The Multidisciplinary Team and COVID-19

Original Editor - Wanda van Niekerk

Top Contributors - Wanda van Niekerk  

Introduction

If there is one thing that we as healthcare professionals have realised even more during the COVID-19 pandemic is that we need our team members from other disciplines, and we need to work together to provide the best possible outcome for our patients. With regards to the various impairments that patients may have to deal with and the rehabilitation aspects of these impairments, the multidisciplinary approach in the management and rehabilitation of patients are key.

Multidisciplinary Team Members

Some examples of multidisciplinary team members in the management of COVID-19 patients are:

  • Physiotherapists
  • Occupational Therapists
  • Speech and Language Pathologists
  • Dieticians
  • Nursing staff
  • Psychologists
  • Physicians
  • Neurologists
  • Social workers

COVID-19 has also shown us how intertwined and important the multidisciplinary team is and that many of our treatment and rehabilitation goals can be achieved through teamwork.

[1]

The Role of Speech and Language Pathologists in Covid-19 Rehabilitation

The different respiratory and neurological complications that patients experience in various stages of COVID-19, highlights the role of speech-language pathologists in the assessment and management swallowing and communication deficits. Speech and language pathologists play a critical role in the care of COVID-19 patients.[2]

One complication of ARDS secondary to COVID-19 is dysphagia or swallowing impairments. With ARDS the respiratory system is compromised and this can lead to issues of the respiratory-swallowing system.[3] A risk factor for aspiration pneumonia in frail and immunocompromised older people is oropharyngeal dysphagia which involves food residue in the throat and aspiration into the airway. This can lead to deterioration of ventilatory functions.[4] Furthermore, patients with severe ARDS may be intubated for mechanical ventilation and this may result in laryngeal injury. This may affect swallowing and voice. A high number of extubated patients are at risk of dysphagia.[5] Post-extubation dysphagia has been linked to poor outcomes, such as[6]:

  • Increased risk of developing pneumonia
  • Need for feeding tubes
  • Malnutrition
  • Increased length of hospital stays
  • Increased rate of in-hospital mortality

The various needs of the COVID-19 patients determine what role the speech and language pathologist will have.

Intensive Care and Acute Care Units

  • Identification and diagnosis of dysphagia[2]
  • Increased incidence of dysphagia in severe and critically ill patients with Covid-19[7]
  • Swallow evaluation recommended before initiating oral feeding in patient that have been intubated for longer than 2 days[8]
  • Dysphagia screening tool by Johnson et al (2018) often used by nursing staff [9]
  • Speech and language pathologists need to perform clinical bedside screenings, including[2]:
    • Patient medical history
    • Examination of structure and function of oropharynx
    • Trial swallows of food and liquids

Inpatient Rehabilitation Units

Once patients are stable enough they are often transferred to inpatient or transitional rehabilitation units. The goals of the speech and language pathologists' management of patients with dysphagia are to[2]:

  • Eliminate or reduce risk of aspiration pneumonia
  • Maintain nutrition and hydration through measures such as dietary modification and behavioural interventions. These interventions depend on various factors, such as[2]:
    • Lung function
    • Age
    • Extent of laryngeal trauma
    • Comorbidities

Dietary modification

  • Intubated patients will be on nasogastric or enteral feeding for nutrition and hydration.[10]
  • The speech and language pathologist in collaboration with other members of the multidisciplinary team (physician, dietitian, nurse etc) determines the safety of oral feeding and recommendation of least restrictive food and liquid diet to reduce the risk of aspiration.
  • Collaboration between speech and language pathologists and dietitians is important, as dysphagia is associated with malnutrition and dehydration.[11]

Compensatory Training

Compensatory strategies are recommended by speech and language pathologists to support safe oral intake of food and liquids. Some of these strategies include[12][13]:

  • Postural changes, such as:
    • Chin tuck
    • Head turn
    • Reclining sitting positions

These postural changes reduce the risk of aspiration, by influencing the speed and direction of bolus flow away from the laryngeal valve.[12][13]

Collaborations between speech and language pathologists, physiotherapists, occupational therapists and nursing staff are key during this process in order to determine the most appropriate body positioning during mealtimes and to monitor the effectiveness of these compensatory strategies.[2] Speech and language therapists also often recommend behavioural changes such as[2][14]:

  • Taking small bites when eating to overcome physiological deficits
  • Reduce environmental distractions to encourage safe and intentional control of food bolus in the mouth

Swallowing Exercises

Neuromuscular weakness and reduced oropharyngeal sensitivity may be present in patients requiring mechanical ventilation. This may be a result of laryngeal trauma from long-term intubation and non-use of oropharyngeal structures.[2] When respiration improves post-extubation, the speech and language therapist may recommend swallowing exercises to improve strength and range of motion of the pharyngeal and laryngeal structures.

Tracheostomy Management

Critical ill Covid-19 patients that need prolonged mechanical ventilation, may receive a tracheostomy to facilitate weaning of ventilation. Prolonged periods of intubation and delays in the decision to tracheostomise patients may lead to[15]:

  • Muscular atrophy
  • Changes in vocal fold and hyolaryngeal movements
  • Laryngeal trauma that may impact speech and swallowing

As a result of the above reasons, tracheostomy with and without mechanical ventilation has been associated with aspiration[15]

In patients with A tracheostomy the speech and language pathologist will also evaluate swallowing prior to the commencement of an oral diet. In collaboration with the rehabilitation team, speech and language pathologists will also determine the eligibility for the use of a speaking valve. The risk of aspiration is reduced in patients with a speaking valve and the patient’s swallowing physiology and olfaction improves.[16][17]

Oral Care and Hygiene

Bacterial colonisation in the oropharynx is often observed in previously intubated patients. Factors that cause this include[18]:

  • Increased intake of medication
  • Reduced oral intake of food or liquids
  • Dry mouth
  • Old age

This bacterial colonisation in the oropharynx may increased the risk of aspiration in Covid-19 patients. Speech and language pathologists collaborate with nursing staff and occupational therapists to educate patients on oral hygiene and consistent oral care. This can include things such as[19]:

  • Daily and frequent brushing
  • Moistening of the oral mucosa
  • Management of oral secretions to prevent aspiration pneumonia

Delirium Screening

Patients with COVID -19 may be confused, disorientated and delirious.[20] Reasons for this may be[20]:

  • Prolonged invasive respiratory management
  • Sedation
  • Social isolation in wards

Ways in which speech and language pathologists can reduce the risk of delirium in patients during their sessions with the patients are[21]:

  • Orienting the patient to the time, place, people and situation
  • Engage the patients in cognitively stimulating exercises

Outpatient Rehabilitation Units

In various outpatient settings such as (clinics, private practice, home-based therapy) speech and language pathologists may continue with dysphagia interventions strategies, such as[2]:

  • Modified oral diet
  • Compensatory strategies
  • Swallowing exercises
  • Long-term problems associated with dysphagia and respiratory distress on voice and cognition can also be addressed

Speech Intelligibility Enhancement

In patients with a tracheostomy speech and language pathologists can train the patients to swallow and speak by[22]:

  • Digitally occluding the tracheostomy
  • Using a one-way speaking valve
    • Speech therapy using a one-way valve improves speech intelligibility and quality of life in patients with tracheostomy

Voice Rehabilitation

Post-intubation dysphonia is characterised by a hoarseness of voice and frequent throat cleaning.[23][24] This is often seen In patients with prolonged endotracheal intubation.[23] The voice may improve with physical recovery of the vocal structures post-extubation. In patients with persistent dysphonia, speech and language pathologists can assess the vocal parameters and educate patients on vocal hygiene and strategies to improve voice projection and quality.[25]

Neurocognitive Management

Neurocognitive deficits have been reported in ARDS survivors. These deficits include[26]:

  • Impaired memory
  • Reduced attention
  • Executive dysfunction
  • Global intellectual decline
  • Impaired verbal fluency

These deficits can impact a person’s quality of life as well as overall disability. Speech and language pathologists can collaborate with psychologists and cognitive behavioural therapists to provide adequate services such as[2]:

  • Cognitive screening
  • Detailed assessments in each cognitive domain
  • Providing appropriate cognitive training exercises
[27]

The Role of Occupational Therapists in Covid-19 Rehabilitation

Occupational therapists are involved in remedial, restorative treatments and rehabilitation of people with physical, cognitive, psychosocial and developmental impairments.

Acute Care

The intensive care or acute care unit is a unique practice setting for occupational therapists. These healthcare professionals have a unique and distinctive skill set as well as focus. Their holistic care approach and consideration of the person – occupation – environment interaction as well as their skill of task analysis may provide so many benefits and good outcomes to the critically ill patient.[28] Occupational therapists may provide remedial services and restorative care services in hospital set-ups. The following areas of intervention may be necessary depending on the needs of the patient and the severity of Covid-19 infection:

  • Prevention, detection and monitoring of delirium[29]
  • Assessment and management of physical functioning impairments as well as cognitive functioning impairments[30]
  • Adjust and enhance bed and seating positioning using pressure relief principles[31]
  • Positioning for maximising respiratory function[32]
  • Bed mobility[32]
  • Assessment and management of Activities of Daily Living (ADL’s) to encourage early mobilisation[30]
    • for example combing hair, brushing teeth, holding and drinking from a cup[33]
  • Assessment for the need and provision of assistive devices for ADL’s, communication, seating and mobility[31]
  • Communication management to increase social participation[32]
  • Assess and consider the mental health of the patient and recommend emotional coping strategies for patients[34]
  • Sensory stimulation[32]
  • Energy Conservation[32]

Post-Acute Care

In the post-acute phase of Covid-19 rehabilitation occupational therapists can play an important role. Some of the general principles of their management across various settings include the following[35][36]:

  • Re-assess and address cognitive changes to facilitate functional independence
  • Preparation and planning for hospital or rehabilitation centre discharge
    • This includes home safety assessments and caregiver support
  • Consideration of social determinants of health (e.g. income) when planning for discharge
  • Reassessment and management of activities of daily living
    • This includes adaptive strategies, such as assistive devices and energy conservation
  • Assess and consider the mental health and psychosocial need of the patients and their caregivers

Physiotherapy and Occupational Therapy Collaboration

Collaborations between physiotherapists and occupational therapists have been important in the management of Covid -19 patients. Often the physiotherapist and occupational therapist would work together and see the patients at the same time as the patients are initially very weak with low endurance. As a team the physiotherapist and occupational therapist can address mobility and activities of daily living together in Covid-19 patients.[33] In rehabilitation units where there is not always a speech and language pathologist available, the occupational therapist and physiotherapist can help with the continued care of the patient and help with swallowing exercises by encouraging the patients to take a few sips of water for instance.[33] The treatment or rehabilitation goals are often intertwined and the physiotherapist and occupational therapist are in a unique position to reach the goals of independence, respiratory rehabilitation and maintenance of function through teamwork in the management of Covid-19 patients. Once patients are strong enough, therapy sessions could be split and specific rehabilitation goals could be addressed. Wherever possible, patients need to be able to perform basic activities of daily living once discharged.[33] Physiotherapists and occupational therapists are key to making this happen.

The Role of Dietitians in Covid-19 Rehabilitation

Dietitians are highly qualified nutritional experts and specifically trained to support the nutrition and hydration needs of acutely and chronically ill people. Dietitians are in the best position to monitor the nutritional status of Covid-19 patients through all levels of care.[37]

Acute Care

Many critically ill Covid-19 patients in the intensive care unit will be sedated and mechanically ventilated. Feeding tubes are used to deliver nutrition, hydration and medication to these patients. These patients receive the necessary proteins and calories through the feeding tubes. It is the role of the dietitian to ensure that nutrition and hydration is delivered to the patient in the safest and most effective way.[38] A dietitian will assess the nutritional demands of a patient with Covid-19 by considering various factors such as[38]:

  • The patient’s age and sex
  • Underlying medical conditions

Critically ill patients can experience malnutrition or changes in their eating patterns. In Covid-19 patients it is evident that people experience a loss of taste and smell. This may have already resulted in the patient experiencing a poor appetite, even before hospitalisation and the patient may already be experiencing malnutrition. This may also persist after critical illness. This can have a great impact on the recovery and rehabilitation of the patient.[38]

Furthermore, some of the drugs used for sedation of a patient contains calories. This needs to be taken into consideration when feeding regimes are prescribed for a patient as overfeeding may be harmful to a critically ill patient in the acute phase of illness. Many critically ill patients will be sedated with the drug propofol. This is a lipid solution and when infused continuously it adds up to a lot of calories. Other types of drugs such as prokinetics are also administered to allow the contents of the stomach to empty faster. This is important especially if patients are proned. Patients may also need volume restrictions to manage respiratory symptoms and they might be provided with more concentrated energy dense feeds, but these types of feed may cause gastrointestinal upset. Dietitians are vital in monitoring all of these factors and avoid any possible complications.[39]  

Post-Acute Care

Even after discharge after Covid-19 infection, a patient may still require the expertise of a dietitian. Dietitians play an important role in the post-acute rehabilitation of Covid-19 patients. With the proper dietary recommendations, the risk of complications can be reduced, and it can speed up the recovery time of the patient. Patients recovering from severe Covid-19 infection are at an increased risk of malnutrition. They will most likely also have suffered muscle loss during their stay in hospital as a result of heavy sedation and inactivity. Dietitians can help these patients by recommending nutrient rich, fortified food or specialist nutrition supplements to aid in the recovery of the patient and to regain the weight and muscle mass they may have lost during their illness.[38][39]

[40]

Other Multidisciplinary Team Members' Roles

Physiotherapy

For more information on the role of physiotherapists in the rehabilitation of Covid-19 patients have a look at these Physiopedia Pages:

Psychologists

For more information on mental health and Covid-19 have a look at these Physiopedia Pages:

Conclusion

Rehabilitation of critically ill Covid-19 patients is important to reduce long-term complications. A multidisciplinary approach is necessary to reduce these complications and to provide the patient with the best possible outcome.[41]

Resources

[42]

References

  1. Silver Cross.Therapy and COVID-19. Available from https://www.youtube.com/watch?v=7i9J_0D1hZE (last accessed 10 October 2020)
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 Mohapatra B, Mohan R. Speech Language Pathologists' Role in the Multidisciplinary Management and Rehabilitation of Patients with COVID-19. Journal of Rehabilitation Medicine. 2020 Jul 3:1-6.
  3. Verin E, Clavé P, Bonsignore MR, Marie JP, Bertolus C, Similowski T, Laveneziana P. Oropharyngeal dysphagia: when swallowing disorders meet respiratory diseases. The European Respiratory Journal. 2017 Apr 12;49(4).
  4. Cabré M, Serra-Prat M, Force LL, Almirall J, Palomera E, Clavé P. Oropharyngeal dysphagia is a risk factor for readmission for pneumonia in the very elderly persons: observational prospective study. Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences. 2014 Mar 1;69(3):330-7.
  5. Brodsky MB, Huang M, Shanholtz C, Mendez-Tellez PA, Palmer JB, Colantuoni E, Needham DM. Recovery from dysphagia symptoms after oral endotracheal intubation in acute respiratory distress syndrome survivors. A 5-year longitudinal study. Annals of the American Thoracic Society. 2017 Mar;14(3):376-83.
  6. Macht M, Wimbish T, Clark BJ, Benson AB, Burnham EL, Williams A, Moss M. Postextubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness. Critical care. 2011 Oct 1;15(5):R231.
  7. Carda S, Invernizzi M, Bavikatte G, Bensmaïl D, Bianchi F, Deltombe T, Draulans N, Esquenazi A, Francisco GE, Gross R, Jacinto LJ. The role of physical and rehabilitation medicine in the COVID-19 pandemic: the clinician's view. Annals of physical and rehabilitation medicine. 2020 Apr 18.
  8. Metheny N. Prevention of Aspiration in Adults. Critical Care Nurse. 2016 Feb 1;36(1).
  9. Johnson KL, Speirs L, Mitchell A, Przybyl H, Anderson D, Manos B, Schaenzer AT, Winchester K. Validation of a postextubation dysphagia screening tool for patients after prolonged endotracheal intubation. American Journal of Critical Care. 2018 Mar 1;27(2):89-96.
  10. Martindale R, Patel JJ, Taylor B, Warner M, McClave SA. Nutrition therapy in the patient with COVID‐19 disease requiring ICU care. Nutrition Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition. 2020 Apr.
  11. Tagliaferri S, Lauretani F, Pelá G, Meschi T, Maggio M. The risk of dysphagia is associated with malnutrition and poor functional outcomes in a large population of outpatient older individuals. Clinical Nutrition. 2019 Dec 1;38(6):2684-9.
  12. 12.0 12.1 Kagaya H, Inamoto Y, Okada S, Saitoh E. Body positions and functional training to reduce aspiration in patients with dysphagia. JMAJ. 2011 Jan 1;54(1):35-8.
  13. 13.0 13.1 Cvejic L, Bardin PG. Swallow and aspiration in chronic obstructive pulmonary disease. American journal of respiratory and critical care medicine. 2018 Nov 1;198(9):1122-9.
  14. Ney DM, Weiss JM, Kind AJ, Robbins J. Senescent swallowing: impact, strategies, and interventions. Nutrition in clinical practice. 2009 Jun;24(3):395-413.
  15. 15.0 15.1 Bailey RL. Tracheostomy and dysphagia: A complex association. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 2005 Dec;14(4):2-7.
  16. Dettelbach MA, Gross RD, Mahlmann J, Eibling DE. Effect of the Passy‐Muir valve on aspiration in patients with tracheostomy. Head & neck. 1995 Jul;17(4):297-302.
  17. Lichtman SW, Birnbaum IL, Sanfilippo MR, Pellicone JT, Damon WJ, King ML. Effect of a tracheostomy speaking valve on secretions, arterial oxygenation, and olfaction: a quantitative evaluation. Journal of Speech, Language, and Hearing Research. 1995 Jun;38(3):549-55.
  18. Almirall J, Cabré M, Clavé P. Complications of oropharyngeal dysphagia: aspiration pneumonia. InStepping Stones to Living Well with Dysphagia 2012 (Vol. 72, pp. 67-76). Karger Publishers.
  19. Tada A, Miura H. Prevention of aspiration pneumonia (AP) with oral care. Archives of gerontology and geriatrics. 2012 Jul 1;55(1):16-21.
  20. 20.0 20.1 Kotfis K, Williams Roberson S, Wilson JE, Dabrowski W, Pun BT, Ely EW. COVID-19: ICU delirium management during SARS-CoV-2 pandemic. Critical care. 2020 Dec;24:1-9.
  21. Girard TD, Pandharipande PP, Ely EW. Delirium in the intensive care unit. Critical Care. 2008 May 1;12(S3):S3.
  22. Hess DR. Facilitating speech in the patient with a tracheostomy. Respiratory Care. 2005 Apr 1;50(4):519-25.
  23. 23.0 23.1 Mendels EJ, Brunings JW, Hamaekers AE, Stokroos RJ, Kremer B, Baijens LW. Adverse laryngeal effects following short-term general anesthesia: a systematic review. Archives of Otolaryngology–Head & Neck Surgery. 2012 Mar 19;138(3):257-64.
  24. Vyshnavi S, Kotekar N. Aphonia following tracheal intubation: An unanticipated post-operative complication. Indian journal of anaesthesia. 2013 May;57(3):306.
  25. Feder RJ. Early recognition and treatment of postintubation dysphonia. The Laryngoscope. 1983 Aug;93(8):1070-2.
  26. Mikkelsen ME, Christie JD, Lanken PN, Biester RC, Thompson BT, Bellamy SL, Localio AR, Demissie E, Hopkins RO, Angus DC. The adult respiratory distress syndrome cognitive outcomes study: long-term neuropsychological function in survivors of acute lung injury. American journal of respiratory and critical care medicine. 2012 Jun 15;185(12):1307-15.
  27. American Speech Language Hearing Association. COVID-19 and Healthcare Speech-Language Pathologists: Providing Critical Care on Road to Recovery. Available from https://www.youtube.com/watch?v=Kk1Jks4eJFY (last accessed 10 October 2020)
  28. Weinreich M, Herman J, Dickason S, Mayo H. Occupational therapy in the intensive care unit: a systematic review. Occupational Therapy in Health Care. 2017 Jul 3;31(3):205-13.
  29. Álvarez EA, Garrido MA, Tobar EA, Prieto SA, Vergara SO, Briceño CD, González FJ. Occupational therapy for delirium management in elderly patients without mechanical ventilation in an intensive care unit: A pilot randomized clinical trial. Journal of Critical Care. 2017 Feb 1;37:85-90.
  30. 30.0 30.1 Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D, Schmidt GA. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. The Lancet. 2009 May 30;373(9678):1874-82.
  31. 31.0 31.1 Kho M, Brooks D, Namasivayam-MacDonald A, Sangrar R, Vrkljan B. Rehabilitation for Patients with COVID-19: Guidance for Occupational Therapists, Physical Therapists, Speech-Language Pathologists, and Assistants. McMaster School of Rehabilitation Science URL: https://srs-mcmaster. ca/wp-content/uploads/2020/04/Rehabilitation-for-Patients-with-COVID-19-Apr-08-2020. pdf
  32. 32.0 32.1 32.2 32.3 32.4 World Federation of Occupational Therapists. Occupational Therapy Intervention in Covid-19. Available from:https://www.wfot.org/assets/resources/occupational-therpy-intervention-in-COVID19_Final.pdf (last accessed 10 October 2020)
  33. 33.0 33.1 33.2 33.3 Covid-19 and The Multidisciplinary Team. Physioplus Course. 2020
  34. Jackson JC, Pandharipande PP, Girard TD, Brummel NE, Thompson JL, Hughes CG, Pun BT, Vasilevskis EE, Morandi A, Shintani AK, Hopkins RO. Depression, post-traumatic stress disorder, and functional disability in survivors of critical illness in the BRAIN-ICU study: a longitudinal cohort study. The lancet Respiratory medicine. 2014 May 1;2(5):369-79.
  35. Kingston G, Pain T, Murphy K, Bennett M, Watson M. Perceptions of acute hospital occupational therapy services: developing a new model of care for occupational therapy on acute medical wards. International Journal of Therapy And Rehabilitation. 2019 Dec 2;26(12):1-9.
  36. Provencher V, Clemson L, Wales K, Cameron ID, Gitlin LN, Grenier A, Lannin NA. Supporting at-risk older adults transitioning from hospital to home: who benefits from an evidence-based patient-centered discharge planning intervention? Post-hoc analysis from a randomized trial. BMC geriatrics. 2020 Dec;20(1):1-0.
  37. Minnelli N, Gibbs L, Larrivee J, Sahu KK. Challenges of Maintaining Optimal Nutritional Status in COVID‐19 Patients in Intensive Care Settings. Journal of Parenteral and Enteral Nutrition. 2020 Aug 16.
  38. 38.0 38.1 38.2 38.3 The European Federation of the Associations of Dietitians. Role of Dietitians in the fight against COVID-19. (last accessed 10 October 2020)
  39. 39.0 39.1 British Dietetic Association. What are dietitians doing as part of the COVID-19 response? (last accessed 10 October 2020)
  40. Aspen. Nutrition Support for Critically Ill Patients with COVID-19 Disease: Top 10 Key Recommendations. Available from https://www.youtube.com/watch?v=dNmMW3ybXdY. (last accessed 10 October 2020)
  41. Korupolu R, Francisco GE, Levin H, Needham DM. Rehabilitation of critically ill COVID-19 survivors. The Journal of the International Society of Physical and Rehabilitation Medicine. 2020 Apr 1;3(2):45.
  42. The ACPRC. COVID CPD Series - ICU Recovery and MDT Care. Available from https://www.youtube.com/watch?v=4GiQynZNE3c (last accessed 5 October 2020)