Can you tell us a little about how your service operated before the pandemic?
Prior to the COVID pandemic a team of Specialist Respiratory Physiotherapists and Fitness instructors provided face to face pulmonary rehabilitation for all chronic respiratory conditions (COPD, Bronchiectasis, ILD, Asthma, Pulmonary Hypertension) across one hospital gym and 5 community gym sites. We did not offer any remote options. Assessment involved the Incremental Shuttle Walk Test (ISWT), one repetition maximum testing (1 rep MAX) , Health-related quality of life (HRQOL) questionnaires as well as an assessment of mood. The programme typically involved 20 minutes of cardio exercise (bike, treadmill) and resistance exercise for the upper and lower limbs using gym equipment and face to face education sessions.
What happened to services during the first wave of COVID?
At the beginning of the pandemic all face to face assessments and programmes stopped. We did have a cohort of patients who had been assessed ready to commence a programme and these patients were initially supported by our fitness instructors to carry out their home exercise programmes.
Did you provide online support for rehab?
Our team worked to develop both an online and handbook version of our exercise and education programmes and these were then offered to cohorts of patients.
Initially a remote assessment was completed using the one minute sit to stand (STS) test as an outcome measure, which was assessed remotely (phone or attend anywhere) and with the use of home observation monitoring equipment (saturations probe and blood pressure monitor).
We also used a falls screening questionnaire, FES-I, to identify patients for whom this would not be suitable.
How well did the online assessment work?
It quickly became apparent that the team did not feel this online assessment would be appropriate for patients that had not been previously seen face to face. We were concerned about how we may miss things such as exertional desaturation, mobility issues, comorbidities such as Atrial Fibrillation (AF) and we were unable to prescribe exercise based on the one minute STS test as we would have done using the ISWT. We were therefore keen to return at least to face to face assessment as soon as possible.
It sounds like getting back to face to face assessments became a priority. How did you achieve this?
Following the end of the first wave we were driven to get back to face to face assessments as soon as possible. At our hospital site a number of processes were followed to ensure this was safe for both staff and patients. We consulted with infection control to ensure we had all appropriate measures in place for staff and patients. The Trust’s lead infection control nurse visited the department and reviewed, and approved the standard operating procedures before we commenced seeing patients face to face.
What were the specific measures for the department?
On a department level we ensured:
- Safe spacing 2m+.
- Appropriate PPE.
- Clean masks were worn in clinical areas.
- Sanitizer was readily available.
- We had the air changes for the assessment room assessed to ensure we had adequate ventilation.
- More time between patients to allow for extra cleaning.
- Logs of patient temperatures and cleaning checks were maintained too.
What were the specific measures for patients?
For our patients, we:
- Used a COVID symptom questionnaire.
- Used temperature checks.
- Made sure masks were worn.
- Encouraged patients not to arrive in the department more than 5 minutes before their start time.
- Ensured patients were complying with social distancing when waiting to enter department.
Were there impacts on the number of patients you could see, and the length of the appointments?
At the hospital site our group sizes had to be halved as we could only safely have six patients spaced in their two metre bubbles with individualised equipment.
We also minimised the contact time by keeping the educational element virtual, so patients were attending for one hour exercise only. Each patient was set up with their own box to put their belongings; they were encouraged to bring their own water.
Movement within the room between cardio and resistance equipment would happen once in the session in a unidirectional manner and patient would move their chair and belongings with them once their allocated area had been cleaned between uses. Patients were encouraged to wear masks at all time if possible, or to remove it while using cardio equipment when facing a wall.
You offer rehabilitation in the community too. How has this been affected?
At our community gym sites we have worked in conjunction with the gym managers and made use of their risk assessments. We have enabled patients to safely access the pulmonary rehab programmes at community sites, albeit in smaller numbers. We have continued with all the PPE guidance, temperature checks and cleaning as per hospital site and followed their unidirectional flow between adequately spaced equipment.