37
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President of ISPRM World Youth Forum.
Resident Physician at University of Miami/Jackson Health, USA.
Cofounder of Nepalese Association of PM&R.
Manoj Poudel MD USA/Nepal
Moderator
Past President, ISPRM 2012-2014.
Past President, ABMFR 2008-2012.
Professor of Physiatry, Universidade de Sao Paulo, Brazil.
Member, PAHO/WHO Collaboration Center for Rehabilitation.
Marta Imamura MD PhD Brazil
Panelist
President-Elect of ISPRM.
Associate Professor; Chair of PRM Residency Program and Chair
of Unit of General & Specialist Rehabilitation Medicine in
University of Campania “Luigi Vanvitelli”, Italy.
Cochrane Rehabilitation Communication Committee Chair.
Francesca Gimigliano, MD, PhD Italy
Panelist
Senior Vice President & CMO, Burke Rehabilitation Hospital, USA.
Professor, Rehabilitation Medicine at Albert Einstein College of Medicine.
Board-certified in PM&R, Electrodiagnostic/Neuromuscular Medicine, &
Sports Medicine.
Mooyeon Oh-Park, MD, MS USA
Panelist
Chair, Education Committee of the ISPRM.
Associate Professor at Baylor College of Medicine, USA.
Pediatric Physiatrist & Clinic Chief, PM&R, Texas Children's Hospital.
Director, PM&R residency & pediatric rehabilitation fellowship programs.
Board certified in Pediatrics, PM&R and Pediatric Rehabilitation.
Rochelle Dy, MD USA/Philippines
Panelist
Brazil
Situation Report: Brazil Population: 216 million inhabitants, 9th world GDP Confirmed COVID-19: 110,000 cases / 7,485 deaths Recovered: 45,815 35 million
don’t have
access to
treated
water
State of São Paulo (as of May 06, 2020) Population: 44 million inhabitants Confirmed cases: 37,853 In-patients (confirmed or suspected): 8,601 (3,404 in ICUs) Confirmed deaths: 3,045
National Government-mandated COVID-19 Response:
Stay-at-Home Order 2020: By State
National Response:
Containment and mitigation:
• National guidance defined essential services and recommendations for social distancing
• Foreign entry restricted
Non-essential services suspended
Health care: Universal Health Coverage (Sistema Unico de Saude)
Bettger JP et al. COVID-19: maintaining essential rehabilitation services across the care continuum. BMJ Global Health 2020;5:e002670
Situation report Italy
Italian Population > 60 million inhabitants
Second oldest country after Japan
Covid 19 cases as per May 7, 2020:
• 215,858 total cases
• 89,624 currently positive
• 29,958 dead
• 96,276 healed
1.2 Million+, 329,400 in NYS
https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html#map
COVID-19 Cases at Burke & Montefiore (MHS)
0 0 0 0 0 0 0 1 1 1 1 2 3 2 3 3 3 3 4 8
11 14
19 25
30
38
52
63 68
71 69 70
77
84 85 83 81 82 84 88 89 88
85 88 86
89 86
89 88 90 90 90
89
0 3 3 7 11 12 22 56 71 92 97
190 227
296 344
454
540 576
612
751
1044 1033
1323
1400
1521 1540 1595
1635
1800 1819
1919 1942 1972
2062 2037
1892 1856
1684
1789 1760
1627 1556
1672
1399
1286 1286 1249
1207 1144
1074 1144
1074 1005
0
500
1000
1500
2000
0
20
40
60
80
100
120
140
160
180
200
Date 13-Mar 16-Mar 19-Mar 22-Mar 25-Mar 28-Mar 31-Mar 3-Apr 6-Apr 9-Apr 12-Apr 15-Apr 18-Apr 21-Apr 24-Apr 27-Apr 30-Apr
Po
siti
ve C
ase
s at
MH
S
Po
siti
ve C
ase
s at
Bu
rke
Burke MHS
11
Timeline of Strategic Planning & Action Taken
0 0 0 0 0 0 0 1 1 1 1 2 3 2 3 3 3 3 4 8
11 14
19 25
30
38
52
63 68
71 69 70
77
84 85 83 81 82 84 88 89 88
85 88 86
89 86
89 88 90 90 90 89
0
10
20
30
40
50
60
70
80
90
100
Date 13-Mar 16-Mar 19-Mar 22-Mar 25-Mar 28-Mar 31-Mar 3-Apr 6-Apr 9-Apr 12-Apr 15-Apr 18-Apr 21-Apr 24-Apr 27-Apr 30-Apr
Po
siti
ve C
ase
s at
Bu
rke
NYS State of Emergency Declared
03/07/2020
Staff wellness check,
Negative pressure rooms
Hudson Valley CEO call
Suspension of visiting hours
Fitness center, partial closure of outpatient
Command Center by CEO (10am, 3pm briefing)
Clinical Update by CMO 2pm daily (5am)
Daily distribution of surgical mask
Emergency status declaration to
ACGME 03/29/20
Monte fellows, faculty joining Burke
Retraining & Deployment of outpatient staff
Surge bed opened as per Governor’s executive order
Hudson Valley CMO/CNO call
Rapid testing available at WPH
Three WPH Hospitalists joining Burke
Antibody testing for HCP training
Antibody testing 05/04/20
Communication Resource: Dr. Ozuah 1pm call, Dr. Madaline, Dr. Racine communications from MHS 12
Discussion on status of PM&R specialty in Brazil, Italy and New York.
• How has COVID-19 pandemic affected PM&R specialty?
• What you have you done to overcome these challenges in your region?
Status of PRM Specialty during COVID-19 in Brazil
Source: Scheffer M, et al., Demografia Médica no Brasil 2018
• Temporarily ceased, decreased or diverted
• Continuity of rehabilitation for non COVID-19 patients: – selected services under alternative
conditions
– priority needs
– expand delivery of telehealth and in-home services
• Procedures: avoid in patients with high risk, under infection prevention and control measures (Botulinum toxin, acute pain and movement disorders)
Rehabilitation Services during COVID-19 in Brazil
• Reduced operations for in-patient rehabilitation
• Shift in rehabilitation personnel and outpatient services, encouraged to use telehealth: MD, PT, OP, nurses, psychology, nutrition
• Federal Medical Council acknowledges use of telemedicine:
teleorientation (distance guidance, training and patient referral)
telemonitoring under medical supervision or guidance
teleinterconsultation (between physicians)
• Federal Medicinal Council recommends suspension of outpatient elective treatment (as of March 20)
Bettger JP et al. COVID-19: maintaining essential rehabilitation services across the care continuum. BMJ Global Health 2020;5:e002670
IMREA’s Response:
• Identify patients and caregivers at greater risk
• Reduce potential exposure to COVID-19 during provision of rehabilitation services
• Ensure continuation of care and support
• In-patient rehabilitation
• Short-term for transfer to homecare
• Rehabilitation needs addressed for non COVID-19 and COVID-19 patients
• Telehealth
• Continuous monitoring for rehabilitation needs or COVID-19 symptoms
• Support workforce well- being and mental health
• 575 health professionals
• 291 management • 241 tertiary • Total: 1,107
• 418,341 multiprofessional interventions • 41,357 medical and dental consultations • 7,340 exams • 541 in-patient discharge
Status of PRM Specialty during COVID-19 in Italy SIMFER recommendations
In ACUTE CARE:
• to prevent disabling complications and comorbidities
• to support the achievement of clinical stability
• to plan the following clinical pathway
In INPATIENT REHABILITATION SETTINGS:
• to ensure adequate delivery of rehabilitation interventions for patients directly admitted from the acute care, including Covid-19 patients with disabling sequelae
• to increase admission capacity of rehabilitation facilities, thus supporting early discharge from acute care units
• to facilitate early and safe discharge to outpatient and home rehabilitation services
In OUTPATIENT AND HOME BASED REHABILITATION SERVICES:
• to ensure rehabilitation intervention for patients who suffered from a recent acute event
• to consider alternative treatment options (such as remote consultation, telerehabilitation…) for patients with chronic disabling conditions
PROTECTION OF PATIENTS AND PROFESSIONALS
• Phone triage or pre-admission triage or preliminary interview
• Reorganization of spaces in compliance to rules and recommendations of social distancing
• Use of Personal Protective Equipment
• Adoption of alternative modalities for the delivery of care whenever possible (remote consultation, telerehabilitation, educational and training material available in remote mode…)
FREE-OF-CHARGE REMOTE SUPPORT SERVICE BY SIMFER
• SIMFER has activated a remote support service of “tele-rehabilitation medicine”, with the aim of providing information and advice to persons with disabling conditions of different origin, family members and caregivers. The service is free-of-charge and is delivered by a pool of PRM doctors from all the different areas of the country.
• The person in need of support can contact SIMFER through a dedicated e-mail address: [email protected]
Status of PRM Specialty during COVID-19 in Italy SIMFER recommendations
Rehabilitation Needs of COVID-19 Patients
Physical
• Reduced Pulmonary Function
• ICU acquired weakness (25-100%): Critical illness neuropathy, myopathy
• Entrapment neuropathy
• Central nervous system disorders (6% of acute stroke)
• Deep vein thrombosis, post thrombotic limb syndrome
• Cardiopulmonary deconditioning
• Contractures
• Pressure injury
• Functional and Neurogenic incontinence
• Nutritional deficit
Cognitive
• Delirium (80% of ICU patients)
• Cognitive impairment following ARDS (10% persistent)
• Attention, executive function, memory
• Treatment for delirium
• Early mobilization, exercise
• Human engagement (family, staff) and empowerment
Psychosocial
• Persistent mental health impairment after ICU stay
• Depression (30%)
• PTSD (22%)
• Anxiety (34%) at 1 year post ICU stay
• High level of emotional distress across society associated with pandemic
• Separation from family, social stigma
• Distress to family
19
Discussion on status of graduate medical education (like residency, fellowship) in Brazil, Italy and New York.
Resident/fellow safety
Educational activities
Work environment.
Graduate Medical Education in Brazil Total Number of Residency Programs: 17 Average number of Residents in Training: 99
Schiappacasse C, Guzmán JM, Dean MH, Corletto S, Battistella LR, Imamura M, Gutiérrez J, Borelli G, Muzio D, Micheo W. Physical Medicine
and Rehabilitation in Latin America: Development and Current Status. Phys Med Rehabil Clin N Am. 2019 Nov;30(4):749-755.
• Safety
• Education
• Work
Undergraduate Medical Education: Rehabilitation Participants: 3rd year medical students (core curriculum) Faculdade de Medicina da Universidade de São Paulo
• Student-centered Program – discussion of real cases
Educational Objectives
• Assessment and care
for people with
disabilities;
• Make students aware
of the psycho-social
aspects;
• Develop clinical
reasoning for the
need for functional
assessment and the
result based on
functional outcomes,
in the continuum of
care.
PRM Residency training program in Italy
• In Italy the training program for PRM residents lasts 4 years
• 191 x 4 ~ 764 PRM Residents
12
15
38
6
41
4
13
16
11
10
25
Italian Regions # of activated PRM Residency Training Program 2018/2019
total # of Resident in PRM at the I year of training
Campania 1 12 Emilia-Romagna 2 15 Lazio 4 38 Liguria 1 6
Lombardia 4 41 Marche 1 4 Piemonte 2 13 Puglia 2 16 Sicilia 1 11
Toscana 2 10 Veneto 2 25 Total 22 191
University of Campania “Luigi Vanvitelli”
• Undergraduate students are continuing all their activities online (frontal lessons and interactive discussions of clinical cases)
• 37 PRM Residents • 28 others are working at the University hospital or doing
rotations in one of the 10 structure of the University internal network
• 6 are doing an external rotation in other Italian Regions (1 in Lazio, 2 in Lombardia, and 2 in Puglia), most of them are currently working with Covid 19 patients
• 3 on maternity leave
12
Three Stages of GME during COVID-19 Pandemic
Stage 1: Business as Usual
Stage 2: Increased Clinical
Demands Guidance
Stage 3: Pandemic Emergency
Status Guidance
Definition No disruption of patient care & educational activities; planning underway for future.
Some trainees need to shift to patient care duties, some educational activities suspended.
Most/all trainees shift to patient care, majority of educational activities suspended.
Requirement in effect
Common/specialty specific program requirement
Common/specialty specific program requirement
4 overriding requirements: • Work hour limit • Resource/training • Supervision • Fellows allowed to function
in core specialty
Flexibility Suspended site visits Fellow as attending Specialty specific requirements waived
ACGME Notification
Sponsoring institutions can declare Pandemic emergency status
www.tmc.edu
Started on minimal staff; Resident independent study at home and learning plan; Virtual didactics
Mandatory stay at home order
Surge plan for faculty and trainees
Phase 1 re-opening
Modified trainee calls to day and night shifts for rehab hospital
• Biweekly Town Hall Meetings with Residents and Fellows, with intermittent individual check-in
Slow return of limited staff & trainees to work
Inpatient Rehab and consults service remain; No elective surgeries/procedures (EMG, INJ) ; ITB refills remain; Telemedicine for outpatient visits ramp up
Limited INJ and EMG
Legend: Clinical activity GME response State condition
Predicted surge
GME COVID-19 Status: Stage 2
Discussion on key leadership skills at different levels during a pandemic or disaster.
PAHO - WHO
• Provide evidence-based recommendations
Rehabilitation improves the health outcomes of patients with severe cases of COVID-19 and benefits health services through:
– Optimizing health & functioning outcomes
– Facilitating early discharge
– Reducing the risk of readmission
• Provide framework for coordinated actions
• Centralized data collection and information systems
• Engagement of stakeholders from all sectors
https://www.paho.org/en/topics/rehabilitation
“ The vision of a world where persons with disabilities and their families enjoy the highest
attainable standard of health ”
http://www.who.int/disabilities/actionplan/en/
Plan of ISPRM for resident/fellow education world-wide and suggestions for residents and fellows as a closing remarks.
Leadership
Reflections
• Communication and connection – the how is just as important as the what
• Courage – not the absence of fear…
• Compassion
- Dalai Lama
