Hello. Very good morning to everyone. I hope you're enjoying the AAPMNR meeting as much as we all have done. I want to introduce this session. This session is Efficacy of Early Inpatient Rehabilitation of Post-COVID-19 Survivors, and this is our own center retrospective data analysis. I have with me really wonderful clinicians and illustrious physiatrists who have collaborated with this effort without any hesitation. Ning Chao, who is the clinical program director of the stroke program at Moss Rehab. Tom Wadnabe, who's the clinical director of the brain injury rehabilitation program here at Moss Rehab. Jacqueline Barsakowski, who is an attending physician in both our stroke and brain injury program and the associate program director of our residency training program. And then Mike Wasniewski, who's the clinical director of the inpatient and amputation rehabilitation program here at Moss Rehab. I'm Alberto Scanasi. I'm the chair of the department, and you may notice that our name has changed, and now it says Jefferson Health. We recently went through a merger, and now we are proud partners of Jefferson Health. So without further ado, I'm going to get started. I do encourage you to use the chat feature and put questions or comments there, and we'll do our best to try to get to all of them. I'm going to ask my co-presenters to kindly put themselves on mute, and we will bring them back as we go through the process. So let me outline the presentation. We'll use this to describe the program that we've developed, which is important because that allows us to treat many of the patients with COVID, and what was the development and protocol process for that. We'll have the opportunity to review the clinical characteristics of the patients that we treated, what were the functional outcomes for these patients divided by categories, those with pulmonary diagnosis as a primary presentation, those that were diagnosed by having COVID positive compared to our non-COVID positive with other diagnostic categories, and then finally present to you some of the longer-term outcomes and complications we've seen in this patient population. So MOS Rehab is organized in diagnostic-specific units, which vary in size. Last year, under the huge pressure of the pandemic caused by COVID-19, we decided to move forward and open a dedicated unit for the care of patients with COVID who also had rehabilitation needs, and we conceptualized this by saying that we thought that with adequate planning, appropriate training, and equipment, we could treat these patients in a relatively safe environment, both for patients and all of our clinical staff. We projected essentially three sources of patients. Patients who were in rehabilitation and were in need of rehabilitation and were COVID positive. Those patients who were COVID positive patients who could benefit from services of an IRF, although may not have had other concomitant diagnoses. And then finally, those patients who were in rehabilitation, were receiving care, and then developed COVID while they were here. We estimated about 10% of our patients could benefit from these services, and we decided on April 7, 2020, to open a 14-bed unit that we call the Core Plus Unit, COVID rehabilitation, and it was a plus for the positive patients who were in the unit. From the period of April 7, 2020, until July 6, 2021, when we closed the unit, we treated 180 patients in that unit, and they, after that date, we've moved those patients that are COVID positive to our regular diagnostic specific units. And since the beginning of the pandemic, we've treated about 230 patients who are COVID positive. Patients treated are assigned to a rehabilitation team with no rotating staff, and they were in a segregated unit, this 14-unit bed that we created. We assure staff safety by training them and retraining them in the appropriate use of PPE. They all had N95 respirators. They all were asked to wear eye protection, gowns, gloves, and be sure that were frequently exchanged. All staff working on this unit were monitored for fever and symptoms every shift. We had a dedicated elevator for all core staff and patients, and we did not allow any visitation. Of course, these patients could run into trouble, and so we went ahead, and for any rapid response or code, we follow regular protocols but ask that an individual be posted at the entrance of the room needed help to assure that everybody was wearing the appropriate PPE. And then the other two items were radiographic assessments were done in their room if it was positive, if it was possible, and if they needed more complex imaging, then we would alert the staff so that the patient would be moved into the CT scanner or the MRI if that's what was needed. We converted our rooms to be able to have a setup to provide hemodialysis in the room. This is a core unit, and this is Dr. Barsakowski going into the unit. All of the rehabilitation equipment in this unit was dedicated to the patients with active COVID, including several robotic devices that we were able to obtain either through purchasing or donations. The admission criteria for the unit were for patients admitted with a diagnosis of COVID-19 positive. They needed to require isolation. In the beginning, we used a PCR testing result as a way to end isolation, but as of October 2020, when the CDC updated its guidelines, we used a time-based strategy. We wanted to be sure the patients had at least 72 hours with no fever, and they were not on any fever-reducing medications. If they were using aerosol treatments, we provided those in a negative pressure room, and if they had a tracheostomy, it was important that they did not have a prescribed suction timing, but that only on a needed basis. Oxygen needs were acceptable at no more than five liters at rest so that they could participate in therapy. We wanted to be sure that these patients had improving symptoms and being able to participate in rehabilitation. Every case was reviewed by at least two of the attendings to be sure that it merited admission. For treatment, we incorporated pulmonary rehabilitation. We certainly looked at optimizing medical management. We established a progressive exercise protocol with close monitoring, and we monitor not only the vitals but also pulse oximetry. We implemented energy conservation techniques and respiratory therapy. We worked on mobility and ADLs, and we worked on those patients that needed speech and swallow. We had neuropsychological services for cognitive assessment and addressing psychological needs, and because patients were not allowed to have visitation, social workers were really there to provide emotional support. We used recreational therapy for video conferencing so that the families could be aware of what the patient was going through. All right, so I'm Mike Kwaszewski. Thanks, Alberto. We're going to be talking a little bit about the clinical characteristics comparison between COVID-19 patients with primarily pulmonary manifestations versus the other rehab diagnosis with COVID co-infection in their rehab core unit. So the data that we'll be looking at was based off of review of the electronic medical records from our patient to admit to the core unit. As Dr. Espinosa had mentioned, the unit was open from April 2020 through July 2021. Mike, if you could get closer to your microphone. I don't hear your voice very strong. Okay, let's see. Is that any better? Much better. Thank you. Sure. So as I said, the data reviewed was from April of 2020 through July of 2021. For the purposes of this talk, however, the patient population we'll be looking through was analyzed from April of 2020 through December of 2020. We'll be looking at demographics as well as comorbidities and supplemental oxygen use, the length of their hospital stay, including any ICU time prior to their transfer to us on the rehab unit, as well as presence of any post-intensive care syndrome at rehab admission, including electrodiagnostic evaluation for critical care neuropathies, and finally, looking at analysis for clinical characteristics for the group within COVID that required ventilator support versus those not requiring ventilator support. Next. So as I previously mentioned, we looked at a total of 101 patients through the time frame of April 2020 through December of 2020. I am getting some messages saying the speaker's not coming through clear, so let me try switching over. Is that any better? Yes. Okay. Sorry about that. So as I said, 101 patients from April through December of 2020. Now, the way that we classified was primary pulmonary diagnosis versus other primary diagnosis, and upon chart review, looking at H&Ps for the patients who did come to us, we classified the primary pulmonary folks as those who had a positive COVID diagnosis, which was confirmed by PCR, and this is for all of our patients, obviously, but confirmed by PCR, and the primary portion of their debility and functional needs were really secondary to respiratory distress and having received treatment secondary to COVID. The other primary group was any patient who was admitted to our service who may have incidentally been found to be COVID positive, either upon admission to the acute care hospital or to our rehab unit, as well as anyone who potentially had developed symptoms and tested positive during the rehab stay. So from a numbers perspective, we had about 59 patients in the primary pulmonary group versus 42 in the other primary. Age range was fairly even comparable on the primary side for primary pulmonary. The mean was 65 years old versus the other primary group at a mean of 62, and looking at age ranges, give or take about the same. Slightly younger population on the younger side for the primary group, if you look at the range, and this is because, you know, included patients, spinal cord, et cetera, polytrauma who may have been on the younger side. With regards to males versus females, numbers were about even, give or take a little bit less than 50% for both groups. Next slide. So this is just a table breakdown, looking specifically at the different numbers for the comorbidities, as well as general demographics. And then at the bottom, you'll see DBT and PE, which were one of the things that we had followed up in as far as anything that may develop throughout the hospital stay. Next slide. So looking at comorbid conditions with regards to potential modifiable risk factors, we all know that obesity is, you know, an epidemic in the United States, and we have very large numbers. So within the pulmonary group, the mean BMI for the patient group that we saw was 30 kilograms per meter squared, and that classifies them as obese. Comparatively, in the other primary group, the mean was about 28, which is overweight, as per the chart over on the side, which I know everyone is familiar with. While not a huge difference and not statistically significant, you know, we do know that obesity increases risk factors for potential severe illnesses as it can compromise the immune system. As, you know, as BMI continues to increase, it can decrease overall lung capacity, so some increase in risk there. Folks who were cigarette smokers, and this is folks who were essentially actively smoking or, you know, fairly close history, no one with remote histories, you know, the numbers were pretty even. It's about 23, 24 percent were cigarette smokers in the pulmonary group versus 33 percent in the primary group. You know, a little bit higher in other primary, but both groups, both BMI and cigarette smokers, the numbers were not statistically significant for any difference between the two groups. Next, please. So, moving down from the table we previously looked at, going into comorbid conditions, the most prevalent comorbid condition in both groups was hypertension, which is not totally surprising as it is about 47 percent of the U.S. population with hypertension and about a quarter of them only having it controlled. Now, 81 percent of the patients in the primary group had a premorbid diagnosis, primary pulmonary, excuse me, had a premorbid diagnosis of hypertension versus 62 percent in the other primary group or the co-infection group. And this was one of the few comorbid conditions that we looked at that was approaching statistical significance and almost pretty much right there. Now, the type 2 diabetes, again, this was a premorbidly diagnosed condition for these patients, so all of these patients when they came into the hospital had these diagnoses. The numbers were about the same for both the primary pulmonary group and the other pulmonary or co-infection group. That's about 40 percent in both, so not statistically significant from that perspective. Now, cardiac dysfunction, which we classified as essentially the gamut of cardiac conditions, so CHF, CAD, any arrhythmias, et cetera, were classified as cardiac dysfunction. Between the two groups themselves, the primary pulmonary group was about 40 percent premorbidly diagnosed versus 50 percent in the other primary group, so a little bit of a difference, but given the numbers, no statistical significance was seen between the two groups. Next, thank you. Now, continuing to go down the table, kidney disease comparatively between the two groups was about 20 percent, so no major difference there. COPD did have a higher rate noted in the primary pulmonary group, about 14 percent in the primary pulmonary group versus about 7 percent, so half. However, the numbers were still slightly on the lower side, and so this did not make up any statistical significance between the two groups, though there have been discussions about how COPD plays into development of COVID and COVID diagnosis. Malignancy, which we also included as a comorbid condition was looked at and it was found to be more prevalent in the other primary group versus the primary pulmonary group. But again, no statistical significance was seen there. Next slide. And that does tie into one of the main complications that we looked at as well, and that was development of DVT or PE. And this was throughout the patient's hospital stay, both acute as well as the rehabilitation stay with us. Now while DVT was almost four times more prevalent in the primary pulmonary group, again, there was no statistical significance seen, but again, may have been secondary to the lower numbers that were seen or the lower numbers that we evaluated within our study. Now PE was about equal in prevalence on both sides and we did utilize screening methods. Not every patient who was admitted to our unit was screened for DVT or PE, but we did look at risk factors, we looked at clinical signs and symptoms as well as some laboratory studies including D-dimer levels to determine whether certain patients needed to be screened upon admission or throughout their hospitalization stay. So I'll pass it off to Dr. Jacqueline Barsikowsky for the next section. Thank you. I'm Jacqueline Barsikowsky. I'm going to be presenting about the functional outcomes of the particular group of patients who we looked at with primary pulmonary manifestation. And as a reminder, those are the patients who presented with a primary diagnosis of COVID-19 infection, COVID-19 pulmonary sequela or COVID-19 pneumonia or acute respiratory failure due to the COVID-19 virus. And then this cohort of patients was further assessed and then kind of split apart and compared with for those who had an acute ICU stay and those who did not have an ICU stay. So, oh, next slide. So those are the 59 patients that Dr. Kwasniewski had previously talked about within all of our patients on the core unit. And of those patients, 14 had ICU admissions. So those 14 patients also required a mechanical ventilation. As to be expected, the acute care length of stay was significantly different for those patients who had ICU stays and versus those who did not, with those who were admitted to the ICU having a longer length of stay versus those who did not. And in general, the average length of stay amongst all primary pulmonary manifestation patients was about 12 days. And it was 18 days for those admitted to the ICU and then about 10 with those who admitted which did not have ICU admissions. The rehab length of stay was not statistically different between patients with and without ICU stays. And the average length of stay in acute rehab amongst all pulmonary patients was about 13 days. So not really different from those patients with, you know, in general for IRF admissions. Okay, next slide. So functional outcomes. So we looked at the different GG functional measure scores in our patients in the primary pulmonary patients. And we looked at mobility from a physical therapy perspective, as well as OT from self-care perspective. And then of course, from a cognitive perspective. Cognitive we looked at within, we kind of looked at it within the speech therapy domain. And so really no statistical significance difference in GG scores across all functional domains between our patients who underwent ICU stays and those who did not. But I think really important to highlight in these patients was that over 70% of the patients in both of these groups, so all of the patients who had primary COVID diagnoses did require cognitive supports on admission. Maybe suggesting that, you know, the return to, and then at discharge, they still were requiring cognitive support. Really kind of a suggestion that possibly that the cognitive impairment is just more challenging to return to the baseline versus the functional and physical impairments. A greater percentage of patients who did not undergo ICU stays, again, needed cognitive supported discharge. Next slide. So these are some of the other outcomes that we looked at in some of our patients. We looked at the neuropsychological need, and that was determined by whether or not a neuropsych, you know, most patients were seen by neuropsychology, but whether or not they were continued to need to be followed throughout the stay was how we defined that need. And there really wasn't a big difference in between the patients, percentage of patients who required neuropsychology support in between the two groups. And it was interestingly low across both groups. We'll say about, so in terms of dysphagia, we looked at, it looks like the number of patients who had difficulty swallowing were greater after the ICU stay versus the patients who did not have an ICU stay, which is of course more than likely due to requiring mechanical ventilation. And we would almost expect that kind of a result. We also looked at supplemental oxygen use at admission, and then also at discharge. About 45% of patients across both groups, so 45% of patients required oxygen supplementation at the time that they were admitted. But luckily at the time of discharge, there was really no difference between the groups for patients requiring oxygen at admission, I mean, at discharge. So I think that that really just helps to demonstrate that they really responded quite well to the interventional, like the rehabilitation, and then they pulled from a pulmonary perspective recovered quite nicely. Next slide. Discharge outcomes. I think that this is such, honestly, an exciting slide to present to you all today, because I think we're all pretty proud of the fact that most of our patients really made it home. This is especially after a long acute care stay, rehab stay, and just a kind of a very anxiety provoking and just difficult and challenging time. And so as you can see across the board, out of 59 of our patients who presented to the unit in this group with primary pulmonary manifestation, 55 were discharged to home. A couple went to skilled nursing facilities. And then a few did, unfortunately, were admitted back to acute care, and that primarily was due to pulmonary compromise. And so, and that was statistically significant in between the two groups, and that certainly could be likely due to the fact that there's just a smaller group of the post ICU patients. But like I said, it's pretty, I think we're all pretty proud of the fact that most of these patients, I think it also represents that these patients tolerated inpatient rehab and did well with it as well and made it home. Next slide. So lastly, our key points. So all patients had significant functional gains across physical therapy, physical and OT within the GG section scale, regardless of whether or not they were admitted to the ICU. And I think that we've observed that COVID patients, so the primary patients with primary pulmonary dysfunction were able to tolerate and benefit from at least three hours of multidisciplinary acute inpatient rehab care with great functional gain. Most patients did still require cognitive rehabilitation at the time of discharge. And so again, as I mentioned earlier, this could just kind of lend to the, maybe lend support to that cognitive impairment is a little bit more challenging to return to baseline. Again, more than 40% of patients required new supplemental oxygen on admission and almost all were able to be weaned off of oxygen by discharge. And then almost all patients with primary pulmonary manifestations following COVID-19 were discharged to home from our COVID unit, as I mentioned. And then post ICU patients had a slightly higher rate of acute transfers and discharges to skilled nursing facilities. I do see a question I want to just make sure I answer in the chat about the cognitive defects. So Dr. Watanabe is going to mention this a little bit further along, but I will say that inpatient, the cognitive impairments that we were seeing primarily had to do with, you know, memory, attention, and a little bit of executive functioning. But I will now pass along the rest, the next part to Dr. Ning Chao. Hello, morning. Thanks, Jacqueline's wonderful presentation. So what I'm going to present are the data, which is preliminary. Look at the functional outcomes of the patients with other rehab diagnosis admitted to the core unit, which compared to the impairment matched groups at the completion of the inpatient rehabilitation stay. Next. So this is an overview of the data collection. So the functional outcomes in the patients with the stroke, spinal cord injury, medical complex rehab diagnosis admitted to the core unit were compared to impairment matched group admitted to the regular inpatient rehab unit during the same period of time from April to December 2020. And as we mentioned before, the functional outcomes were captured by the mission and discharge GG score in both mobility and self-care domains. Next. So before we dive into the details of the data, there is some background information I want to point out. So the reason we include a stroke, spinal cord injury, and medical complex patients because these are diagnosis comprised majority of the non-pulmonary COVID-19 rehab diagnosis admitted to the core unit during pandemic. And also, these are the most prevalent diagnosis admitted to the inpatient rehab unit. So I want to delineate a little bit more regarding the component of the core units for other rehab diagnosis. Among 15 stroke patients with a positive COVID, four of them were internally transferred from stroke rehab program with either incidental screening findings or mild symptoms. Similarly, three out of 11 spinal cord injury patients were transferred internally from spinal cord injury program. And four out of eight medically complex patients in core unit were internal transfers as well. So this data really indicate that despite the strict precautions and because of the high community transmission rate during the pandemic and the nature how we deliver the rehab treatment really put us very challenging situation to contain the highly contagious COVID-19. This is also emphasized that the core unit enable us to accommodate both the primary rehabilitation need and the related COVID-19 symptoms and functional deficits. Next. So as we mentioned, those are the diagnosis. We did analysis. And another key point we want to emphasize as well, we only report the patients with a positive COVID admitted to the inpatient rehabilitation setting based on the standard admission criteria. So they do have the potential to be able to tolerate three hours a day, five to seven days a week, multidisciplinary intervention, and they do have potential to improve based on the admission criteria. So the results we present here not necessarily representative of the entire COVID-positive population. Next, please. So if we look at the subgroup analysis for a stroke patient population, as I highlight over here, as we can see, on admission, the core unit stroke patients do appear have lower functional admission on admission in mobility and self-care. The functional gain is comparable, however, slightly lower than the impairment matched control group. Next, please. So when we look at the spinal cord injury group, with the positive COVID group, the similar finding was observed on admission. GG score was lower than the impairment matched group. Although they made a similar functional gain by discharge, however, in both mobility and self-care domain, they do appear lower functionally by discharge. Next, please. Medical complex group, which is kind of interesting because we want to compare this group of patients not only with the impairment matched control group, which we had similar findings, on average, the GG admission and discharge were lower than the non-COVID co-infection group. However, when we look at the ability secondary to the primary COVID group, they have a similar admission and discharge GG score, however, the COVID patient with the respiratory symptom made a better, greater functional gain overall. Next, please. So in summary, although the functional improvement in both self-care and mobility domains was observed after inpatient rehabilitation, the positive COVID group showed a little bit smaller functional gains at discharge compared to the respective impairment matched groups. Although they did receive a little bit longer length of stay in the inpatient rehab setting. But, you know, these are not statistical analysis. It's pretty much, you know, very preliminary observation. The primary pulmonary COVID-19 patients showed a trend of greater functional gain than those with other medical conditions or other neurological diagnosis. The self-group analysis from, you know, this table really provide insights as to the impact of the COVID-19 on rehabilitation outcomes. And this is really need to be further investigated. So I'm going to hand it over to Dr. Wannabell. Thank you. And I really appreciate the opportunity that I have to share some further information we have at looking at this cohort of patients. Specifically looking at differences in patients who had a history of being on a ventilator versus not. And then also sharing some of our experiences in longer-term follow-up for these patients. Next slide, please. Yes, good. This is a slide that looks at the comparison of patients who did require mechanical ventilation at some point in their acute hospital stay versus those who did not. And for looking at comorbidities, we see that there is no significant differences in comorbidities examined demonstrated here. Next slide. As mentioned by Dr. Chow, it's really important to remember that this is a very selected population. I think pretty much all studies looking at patients who receive acute inpatient rehabilitation are challenged by this because you really can't ethically do a study comparing patients who get rehab and those who don't. But nevertheless, we do want to take some look at these intergroup comparisons. In the acute care setting, we know that there are certain risk factors for the need for ventilation, and they are listed here. So I just want to remind you that although we did not see differences in acute care, we know that there are risk factors, and some of these have already been discussed as well. Next slide, please. So while a greater percentage of patients that required mechanical ventilation did have acute DVT and PE, these results were not statistically significant. As mentioned before, it's also important to note that there were significant changes going on in terms of our protocols for diagnosis and management of VTE, So both prophylaxis and workup for PE, especially in the first few weeks to months that the unit was open, you know, literature was coming out, you know, almost daily or weekly looking at some of these newer complications that people were, frankly, weren't aware of initially. So this probably did have some impact on our overall rates and perhaps at some point we can look at how these rates changed over time as our procedures changed over time. The acute rates of DVT and PE for those who were and were not on mechanical ventilation were comparable to other studies that were coming up from the same time period and I just quote one of those studies here. Next slide, please. One of the advantages that we had in being able to follow patients closely, fairly acutely in their stay and then even later was the ability to identify clinical findings or suspicion that might suggest some neurologic complications. There is another, there's a fuller study that will be presented elsewhere at this meeting looking at electro diagnostic findings for patients who are COVID positive, but many of those patients were on our units. I just wanted to share a little of that information here. So 19 patients had been, have been evaluated for the other study. 15 of those 19 who had positive findings were on a ventilator at some point. And those, for those who are on a ventilator, the majority of them had critical illness myopathy. Also, the majority of them had critical illness neuropathy. And as you can see, many of them had both, not surprising given the nature of the disease course. For those who are not on a ventilator, none of them had critical illness myopathy or neuropathy. They had other findings, again, suggested that there might be some difference in the populations who required ventilation and those who did not. Okay. Next slide, please. There are going to be other presentations at this meeting. I'm looking forward to seeing them focusing on longer term complications of COVID-19, but we thought we had a relatively unique opportunity because we have been following these patients so closely and inpatient to maybe get a different perspective on risk factors and outcomes on longer term. So this is just a general slide that reminds us of a number of the problems that have been identified as arising long-term after rehab. And I think we might be able to specifically have a much better sense of what was going in that subacute to early post-acute phase. And then I'll share some information more chronically as well. Next slide, please. Okay. So this is a list of the most common symptoms that are seen long-term with COVID-19 infection. I know that most of you are aware of these and aware of the fact that many of these symptoms have really significant impact on function, which we as physiatrists are very interested in, and also as physiatrists have the opportunity to have a positive impact on these. So we are always mindful of these as we're following our patients. Additionally, I just pulled out another slide looking specifically at neurologic complications, especially neuropsychiatric complications, because not only their impact on function, but many of us who are part of this unit are neuro-focused rehabilitation physicians, and really wanted to take a look at cognitive effects and our ability to impact them and improve overall function. Next slide, please. Okay. So early on, as we developed this unit, we did realize, and there was emerging information at that time, and of course it continues to emerge, about longer-term sequelae. So we wanted to develop a plan to be able to follow our patients long-term so that we could provide more information about what long COVID it is all about. Some of the outpatient measures that we determined would be useful include the SLUMS, GG scores, 10-meter walk test, FEV1, authoritative quality of life 14. I saw earlier in the chat a question about evaluation of cognition. So the SLUMS, I guess we can go to the next slide, SLUMS, is a non-proprietary measure of cognition. For those of you who aren't familiar with it, it's similar to the mini mental status exam or the MOCA. We use the SLUMS in inpatient rehabilitation as well. So this was an opportunity to follow these patients both during their acute rehab course and post-discharge as well. It was mentioned previously by Dr. Braskowski about some of the cognitive deficits, and I know this might help answer another question as well, that we saw in other literature issues with working memory, set shifting, divided attention, and processing speed seem to be some of the more likely longer-term cognitive deficits seen with COVID-19. Executive function relatively spared, although not fully. The other study, El Emano, that I just listed here, also demonstrated that patients in a European COVID positive rehabilitation setting, which is a bit different from ours, but somewhat comparable, a large percentage of those patients had cognitive and mood-related deficits, and we shouldn't really consider mood as part of the longer-term complications. And something that can significantly impact outcome as well. Next slide, please. The HR QOL-14 is an instrument that some of you may or may not be as familiar with. The CDC developed it, and it's to look at overall health status. There was a question about looking at fatigue, and this instrument, to some degree, assesses fatigue and other problems. So it looks at specific activity limitations, what limitations patients are having physically, mentally, and emotionally. And then it has a set of questions, and it's called healthy days, and it asks, in the past 30 days, problems that you may have had with pain, mood, anxiety, et cetera. And overall, in the past 30 days, how you would rate aspects of quality of life, aspects of quality of life, such as pain, mood, sleep, energy levels, and things like that. So we thought that this would be a good long-term measure of outcome and hopefully recovery after COVID-19. Next slide, please. Okay, so today, actually, we have a few more patients who have followed up since I made this slide. So we're continuing to have patients follow up in our outpatient setting, although you can see it's still a small number. So it's maybe about 14 or 15 patients, and the number of visits is they're probably averaging two to three visits, and as time goes on, they'll keep coming back. One reason that became clear why we had small follow-ups initially is recall that this unit was started over a year ago. There was a lot of concern about going out in the community, going out into a hospital setting, into a clinic setting after recovery from the COVID infection. So some patients were really very reluctant to show. Some of them have subsequently started coming back, and we are going to make efforts to reach out to them and encourage them to get back so that we can continue to follow them. Something else that we identified is that most patients at the time of discharge, and perhaps this goes to Jacqueline's sharing of data about how many patients went home, as you might imagine, GG scores were quite high for most of those patients. So the ability to detect further improvement is a bit limited, although in the long run, the ability to detect a decline in function, the HGG scores might be something that will be useful. We'll have to see about that. Next slide, please. Okay, so in terms of the outpatients that we've seen, those patients who've gone from inpatient to outpatient setting, at least, or more than 75% of patients have at least mild cognitive impairment as rated on the slums. Of course, we can't determine specific causation for cognitive deficits. So there are likely direct effects from infection, indirect effects, for instance, with effects on mood, for instance, or sleep and things like that, that can affect cognition. We know that there are so many other variables that can affect cognition, or some that are maybe totally unrelated to the COVID-19 infection. Many of our patients have other underlying comorbidities that may, in part, impact cognition. We will continue to follow these, link our outpatient follow-up scores with scores that patients had in inpatient to try to get a little better understanding of these cognitive deficits. We've also noted a wide variation in the health-related quality of life scores among participants. It's interesting, many of the participants who have started out with low HRQL scores, the scores remain persistently low, even though from a functional standpoint, we've been able to demonstrate some improvement. At least half of the patients we followed have scores in multiple domains that are at the two extremes of the instrument. So if you remember, for part of the instrument, it's how many days have you had problems or how many days have you felt healthy, and at least half the participants scored either zero for all of them or 30 for all of them. So we'll have to see if the instrument helps us identify more subtle improvements over time. Although I have to say, it's a very well-validated instrument in general, so hopefully we'll be able to continue to use that to help us identify longer-term follow-ups. Next slide, please. In summary, we hope that the information that we've provided are helpful. It's the findings related to post-acute care in an IRF for patients with COVID-19 and with its focus on functional status and rehabilitation interventions and outcomes. These data, remember, are from a single rehabilitation facility, but we still feel that they're helpful because there is really not much information about the specific COVID-positive acute inpatient unit, and we hope that the data that we collected there can also lead to further understanding of longer-term outcomes. And this is an ongoing study, and we expect to have some more longer-term outcomes as well. Okay, next slide, please. So we, of course, want to thank the staff of the CORE Plus unit for all that they did. Times have really changed, but I can still remember quite clearly, literally, you know, the fear that people had in being exposed to patients with COVID-19, especially early on. So we really are thankful to all the staff who participated in the care of these patients. Of course, thanks to patients and their families for allowing us to work with them, and to all of you. And I hope we have a little time for questions and hopefully answers. We, in fact, do, Tom. There is one question here on the chat box that I thought might be appropriate to try to answer, and it says, also, the MOCA test has more executive functions than set shifting. Do you use it and find it useful? Okay, we have not done any work like that, comparing whether one instrument is more helpful than another in assessing executive function. You know, I think from a more clinically-based and not research-based standpoint, when we are seeing patients who have significant cognitive deficits or cognitive deficits that we think are problematic for function, we will move towards the more robust neuropsych testing than just these screening instruments. Thank you. That's, I think, a good answer. I'm watching the chat box and it says, were the cognitive deficits tracked to patients requiring mechanical ventilation versus patients that did not? So maybe you want to emphasize that point that you've made before. So not robust differences in those populations, but, you know, one of the concerns that we've all voiced is that the highly selective nature of this population. So I wouldn't want that to suggest that there's not a relationship between history of mechanical ventilation. In fact, I think I mentioned in passing, or at least listed a study that really looked at changes in cognitive and emotional function and outcomes based on mechanical ventilation or even the type of non-mechanical ventilation. There are some very interesting findings, especially from an emotional standpoint, which can have significant longer-term impacts from a function. Have you thought of community presentations to get info out there that COVID has real effects that impact patients and families? Well, I think we are doing that, educating the community. We've certainly opened up a vaccination clinic here for not only our staff, but for individuals with disabilities. So I think we've certainly taken that approach. We've done some publications. So far, we've done three papers. I think a very relevant paper to mention is one that we just published last month on the impact of vaccination on IRFs. And we were able to compare two episodes before vaccination and then after vaccination and show the significant decrease in the risk of infection when you're vaccinated. So, you know, it's no doubt that vaccination is important and no doubt that having it available both to staff and patients in rehabilitation is of high importance. There's a question here from Dr. Lynn Gerber. She says, if your long-term follow-ups are in your long-term follow-ups, are you measuring work-related outcomes and or disruption to life roles? I guess I can answer that one. So return to work is something that we are looking at for the subset of patients who were working. Disruption to life roles, not a specific measure. I think the quality of life can get at some aspects of that, but not as precisely as perhaps we might want to. So that's a good question and something that we would want to consider. As we all know, outcome is such a broad concept, and I think we want to think holistically in terms of outcomes. So looking at things more than just breathing and walking is important and life roles really an important aspect. Someone asked about our publication. I will just add that that publication, if you just look up our names, you'll find the publication. It was in the Blue Journal of last month. Ning, you were going to say something, and I interrupted you. I apologize. Sorry, yeah. So yeah, the data is going to be published soon. I think the manuscript is in the preparation, so hopefully our data is going to be more visible in the medical society. And also the age of the patient population we have seen is in the 60s range on average. So I think the priority of the return to community is more than return to work. There's a question here about long-haul COVID and the disproportionate impact that it has in minority communities, and I think we are going to look at that in our data. We have not sorted the data out in that fashion, but that's part of our suggested analysis. So thank you for that question. We have two minutes left, and I don't want to finish this presentation, which really I thought was wonderful. You four did just terrific work in it, and I have to give you credit because the COVID unit when we designed it, and I take full responsibility for that, it was a challenging environment. We were really in a crisis mode, and you four stepped up and responded to this crisis in an amazing way, and I want to just recognize you publicly because you deserve that recognition. As physiatrists, you made us all very proud, so thank you for that. With that, I think we're at the end of our time, so if you have additional questions, reach out to us. We are at Moss Rehab, and you certainly can find us, and I appreciate your attention. We had nearly 99 people or 100 people joining today, so I hope this was useful to all of you. Continue enjoying the Academy meeting, and our thanks to the Academy for allowing us to do this presentation. Have a great day.

early inpatient rehabilitation

post-COVID-19 survivors

primary pulmonary manifestations

rehab diagnoses

functional outcomes

length of hospital stay

longer-term outcomes

mechanical ventilation

cognitive impairment