission	Total Motor Cognition	69.60 ± 25.62 38.34 ± 20.09 29.08 ± 8.75
FIM score on discharge	Total Motor Cognition	101.56 ± 18.79 69.43 ± 15.63 32.13 ± 5.91
Physical impairments
	Muscular fatigue	19 (79.1)
	Oxygen requirements	15 (62.5)
	Shortness of breath	13 (54.1)
	Upper limb changes	11 (45.8)
	Pain	3 (12.5)
	Wounds	3 (12.5)
	Incontinence	2 (8.3)
	Other	2 (8.3)
Cognitive impairments
	Confusion	7 (29.1)
	Memory	2 (8.3)
	Insight	2 (8.3)
	Attention	3 (12.5)
Psychosocial impairments
	Anxiety	11 (45.8)
	Low mood	3 (12.5)
	Poor sleep	2 (8.3)
Length of stay
	Acute	61.1 ± 58.4
	Inpatient Rehab	26.4 ± 23.6
Discharge destination
	Home	23 (95.8)
	Residential Aged Care	1 (4.1)
Discharge follow up	ESD Rapid Allied Health Community Based Rehabilitation Other	1 (4.1) 4 (16.7) 13 (54.2) 6 (25.0)

Values are presented as mean ± standard deviation (SD) or number of participants (%)

Note: FIM= Functional Independence Measure; ICU= Intensive Care Unit; ESD=Early Supported Discharge

Table 2. Occupational Therapy interventions

Theme	Type of intervention	*n = 685*
Occupational engagement		378 (55.2)
	Re-training within personal care occupations	109 (15.9)
	Mobility and transfer re-training within occupations	50 (7.2)
	Re-training within domestic occupations	45 (6.5)
	Energy conservation re-training within occupations	43 (6.2)
	Upper limb re-training	24 (3.5)
	Cognitive re-training	23 (3.5)
	Wheelchair re-training within occupations	22 (3.5)
	Motivational techniques within occupations	12 (1.7)
	Anxiety management within occupations	7 (1.0)
	Re-training in leisure occupations	5 (0.7)
	Re-training within community occupations Other	3 (0.4) 35 (5.1)
Education provision		190 (27.7)
	Energy conservation education	65 (9.4)
	Use of oxygen within occupations	39 (5.6)
	Education to carers	19 (2.7)
	Rehabilitation expectations	15 (2.1)
	Equipment and home modifications	13 (1.8)
	NDIS and occupational limitations	10 (1.4)
	Return to work/driving	7 (1.0)
	Anxiety management strategies	7 (1.0)
	Falls prevention	6 (0.8)
	Timetabling and routine within occupations	5 (0.7)
	Pressure care management	3 (0.4)
	Sleep hygiene	1 (0.1)
Discharge planning		117 (17.1)
	Communication with family, MDT and other stakeholders	35 (5.1)
	Equipment prescription	30 (4.3)
	Problem solving oxygen requirements at home	25 (3.6)
	Home assessments	10 (1.4)
	NDIS planning, documentation and implementation	7 (1.0)
	Complex equipment sourcing	6 (0.8)
	Carer training	4 (0.5)

Values are presented as number of occasions (%)

Note: NDIS= National Disability Insurance Scheme; MDT= Multi-disciplinary team

Occupational Therapy Practice for Post-Acute COVID-19 Inpatients Requiring Rehabilitation

Status:

Journal Publication

Version 1

Abstract

Figures

Key Points for Occupational Therapy

Introduction

Rehabilitation needs for PAC patients

Occupational Therapy for PAC patients

Method

Study design

Study setting

Recruitment

File Audits

Patient Interviews

Data collection

File Audits

Functional Independence Measure

Clinical Frailty Score

Patient interviews

Data Analysis

File Audits

Patient interviews

Results

File Audits

Characteristics of PAC patients

Occupational Therapy Role in Current Practice

Strategies for Occupational Engagement

Education Provision

Discharge Planning

Patient Interviews

Impact on Occupational Engagement and Participation

Patients experience of the impact of Occupational Therapy

Combined analysis of EMR and interview data

Discussion

Limitations & Future Directions

Conclusion

Declarations

References

Tables

Status:

Journal Publication

Version 1