COVID-19: Shorter Term Health Considerations
The demands placed on the front line workers in relation to the COVID-19 pandemic have been described elsewhere and their efforts continue to inspire awe and gratitude around the globe. At the same time, health care professionals who do not work on the front line might be wondering “what can I do to help?” as well as, perhaps in the background, “how might this change my practice in the longer term?” Considering that some estimates project that the pandemic will occur in waves and that a vaccine is still 18 months away, we are still in the relatively early days so the full breadth and depth of the impacts will only be known after the fact. For now, the following considerations are based on information available about the current pandemic as well as similar historical situations (e.g. the SARS outbreak in 2003).
Stress disorders are associated with public health emergencies. Assessment and treatment of such disorders in patients already in medical isolation wards is a challenge because mental health professionals may be considered non-essential in that context and therefore unauthorized to enter those wards. The front line professionals who can enter would therefore be responsible for addressing mental health as well (assuming the patient is physically well enough to be evaluated).
For patients with symptoms of COVID-19 who are self-isolating at home because they are not critically ill but feel they are in need of mental health support, mental health care professionals would have to determine if the requested service was considered “essential” at that moment. The definition of “essential” may vary between jurisdictions. From a Canadian perspective, “[a]ll non-essential and elective services should be ceased or reduced to minimal levels...Allowable exceptions can be made for time sensitive circumstance to avert or avoid negative patient outcomes or to avert or avoid a situation that would have a direct impact on the safety of patients.” If not essential, the HCP would be authorized by their respective regulatory college to inform the patient of this determination and delay evaluation/intervention until an appropriate time. If the service was considered essential, the HCP would have to consider what would be the safest way to provide care. Given the reported shortage of PPE available and that community-based HCPs may be inundated with referrals (even before the pandemic started), tele- or video-conferencing may be the most appropriate and efficient option. HCPs would have to consider appropriate security for any online tools they use and also if they are still covered by liability insurance when providing care in this format.
In addition, if a patient was already under an HCP's care but moved to a different jurisdiction in response to the pandemic, the HCP would have to consider if they are still authorized to care for that patient under the regulatory college of the new jurisdiction. Regulatory colleges may allow temporary approval given the extenuating circumstance but HCPs should contact the college to determine this.
Patients or people in general who are experiencing symptoms of mental stress could also access various types of self-directed online health education services, apps and videos that are available (e.g. TikTok, Youtube, Curable for pain management, Headspace for mindfulness training). (Liu 2020) Because these require an internet connection as well as an appropriate device, access might be limited for some people (Yang 2020). As well, some services have a monetary cost which again might prevent access by those with lower income (especially given that many people in non-essential lines of work are unable to work because of isolation guidelines). Some resources have been made freely available in recognition of the difficult situation many people are finding themselves in as a result of the pandemic (e.g.Headspace, Curable).
Front Line Health Care Workers
Front line workers may also suffer from stress disorders given the demands placed upon them. Lai et al (2020) found a high prevalence of mental health symptoms among health care workers who were treating patients with COVID-19 in China. Analysis of the self-report questionnaires indicated 50.4% of respondents had symptoms of depression, 44.6% had symptoms of anxiety, 34.0% had symptoms of insomnia and 71.5% had symptoms of distress. Women reported more severe symptoms of depression which the authors note may be because a high percentage of respondents were female nurses who are likely exposed to a higher risk of infection because of their close frequent contact with patients and also because they are working more hours than usual.
Chen et al (2020) reported that in response to the escalating novel coronavirus public health event in China, a psychological intervention plan was developed which covered three areas: building a psychological intervention medical team (to provide online courses relating to common psychological problems), a psychological assistance hotline team (to provide guidance and supervision to solve psychological problems) and psychological interventions (e.g. various stress-relieving group activities). Medical staff were reportedly reluctant to participate in the interventions despite exhibiting signs of psychological distress. As a result of an interview with staff, several issues were identified;
- getting infected themselves was not an immediate worry once staff started a shift but there were afraid of bringing the virus home to their families
- they did not know how to deal with uncooperative patients
- they worried about the shortage of PPE
- they worried about feeling incapable when caring for critically ill patients.
The same members of staff reported that they did not need psychological intervention but that what would be of benefit was;
- more uninterrupted rest
- sufficient PPE supplies
- training in psychological skills to assist patients with anxiety, panic, etc
- mental health professionals to intervene when required.
As a result, the hospital implemented the following;
- provision of a place of rest for over 100 staff members so they could temporarily isolate themselves from their families
- guarantee of food and daily living supplies
- video recording of staff in their work routines to share with families to alleviate their concerns
- change to pre-job training to include identification of and response to psychological problems
- sending security staff to help with uncooperative patients
- provision of detailed rules on use and management of PPE
- arrangement of leisure activities and training on how to relax effectively
- provision of psychological counsellors to provide support while in the rest area.
Other Aspects of Health
People may avoid hospitals or other health facilities because of the pandemic even though they have a condition that requires attention (whether or not it is a known or diagnosed condition) and in so avoiding, may harm themselves. During the SARS outbreak, it was estimated that four times as many Ontarians would die from lack of medical attention caused by the outbreak than would die from SARS itself.
People who were already receiving treatment but cannot at present due to social distancing requirements and/or closure of the facilities may suffer unless adequate alternatives can be arranged. In addition, Viswanath and Monga (2020) note that there is a concern regarding corticosteroid injections during a pandemic because they may depress the immune system while NSAIDs have been linked with more severe COVID-19 (e.g. prolonged illness and more severe respiratory or cardiac complications). Paracetamol/acetaminophen are instead recommended to treat musculoskeletal pain in those with COVID-19. Some ongoing method of pain management is critical.
Eysenbach (2003) noted that during the SARS outbreak, Singapore General Hospital introduced a webcam-based physiotherapy program. Almost 20 years on, more advanced and more widely available technology are making this option more feasible (although again, access on the end of the patient might be limited by financial or technological circumstances). Some providers are providing tele- and video-conferencing options for their patients. As with mental health services, an HCP may be authorized to provide in-person care if it is considered essential (e.g. post-surgical rehabilitation) provided guidelines for IPC etc are followed.
Elias, Shen and Bar-Yam (2020) state that attention to self-care and wellness during the mild stage of COVID-19 may impact the probability and degree of severity. Means of strengthening the immune response include elevated hydration, balanced nutrition, appropriate sleep and non-interference with a fever unless it exceeds safe limits. The authors make the following recommendations (noting that the recommendations are safe for those with reasonable general health while those with pre-existing health concerns might want to consult a physician first);
- aerobic exercise – to strengthen the cardiovascular system before an infection might occur. If already infected but it is in the mild stage, moderate daily exercise can improve lung ventilation and may also benefit immune system. Ideally exercise should occur outdoors or in a well-ventilated area.
- keep windows open when possible to bring in more oxygen while letting viral particles exit, thus reducing the risk to others in that environment but also reducing re-exposure of the patient to viral particles which could affect pulmonary tissue that has not yet been infected or has been cleared by the immune system.
- clean surfaces and washing clothing/bedding – to protect non-infected people within the household and again to reduce the risk of re-exposure spend time outdoors - for the same reasons
- breathe in through the nose rather than the mouth - to allow cilia and mucous membranes to clean the incoming air
- perform deep breathing exercises multiple times per day – to bring in fresh air, improve lung capacity and expel viral particles from more stagnant areas of the lung
- additional lung health practices (the authors refer readers here)
If working is not an option at present, physiotherapists and other HCPs could use this opportunity to educate themselves, either regarding COVID-19 or in other areas that would be of benefit to their patients and/or their practice, using some of the resources available online such as Physiopedia Plus. Stimulating, purposeful, educational challenges may be a way to assist or improve mental health at a tumultuous time.
More General Ways to Help
In addition to ways physiotherapists can help in this situation based on their profession, there are also ways to help that are an option for all people.
- stay at home except for essential work or errands (e.g. grocery shopping)
- adhere to social distancing guidelines when you do have to go out
- practise proper hand hygiene
- check that neighbours, friends and relatives are doing well
- don't hoard food (everyone else needs to eat too!)
- donate to organizations that are assisting front line workers or that might be struggling just now because of everyone self-isolating (e.g. food banks, community shelters)
- Duan L, Zhu G. Psychological interventions for people affected by the COVID-19 epidemic. Lancet Psychiatry . 2020. 7(4): P300-302. DOI:https://doi.org/10.1016/S2215-0366(20)30073-0
- Williams DC. COVID-19 Directive #2 for Health Care Providers (Regulated Health Professionals or Persons who operate a Group Practice of Regulated Health Professionals). Available at: https://www.peterboroughpublichealth.ca/wp-content/uploads/2020/03/CMOH-Directive-2-RHPA-professionals-2020-03-19.pdf [Accessed 3 April 2020]
- Ontario College of Social Workers and Social Service Workers. Top 10 consideration for using communication technology in practice. Available from: https://perspective.ocswssw.org/top-10-considerations-for-using-communication-technology-in-practice/ [Accessed 3 April 2020]
- The College of Psychologists of Ontario. COVID-19 information for members – March 22, 2020. Available from: http://www.cpo.on.ca/Templates/Default-Inner-Page.aspx?id=2275 [Accessed 3 April 2020]
- Liu S, Yang L, Zhang C, Xiang Y, Liu Z, Hu S et al. Online mental health services in China during the COVID-19 outbreak. Lancet Psychiatry . 2020. 7(4): PE17-E18. DOI:https://doi.org/10.1016/S2215-0366(20)30078-X
- Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N et al. Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. Psychiatry.
- Chen Q, Liang M, Li Y, Guo J, Fei D, Wang L et al. Mental health care for medical staff in China during the COVID-19 outbreak. Lancet Psychiatry . 2020. 7(4): PE15-E16. DOI:https://doi.org/10.1016/S2215-0366(20)30078-X
- Eysenbach G. SARS and Population Health Technology. J Med Internet Res. 2003;5(2):e14.
- Viswanath A, Monga P. Working through the COVID-19 outbreak: Rapid review and recommendations for MSK and allied health personnel. Journal of Clinical Orthopaedics and Trauma. https://doi.org/10.1016/j.jcot.2020.03.014
- Elias B, Shen C, Bar-Yam Y. Respiratory health for better COVID-19 outcomes. New England Complex Systems Institute. March 16, 2020.