Orthopedics

Feature Article Supplemental Data

Outpatient Orthopedic Rehabilitation in New York State During the COVID-19 Pandemic: Therapist Perspectives

Nata Parnes, MD; Cheryl Tousant, PT, DPT; Jeff Perrine, FNP-C; Michael J. Defranco, MD

Abstract

The COVID-19 pandemic has had a strong impact on the care of orthopedic patients. This impact has been particularly difficult in New York State, which experienced the largest number of COVID-19 cases and led to a state-mandated pause on all elective surgeries. As a result, physical and occupational therapists became the principal providers of care and had to adjust their workflow to ensure quality care. Understanding the perspectives and needs of therapists relative to the circumstances created by COVID-19 is critical to safe and effective care. The goal of this study was to define the perspectives of therapists in New York State regarding the impact of COVID-19 on their work. An email-based 20-question survey was distributed to 250 therapists from all 10 regions of New York State who treated outpatient orthopedic patients during the peak of the pandemic in early April 2020. The survey collected demographic and practice information as well as responses regarding several clinical practice issues. The results provide insight into the concerns of therapists regarding the delivery of care, and responses clarify indications for therapy and for the use of telemedicine to achieve goals during the pandemic. The COVID-19 pandemic is profoundly impacting the work of therapists worldwide. Therapists responded to this survey expressing concerns about the safe delivery of care, access to personal protective equipment, use of telemedicine, and their role within health care during the pandemic. The results of this study can be used to establish guidelines for safe, effective, and efficient therapy during the pandemic. [Orthopedics. 2020;43(5):292–294.]

Abstract

The COVID-19 pandemic has had a strong impact on the care of orthopedic patients. This impact has been particularly difficult in New York State, which experienced the largest number of COVID-19 cases and led to a state-mandated pause on all elective surgeries. As a result, physical and occupational therapists became the principal providers of care and had to adjust their workflow to ensure quality care. Understanding the perspectives and needs of therapists relative to the circumstances created by COVID-19 is critical to safe and effective care. The goal of this study was to define the perspectives of therapists in New York State regarding the impact of COVID-19 on their work. An email-based 20-question survey was distributed to 250 therapists from all 10 regions of New York State who treated outpatient orthopedic patients during the peak of the pandemic in early April 2020. The survey collected demographic and practice information as well as responses regarding several clinical practice issues. The results provide insight into the concerns of therapists regarding the delivery of care, and responses clarify indications for therapy and for the use of telemedicine to achieve goals during the pandemic. The COVID-19 pandemic is profoundly impacting the work of therapists worldwide. Therapists responded to this survey expressing concerns about the safe delivery of care, access to personal protective equipment, use of telemedicine, and their role within health care during the pandemic. The results of this study can be used to establish guidelines for safe, effective, and efficient therapy during the pandemic. [Orthopedics. 2020;43(5):292–294.]

The COVID-19 pandemic continues to influence the delivery of health care, especially in areas with a high number of cases such as New York State. As per the executive order from New York Governor Andrew Cuomo on March 25, 2020, no further elective surgery cases are permitted in an effort to reduce transmission of the virus.1 As such, nonsurgical care will become increasingly important for orthopedic patients. Physical and occupational therapists are essential providers of nonsurgical orthopedic care. Understanding the perspectives and needs of therapists relative to the circumstances created by COVID-19 is critical to protecting their health as well as ensuring the delivery of safe and effective care to patients.

The goal of this study was to define the perspectives of therapists in New York State on issues relevant to the impact of COVID-19 on their work. Overall, the authors attempted to provide insight regarding safety of care, indications for care, alternative options for delivery of care, and additional health care roles for therapists during the current pandemic.

Materials and Methods

Physical/occupational therapy offices from all 10 New York State regions were identified from an online search via the Yellow Pages ( http//www.yellowpages.com) for “physical therapy” and “occupational therapy.” Repeat listings were excluded, and any practice that was self-described on the listing as closed was excluded. The authors contacted therapists working at the identified offices via telephone and presented the study. After the therapists confirmed that they were still treating patients with orthopedic conditions at the outpatient setting, they were emailed a survey. The survey, containing 20 questions, was distributed to 250 therapists who treated orthopedic patients during the peak of the COVID-19 pandemic. The first part of the survey elicited information regarding therapist demographics, practice setting, current patient load, use of telemedicine, and level of risk for COVID-19 complications among therapists' household members. On the second part of the survey, respondents rated statements on a 5-point Likert scale regarding therapist perspectives on safety of treatment, patient selection (who should be treated), alternative treatment modalities, clarity of state guidelines, COVID-19 education level, and possible use of therapists in other positions within the health care system.

Statistical Analysis

Likert scale responses were treated as ordinal and reported as percentages of responses in agreement with statements (1,2=disagree; 3=undecided; 4,5=agree). A paired t test was used to compare the differences between hospital-employed therapists and nonhospital-employed therapist responses, and also to compare the differences in responses between therapists with household members at risk of COVID-19 complications and those with no household member at risk of COVID-19 complications. Statistical analyses were conducted by using SPSS Statistics version 25.0 (IBM Corp, Armonk, New York). The significance level was set at P<.05.

Results

Of the invited therapists, 73.2% (n=183) participated in the survey, with a 100% completion rate of all 20 questions of the survey. Among these, 38.3% (n=70) were hospital-employed therapists and 61.7% (n=113) were private practice employees. As a result of the COVID-19 pandemic, patient care work for therapists was just below 40% of their normal volume, reflecting a significant decrease in services provided to patients during the peak of the pandemic in New York State (all therapists, 37.6%; hospital-employed therapists, 38.7%; private practice therapists, 37.3%).

Only 49.7% (n=91) of therapists reported feeling safe while providing face-to-face services at this time, and 39.9% (n=73) of therapists felt that these services were safe for patients to receive (Table A, available in the online version of the article). No significant differences in responses on these issues were identified when comparing hospital-based therapists with those in private practice (P=.251 and P=.890) (Table B, available in the online version of the article) and also when comparing therapists who had household members with risk factors for COVID-19 complications with therapists without increased risk (P=.103 and P=.487) (Table C, available in the online version of the article). Of the therapists, 60.1% (n=110) indicated having adequate access to proper personal protective equipment (PPE). However, hospital-employed therapists felt that their access to proper PPE was significantly better as compared with therapists in private practice (P=.013) (Table B). Among the therapists, 81.4% (n=149) indicated that therapy services should be provided as usual only to patients who have acute pain, recent trauma, emergency/urgent surgery, or surgical complications (Table A).

New York State Therapist Survey Results on Non-surgical Treatment for Orthopaedic Problems During the COVID-19 Pandemic.

Table A:

New York State Therapist Survey Results on Non-surgical Treatment for Orthopaedic Problems During the COVID-19 Pandemic.

Hospital Employees (n=70) Vs Private Practice Employees (n=113)

Table B:

Hospital Employees (n=70) Vs Private Practice Employees (n=113)

Therapists With and Without Household Members Considered High Risk for COVID-19 Complications (Yes-49, NO-134)

Table C:

Therapists With and Without Household Members Considered High Risk for COVID-19 Complications (Yes-49, NO-134)

Among the therapists, 68.9% (n=126) felt that they were well educated about COVID-19; however, 56.3% (n=103) of them felt that the current New York State guidelines on providing face-to-face therapy were unclear (Table A).

Of the therapists, 54.6% (n=100) indicated that telemedicine was an acceptable alternative to face-to-face therapy to achieve treatment goals for patient care (Table A). More specifically, private practice therapists in this survey currently used telemedicine more than hospital-employed therapists (86.7% vs 21.4%). Significantly more private practice therapists indicated that telemedicine was an acceptable alternative to deliver services (P<.001) (Table B). However, only 32.24% (n=59) of all surveyed therapists indicated that standard online videos and therapy protocols were acceptable alternatives (Table A). No significant difference was identified when comparing hospital-employed therapists with those in private practice (P=.139) (Table B).

Of the therapists, 48.6% (n=89) felt that they could be used in other positions within the health care system during this pandemic (Table A). No significant difference was identified when comparing hospital-employed therapists with those in private practice (P=.782) (Table B).

Discussion

The COVID-19 virus continues to have a profound effect on communities and health care systems around the world. As a result, health professionals have been challenged in many ways, specifically with regard to delivery of care. Although therapists have had to confront challenges to their work from prior pandemics, COVID-19 has been unique in its range of morbidity and mortality.2

At the height of the COVID-19 pandemic in New York State, physical and occupational therapists were surveyed as part of this study to understand their perspectives regarding the impact of COVID-19 on their work. The survey results not only define their perspectives but also emphasize areas where better education and preparation could contribute to safer, more efficient, and more effective delivery of therapy services.

Overall, therapists neither felt safe delivering care nor thought it was safe for patients to receive it. No difference in opinion surfaced on this issue between hospital-employed therapists and those working in private practice (P>.05). Despite recommendations for social distancing and the use of facial masks to prevent the transmission of COVID-19, therapy typically requires a hands-on approach, placing both the therapist and patient at increased risk for virus transmission. Personal protective equipment is used to help reduce such transmission, but only 60% of therapists indicated that they had adequate access to PPE. More specifically, the survey results showed that PPE is more accessible to hospital-based therapists. This finding suggests that therapists in private practice may need additional resources to secure PPE. The findings of this study correlate with prior reports from therapists who have confronted the same treatment safety concerns during the COVID-19 pandemic.3–5

Consequently, if safe delivery of care is a concerning issue, the question becomes who should receive therapy during a pandemic. New York State has provided guidelines to help answer this question6; however, most therapists felt that the guidelines were unclear, leaving them to decide the matter on their own. Regardless of the guidelines, the vast majority of all therapists concurred on the indications for therapy. During the COVID-19 pandemic, therapy services should be restricted to the following groups of patients: acute pain, recent trauma or surgery, and surgical complications.

Restrictions placed on the delivery of face-to-face therapy services to prevent transmission of COVID-19 leave many patients in need of instruction on how to self-manage their care. To meet that need, health care providers across all specialties have turned to telemedicine.7,8 The results of the survey indicated that although tele-medicine is an option for therapists, only approximately half of them see it as an adequate alternative to face-to-face therapy to achieve treatment goals. Reasons for this may include limited access to telemedicine, quality of the telemedicine platform, and inexperience with using it. Although telemedicine resources have been available for years, not all providers have realized a need for its use until now. Among the survey participants, significantly more therapists in private practice viewed tele-medicine to be an acceptable alternative to deliver services compared with their colleagues employed by hospitals.

New York State is one of the hardest hit areas by the COVID-19 virus in the world today. As such, the health care system and its providers are being pushed to the limits of their ability to care for patients. Under such circumstances, the need arises to help those providers on the front line to supplement their efforts and provide some relief from the demands of their work.9 Consideration must be given to using therapists in roles other than the ones in which they typically serve, such as providing assistance in emergency departments or on respiratory therapy teams. Regardless of the exact role, nearly half of all therapists participating in the survey expressed an ability and willingness to help in other areas of the health care system outside of physical or occupational therapy.

Overall, like all health care providers, therapists have expressed concerns about the transmission of COVID-19 during their work. To address these concerns and to allow for continuity of patient care, adequate preparation and education requires support from both private practice and hospital system administrators, as well as government officials. The results of this survey echo the need to secure proper PPE for providers and to clarify guidelines relevant to providing care during the pandemic. The use of advanced technology in the way of telemedicine offers an option to assist in the delivery of care. Proper education and access to tele-medicine platforms for therapists would be helpful in making telemedicine an effective means by which to provide care during this time.

References

  1. Executive Order No. 202.10: continuing temporary suspension and modification of laws relating to the disaster emergency. https://www.governor.ny.gov/news/no-20210-continuing-temporary-suspension-and-modification-laws-relating-disaster-emergency. Accessed June 21, 2020.
  2. Jette A. Physical therapy and the global HIV/AIDS pandemic. Physical Therapy. 2017;97(3):273–274.
  3. Thomas P, Baldwin C, Bissett B, et al. Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations. Physiotherapy. 2020;66(2):73–82.
  4. Boldrini P, Bernetti A. Impact of COVID-19 outbreak on rehabilitation services and physical and rehabilitation (PRM) physicians' activities in Italy. Eur J Phys Rehab Med. doi:10.23736/S1973-9087.20.06256-5 [CrossRef]
  5. Alpalhão V, Alpalhão M. Impact of COVID-19 on physical therapist practice in Portugal. Phys Ther. doi:10.1093/ptj/pzaa071 [CrossRef]
  6. Guidance on Executive Order 202.6: guidance for determining whether a business enterprise is subject to a workforce reduction under recent executive orders. https://esd.ny.gov/guidance-executive-order-2026. Accessed June 21, 2020.
  7. Loeb AE, Rao SS, Ficke JR, Morris CD, Riley LH III, Levin AS. Departmental experience and lessons learned with accelerated introduction of telemedicine during the COVID-19 crisis. J Am Acad Orthop Surg. 2020;28(11):e469–e476.
  8. Shokri T, Lighthall JG. Telemedicine in the era of the COVID-19 pandemic: implications in facial plastic surgery. Facial Plast Surg Aesthet Med. 2020;22(3):155–156.
  9. Sarpong NO, Forrester LA, Levine WN. What's important: redeployment of the orthopaedic surgeon during the COVID-19 pandemic: perspectives from the trenches. J Bone Joint Surg Am. 2020;102(12):1019–1021.

New York State Therapist Survey Results on Non-surgical Treatment for Orthopaedic Problems During the COVID-19 Pandemic.

DisagreeUndecidedAgreeMean
Likert1–234–5
1.Physical/occupational therapy services should be provided as usual to all patients during the COVID-19 pandemic.10726502.61
2.Physical/occupational therapy services should be provided as usual only to patients who have acute pain, recent trauma, surgery, or surgical complications.2591494.02
3.I feel safe while providing face to face physical/occupational therapy to patients.4448913.32
4.Participating in face to face physical/occupational therapy is currently safe for patients.4565733.16
5.Telemedicine is an acceptable alternative that allows me to reach my patient treatment goals for physical/occupational therapy at this time.34491003.54
6.Standard online physical/occupational therapy protocols and videos are acceptable alternatives that allow me to reach my patient treatment goals at this time.7549592.89
7.The current NYS guidelines on who should have face to face physical/occupational therapy is clear to me.10340402.60
8.I am adequately/fully educated regarding COVID-19.23341263.71
9.I have access to proper PPE while treating patients.49241103.42
10.Physical/occupational therapists could be better utilized in the current situation in other positions in the healthcare system.3064893.47

Hospital Employees (n=70) Vs Private Practice Employees (n=113)

MeanSDMeanSDP-Value
HospitalhospitalPrivatePrivate
1.Physical/occupational therapy services should be provided as usual to all patients during the COVID-19 pandemic.2.591.152.631.210.8250
2.Physical/occupational therapy services should be provided as usual only to patients who have acute pain, recent trauma, surgery, or surgical complications.3.871.014.111.010.1200
3.I feel safe while providing face to face physical/occupational therapy to patients.3.211.043.391.020.2510
4.Participating in face to face physical/occupational therapy is currently safe for patients.3.170.963.150.940.8898
5.Telemedicine is an acceptable alternative that allows me to reach my patient treatment goals for physical/occupational therapy at this time.3.200.953.771.060.0003
6.Standard online physical/occupational therapy protocols and videos are acceptable alternatives that allow me to reach my patient treatment goals at this time.2.741.052.991.140.1392
7.The current NYS guidelines on who should have face to face physical/occupational therapy is clear to me.2.440.942.691.040.1030
8.I am adequately/fully educated regarding COVID-19.3.591.023.800.870.1394
9.I have access to proper PPE while treating patients.3.690.983.261.210.0131
10.Physical/occupational therapists could be better utilized in the current situation in other positions in the healthcare system.3.51.013.460.910.7821

Therapists With and Without Household Members Considered High Risk for COVID-19 Complications (Yes-49, NO-134)

With Risk of ComplicationsWithout Risk of ComplicationsP-Value
MeanSDMeanSD
1.I feel safe while providing face to face physical/occupational therapy to patients.3.121.003.391.030.1026
2.Participating in face to face physical/occupational therapy is currently safe for patients.3.080.883.190.970.4874
3.I have access to proper PPE while treating patients.3.411.093.431.170.9585
Authors

The authors are from Carthage Area Hospital, Carthage, New York.

The authors have no relevant financial relationships to disclose.

The authors thank Itai Parnes for assistance with data collection and statistical support.

Correspondence should be addressed to: Nata Parnes, MD, Carthage Area Hospital, 3 Bridge St, Carthage, NY 13619 ( nparnes@cahny.org).

Received: May 13, 2020
Accepted: June 01, 2020
Posted Online: August 06, 2020

10.3928/01477447-20200721-16

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