Therapists in the Uniformed Services: Improving Care in Emergency Response Medical Missions

Abstract

People diagnosed with COVID-19 who require hospitalization are primarily admitted secondary to shortness of breath because of hypoxia but also display difficulties with overall muscle weakness, which could impair gait, activities of daily living, speech, cognitive-linguistics, or swallowing. This article provides a clinical perspective of how a physical therapist, occupational therapist, and speech language pathologist in the US Public Health Service Commissioned Corps were deployed with an augmentation team and how they improved care at a hospital that was overwhelmed with patients diagnosed with COVID-19. The rehabilitation team completed 246 evaluation and treatment encounters in a 12-day period and began seeing patients within 24 hours on-site. After the rehabilitation team arrived, patients were noted to be more mobile, independent in activities of daily living, and able to tolerate the least restrictive diets without signs and symptoms of aspiration. As a result of rehabilitation services, safe discharges were expedited, length of stay was reduced, and the hospitals’ inpatient admission capacity was maximized. The augmentation team learned the importance of including rehabilitation specialties for treating patients with COVID-19. Mobilizing rehabilitation specialties along with medical and nursing staff helps maximize the overall recovery, health, and outcomes for patients. Leadership that is responsible for the development and deployment of future medical teams in military, emergency response, and public health efforts should consider all therapy disciplines as an essential component for each team.

The history, origin, and growth of rehabilitation disciplines have had a strong connection with military, emergency, and public health response missions. Physiotherapy and occupational therapy reconstruction aides deployed in 1917 during World War I to the front lines in France, and speech language pathology grew as a profession in the 1920s as many soldiers returned from war with traumatic brain injuries.^1,2 Therapists since the early 1900s have been instrumental in military medicine in the rehabilitation of traumatic neurologic and neuromusculoskeletal injuries, with therapists focusing on improving service members’ mobility, helping them relearn basic life skills, and returning them to productive vocations. ³

Therapists have advanced the science of rehabilitation and enhanced the outcomes of their patients with every subsequent deployment mission since World War I. Advances in prosthetics, cognitive rehabilitation, vocal cord and swallowing dysfunction, wheelchair mobility, wound care, and augmentative and alternative communication devices have all been a result of therapists identifying needs while deployed. Despite the instrumental role of therapists during emergency medical missions, from the beginning, convincing military authorities and other decision makers of the importance of including therapists on deployment teams has been a struggle. ¹

The US Public Health Service (USPHS) has more than 170 Commissioned Corps therapists who frequently deploy to support emergency response medical missions. The USPHS Commissioned Corps is 1 of 8 uniformed services. For more than 200 years, it has served to prevent the spread of disease and protect, promote, and advance our nation’s health in all 50 states and overseas. USPHS Commissioned Corps therapists have deployed to multiple disasters (eg, Hurricanes Katrina, Irma, Harvey, and Maria; the earthquake in Haiti), public health emergencies (eg, Ebola, Zika, COVID-19), and other national and international health emergencies (eg, unaccompanied children missions, mental health response missions). In this article, we provide a recent example of the benefits of deploying a speech language pathologist (SLP), an occupational therapist, and a physical therapist with a medical treatment team to augment a regional hospital that had a substantial number of patients diagnosed with COVID-19. We summarize the critical role of therapists and the importance of having rehabilitation services available on current and future emergency response medical missions.

Purpose

The purpose of the article is to describe the clinical deployment experiences of 3 rehabilitation USPHS Commissioned Corps officers in a regional medical center where most (up to 80%) patients were diagnosed with COVID-19. In addition, this article provides evidence that all uniformed services mobilization teams should consider including SLPs, occupational therapists, and physical therapists as a crucial part of every deployment team to improve health outcomes.

Methods

El Centro Regional Medical Center Mission

A medical augmentation team consisting of 16 staff members was deployed to support El Centro Regional Medical Center (ECRMC) (Figure), a Southern California hospital that was highlighted in the national news for how severely it was affected by the admission of patients diagnosed with COVID-19. ⁴ ECRMC is located in Imperial County, California, which from December 2020 through January 2021 had one of the highest rates of COVID-19 cases per 1 million people—a rate that was nearly double the US average. ⁵ During the 5-week mission, the daily census of the hospital ranged from 174 to 189 patients, which was approximately 70% higher than its typical census, with the percentage of patients with positive diagnosis of COVID-19 being as high as 80%. Most patients with COVID-19 at ECRMC had symptoms that would be classified as either respiratory distress or respiratory failure. ⁶

Figure.

Aerial view of the El Centro Regional Medical Center and the annex that was added to separate patients who received a negative test result for COVID-19 who were treated in the annex from patients who received a positive test result for COVID-19 who were treated in the hospital. The US Public Health Service Commissioned Corps augmentation team, which arrived in December 2020 and departed January 2021, treated patients in both the annex and the medical center. Photo used with permission from El Centro Regional Medical Center.

The medical augmentation team initially deployed with 13 Commissioned Corps officers consisting of 5 physicians, 5 registered nurses, 1 behavioral health provider, 1 SLP who was the team commander and deployed in an administrative lead role, and 1 administrative assistant who also served as the safety staff member. After 1 week on site, the team leadership realized that to reduce patient length of stay and maximize capacity of the facility, an occupational therapist, physical therapist, and an additional SLP to focus on patient care would need to be mobilized, for a final team of 16 staff members.

Physical Therapy

Physical therapists have an important role in response efforts related to major events that affect health and wellness, including the COVID-19 pandemic. ⁷ After natural disasters such as earthquakes, hurricanes, and floods, many patients typically have fractures, amputations, or spinal cord injuries. Early rehabilitation interventions among survivors of critical illness have facilitated early safe hospital discharge, improved functional recovery, and resulted in cost savings. ⁸ One of the primary conditions that arises from patients with COVID-19 is respiratory distress. Patients with respiratory and neuromuscular disease secondary to COVID-19 are complex and pose a myriad of clinical problems that a multidisciplinary team is required to evaluate and treat. ⁹ Physical therapists can aid in the development of protocols for muscular rehabilitation, evaluation and treatments to maximize recovery and function, physical conditioning and exercise, functional mobility, and the assessment of the home environment and assistive devices to aid in a patient’s return to home or a rehabilitation facility.

Occupational Therapy

The occupational therapist was deployed to provide rehabilitation services focused on improving patient function and maximizing independence. ECRMC patients diagnosed with COVID-19 often presented with fatigue, shortness of breath and hypoxia, tachycardia, general weakness, and anxiety—symptoms that decrease the patients’ ability to perform basic daily activities. Patients seen by the occupational therapist were provided a comprehensive individualized evaluation and treatment plan that focused on improving their function and returning the patient to participate in their previous occupations.

Speech Language Pathology

For nearly a century, members of the rehabilitation team have relied on the expertise of SLPs to provide specialized services in articulation, fluency, and voice deficits; dysarthria; receptive and expressive language impairments; cognitive-linguistic disorders; and dysphagia.^10,11 Similar to patients diagnosed with developmental and neurogenic disorders, patients diagnosed with COVID-19 require early referral to an SLP to receive comprehensive assessments and interventions as indicated to alleviate impairments. ¹² Early identification and intervention of speech or language impairment, dysphagia, and cognitive-linguistic disorders could assist with restoring and maintaining sufficient communication, executive functioning, laryngeal airway protection, and adequate oral nutrition and hydration intake that are safe and improve overall health and function.^13-16

Dysarthria, a speech disorder that is caused by muscle weakness, can cause slurred speech secondary to overall oral mechanism weakness. Dysarthria, which was common among COVID-19 patients, may have resulted from the hypoxia that many patients experienced after receiving a positive diagnosis of COVID-19 and affected their oral motor strength, coordination, and range of motion. Aphasia, which is a receptive and expressive language impairment that may be observed in patients diagnosed with neurological deficits, was occasionally observed in patients with COVID-19 in this setting. Cognitive communication impairments (ie, attention, memory, problem solving, and orientation) were other deficiencies documented post-screening and after further assessment was concluded.

Outcomes

The physical therapist on this COVID-19 support mission provided services to improve overall strength, positioning, and transfers in an inpatient setting, providing care to 8 to 10 patients daily to restore mobility as each recovered from the symptoms of COVID-19. The physical therapist worked with patients to minimize their injury risks when they returned to their least restrictive environment, which often was to home. The physical therapist was also involved in discharge planning for each patient whom he followed, including, but not limited to, assessment of any needs for assistive devices or additional equipment needed for discharge location. By educating the medical team and providing physical therapy rehabilitation services, the physical therapist was able to provide services that were vital for caring for the whole patient.

The occupational therapist also evaluated and treated 8 to 10 patients each day, most of whom were diagnosed with COVID-19, who were placed on an evidence-based progressive treatment routine, focused first on bed mobility and simple bed activities and exercises. As they improved, patients were challenged with progressive strengthening exercises, functional mobility, and performance of activities of daily living. Throughout all treatments, patients’ vitals were monitored, and they were educated on energy conservation and activity simplification techniques, while balancing the need to advance aerobic challenges within their limitations. The occupational therapist also cross-trained the interdisciplinary team to assist with transfers and increase patient activity levels, as well as educated staff members on when patients were ready to increase their independence in feeding, dressing, and toileting. Occupational therapy was focused on returning patients home or to the lowest acuity level of care. The occupational therapist worked with ECRMC social work services and family members virtually to maximize a safe transition and prevent the need for readmissions.

The SLP on this COVID-19 support mission assessed and treated patients with cognitive–linguistic impairments and dysphagia. The most prominent impairment seen in this setting was oral and pharyngeal dysphagia. The SLP conducted 5 to 8 clinical bedside or modified barium swallow evaluations daily. Diet modifications, such as changing consistencies of foods and drinks and training on the use of swallow precautions and compensatory strategies for both the patient and staff members, were completed to improve swallow safety while maintaining adequate nutrition and hydration for patients. These diet modifications ensured safe bolus transit and reduced aspiration risks during oral intake.

Overall, the rehabilitation team increased the capacity of ECRMC’s rehabilitation services by >50% and decreased the length of stay, which increased the capacity of the facility and improved the standard of care and health outcomes for patients.

Lessons Learned

Before the augmentation team stood down and was recalled, the hospital census had been reduced and the number of COVID-19 cases had decreased. The augmentation team treated more than 446 patients in less than 6 weeks, and the rehabilitation team completed 246 encounters, with an estimated 80% of the patients being diagnosed with COVID-19. The team worked together and learned the importance of an integrated interdisciplinary approach and how mobilizing medical, nursing, and rehabilitation officers as a team maximizes overall patient health and outcomes.

The rehabilitation team provided the expertise needed to maximize patient independence and helped the interdisciplinary team accurately identify the appropriate discharge setting for each patient. The direct rehabilitation interventions provided, along with the therapists’ expertise in improving accuracy and expediency in discharge planning, maximized ECRMC’s capacity, improved patient care, and reduced readmissions.

The USPHS Commissioned Corps augmentation team supporting ECRMC showed how therapists can serve and improve the capacity of an interdisciplinary emergency response medical team and improve patient health outcomes. There are countless other past examples of therapists improving outcomes in Uniformed Services emergency response medical missions, such as Ebola and Zika; hurricane responses secondary to Hurricanes Katrina, Maria, and Ike; the earthquake in Haiti; and mass casualty situations such as 9/11 and the marathon bomber. As with the ECRMC mission, therapists deploying in the role of their clinical specialty have often been a secondary thought when configuring and deploying medical teams. Therapists have either deployed late after a need was recognized or not deployed at all.

Even though therapists have not always been deployed during emergency response medical missions in the past, therapy services have almost always been needed and will be relied on even more in the future. Occupational therapy, physical therapy, and speech language pathology are not only some of the fastest-growing professions but are projected to grow faster than most other health care professions in the next 10 years.^17,18 Growth rates retrieved from the US Bureau of Labor Statistics Occupational Outlook Handbook indicate the number of pharmacists will decline and the number of physicians will grow by a rate of 5%, but physical therapists, occupational therapists, and SLPs will increase by 16% to 25% during a 10-year span from 2019 to 2029.^17,18 This growth is a reflection of the value of services they provide and the unique medical needs therapists will address in the future.

As our nation continues to open businesses and schools and prepares for the next public health emergency, our Uniformed Services emergency response medical teams need to be ready. During summer 2020, Congress showed its recognition of the importance of preparedness and modernizing the capacity of the USPHS Commissioned Corps and included additional public health and emergency response funding in the Coronavirus Aid, Relief, and Economic Security (CARES) Act. ¹⁹ The CARES Act provided funding for a substantial amount of equipment and training for future USPHS Commissioned Corps deployment teams. In addition, to meet the needs of a rapidly ready and deployable force, former Surgeon General VADM Jerome Adams authorized the development of public health and emergency response strike teams. We urge leadership of all Uniformed Services to consider the future needs of the patients whom the health care community will be called to serve. Whether on a battlefield or on the frontlines within our nation’s borders, strike teams and every future emergency response medical team should include all therapy disciplines on the interdisciplinary team, to maximize the health outcomes of patients and communities.