Preliminary experiences in acute occupational therapy for in-patients with coronavirus-19 (COVID-19): leveraging assistive technology in three case studies of male veterans

Figures & data

Figure 1. Application of the Person-Environment-Occupation-Performance model to individuals with Coronavirus-2019. Application of the Person-Environment-Occupation-Performance model (modified from Baum et al. [9]) to reflect the observed intrinsic and extrinsic factors that impacted an individual’s ability to engage in desired occupations when recovering from Coronavirus-2019 (COVID-19).

Table 1. Acute occupational therapy evaluation guided by the Person-Environment-Occupation-Performance (PEOP) Model.

	Acute care evaluation subcomponents
Person	Current medical status and changes from baseline in intrinsic factors Physiological: Pre-existing systemic conditions, weakness, vital signs Cognition: Orientation, ability to follow directions, retention of new information, self-regulation, presence of hospital-induced cognitive issues (e.g., delirium) Psychological: Presence of pre-existing conditions and community supports Neurobehavioral: Motor skills, mobility, balance
Environment	Existing baseline extrinsic factors: Social environment: Social supports, level of caregiver assistance available Physical Environment: Home accessibility, durable medical equipment needs Environment and Technology: Consideration of technology to augment safety needs (e.g., emergency alert systems, novel use of voice command technologies for social supports) Cultural Environment Societal Environment: Access to community-based resources for transportation, day programming, check-in support.
Occupation	Baseline occupational performance Identification of the occupations needed for a safe discharge to the prior living environment.
Performance	Current physical performance of occupations in the hospital environment

Table 2. Outcome measures following Occupational Therapy evaluation and intervention (if indicated).

	Mr. A		Mr. B		Mr. C
Outcome	Baseline	Discharge	Baseline	Discharge	Baseline	Discharge
Supplemental oxygen	6L High flow via NC	Room air	Room air	Room air	1L via NC	Room air
Therapy session duration	45 min	70 min	15 min	Eval only	30 min	43 min
# of Intrinsic factors impacted	4/5	4/5	1/5	0/5	2/5	0/5
Ability to follow commands	1 step	3 steps	WFL	WFL	WFL	WFL
Orientation	X2	X4	X4	X4	X3	X3
Grip Strength (Lbs)	Unreadable	62# Right UE, 58# Left UE	WFL	WFL	NT	NT
Assistance with bed mobility	Max A ×2	Min A ×1	Independent	Independent	Max assist	Able to laterally scoot once upright
Activity tolerance	0 min unsupported sitting at edge of bed	38 min unsupported sitting at edge of bed, mechanically assisted standing	Reported in room activity per nursing	Independent with in room and basic occupations	Dependent for all mobility	Sat for 5-10 min, tolerated 5 sit to stand transfers via non-mechanical lift
Number of acute care goals achieved at discharge		3 out of 4 goals	N/A. Evaluation only			3 out of 3 goals

Note. The baseline reflects the initial occupational therapy (OT) evaluation and the discharge reflects the completion of acute care OT services. In all three Veteran cases, the Veteran maintained >90% oxygen saturations on the prescribed supplemental oxygen or room air as indicated. The five intrinsic factors as incorporated into the Person-Environment-Occupation-Performance model include: physiological, cognition, spiritual, neurobehavioral, and psychological. A lower number of intrinsic factors impacted by the Coronavirus-2019 subjectively suggests lower severity of impairments. Full orientation × 4 reflects orientation to person, place, time, and situation. Grip strength that is reported within functional limits (WFL) indicates no reports of change grip strength and sufficient grip strength for functional tasks (transfers, use of basic grooming tools). Due to infectious disease policies, OT did not formally test grip strength if the indicators suggested grip strength was WFL. A: Assistance, Lbs: pounds, N/A: Not applicable, NC: Nasal cannula, NT: Not tested, UE: Upper extremity.

Table 3. Acute occupational therapy evaluation and intervention session considerations.

	Strategies	Special considerations
Preparatory to Evaluation	Augment medical chart reviews with phone interviews with the patient and/or family to reduce exposure time.	Follow privacy considerations, obtain permission from the patient prior to contacting family members.
Model to Guide the Evaluation	Consider focussing the evaluation on the intrinsic and extrinsic factors of the PEOP model.	Collaborate with other disciplines on the desired outcome measures to avoid testing fatigue, consider using remote monitoring technology (i.e., telehealth) for the evaluation.
Communicating with Family Members	Explore the novel use of technology to enhance the evaluation or treatment session.	Utilize the patient’s own technology (smart phone/tablet) when possible, work with facility privacy officers for additional supports such as tablet video conferencing options for patients to their family members, incorporate technology by having a second clinician outside of the treatment room on remote monitoring to record outcome data.
Treatment Planning	Prepare the supplies prior to entry into the room and bring in only the necessary supplies, consider a co-treatment session with another discipline for physical assistance.	Laminate rating scales to allow a patient to point in response to a question and use of verbal screening tools to avoid paper/pencil, Address positioning of the patient to avoid muscle tightness by working with nursing. Streamline shared equipment (e.g., remove additional padding at the knees on a patient lift when it does not alter use of equipment, avoid use of the sling if it is not necessary to assess person’s ability to perform sit to stand transfer).
Vital Sign Monitoring	Conduct vigilant monitoring of Vital Signs (i.e., HR, RR, supplemental oxygen, exertion).	Current practices recommend avoiding < 90% oxygenation, RR > 30, HR < 60 or >120, SBp < 90 or > 180
Outcome Measurement	Measure outcomes each session with standardised measures when possible or qualitatively describe the effects of your session by documenting activity tolerance and achievement of goals.	Incorporate infectious disease protocols for sanitising outcome measure supplies. Progress to standardised outcome measures as the individual’s cognition allows, Documentation of outcome measures can be conducted through remote monitoring with second clinician or medical personnel documenting the results. Selection of outcome measures should weigh the duration of testing with the information gained to avoid testing fatigue.

Note. Refer to facility guidance on titrating oxygen, activity, and the use of devices for communicating with family members. In the absence of COVID-19 specific pulmonary rehabilitation guidelines, we deferred to the medicine team and standard clinical practice for the vital sign parameters. The provider modified and individualised the parameters for vital sign monitoring based on the history of baseline comorbidities and patient’s hospital course. HR: Heart rate; PEOP: Person-Environment-Occupation-Performance; RR: Respiratory rate.

Baum CM, Bass-Haugen J, Christiansen CH. 2005. Person-environment-occupation-performance: a model for planning interventions for individuals and organizations. In: Christiansen Charles H, Baum CM, editors. Occupational therapy performance, participation, and well-being (pp. 372–392). Thorofare: Slack Incorporated.

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