By Maria Correa Baylon, BS, RRT/RCP
Within the walls of my outpatient center-based Pulmonary Rehab program, March 16th, 2020, will be remembered infamously. On that day, after 16 years as a respiratory therapist, my primary responsibility shifted from exercising patients on the treadmill to proning patients in the intensive care unit. The comforting hum of the moving belt on the treadmill was replaced by the squawk of alarms from the ventilator.
I never could have imagined the disruptions to daily life that followed: an unprecedented government stay-at-home order (for nonessential citizens), a series of mask mandates, COVID-19 testing requirements and daily symptom checks.
After three months, which felt like a lifetime, our PR program finally received the green light to reopen. Simply picking up where we left off, however, was not an option. Questions of who, what, when, where and why had to be answered before we could resume therapy for the patients.
Leaders from national and state organizations, colleagues from other programs, and various disciplines within our academic facility helped produce key considerations and guidelines for reopening. We used this feedback, from recommendations offered by the American Thoracic Society (ATS)-Pulmonary Rehabilitation assembly to suggestions made during AACVPR’s May 2020 “Returning with Care” Town Hall meeting, as the foundation for reopening our own facility.
A plan for modifying clinic practices was approved by our medical director. Prior to the unforeseen closure, our program was comprised of three, two-month cohorts (a total of 12 cohorts per year) with average enrollment of 10-12 patients in each, along with a few individual one-on-one appointments to serve those who needed individual care due to lung transplant, work schedule, transportation challenges and language, mental or learning barriers. To reopen, we converted from cohorts to strictly one-on-one appointments, delivering a culture shock across the department.
Defining the reasonable number of patients we would be able to serve in a single day presented an additional challenge. The length of appointments increased because the symptom questionnaire patients completed at check-in and sanitizing equipment after patient use added time to each session. We reopened with four patients per day, down substantially from our normal volume of 24 to 26 patients per day.
Aside from focusing on the safety and well-being of everyone involved, the new protocol also meant a reduction in staff. So many of us had be re-assigned to patient screening at the hospital and ambulatory care entrances. Additionally, we faced the question of determining the best outcome measures to use for our new process. What benchmark would we use to evaluate progress, knowing that we have a whole new disease/condition to consider? The answer is still unknown.
To decide our re-open date, we focused first on reaching out to patients whose care was abruptly suspended due to the shutdown. Within three months of our initial re-opening plan, our clinic doors opened and welcomed patients back in June 2020.
After determining the number of patients to safely treat each day (each hour, more specifically), re-configuration of the treatment areas began. Our 1,100-square-foot exercise room was set up in four stations to meet the requirement of maintaining 8 feet between patients and clinicians set forth by our medical director. Each station consisted of two chairs facing each other, a treadmill and a recumbent cross-trainer. We also converted our 150-sq.-foot conference room into an isolated fifth station to accommodate patients who were severely immunocompromised due to post lung transplant or who were undergoing chemotherapy.
To the question of “why should we reopen?” the answer was simple: for the patients. They needed a safe place to exercise, to receive education and to get external motivation – all necessary for successful management of lung disease. As we continued to treat more patients, the ramifications of the lockdown were clear. Due to quarantines, many patients stopped exercising and drastically reduced normal daily activities outside of their homes out of fear of COVID exposure.
Another reason to reopen was the financial impact our clinic faced. Like most programs, the absence of patients meant no billing or reimbursement. Some programs unfortunately did not survive the pandemic closure, leaving patients with fewer options for available centers, thus making it less desirable to attend a program.
One important lesson I learned from the pandemic was that we can and should develop a process for unanticipated events. However, implementing these granular processes takes a lot of planning and resources. Any process developed for operational procedures is to be clearly validated, planned, executed, monitored and modified as necessary. Additional processes we continue to work on in our program include virtual-based PR that was implemented in January 2021 and a strategy to resume cohorts. For now, we are continuing with the individual-based one-on-one care. Our hope is that the pandemic will soon turn endemic and that another public health threat of this magnitude will not surface again in this lifetime.
Maria Correa Baylon, BS, RRT/RCP, is a respiratory therapist and the lead case coordinator at UCSD Pulmonary Rehabilitation in San Diego, California.