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Abstract
Objectives During the COVID-19 pandemic, designated rehabilitation centres were established in the province of Québec, where strict sociosanitary measures such as isolation and mandatory personal protection equipment requirements were followed. This study aimed to describe the impact of the pandemic on rehabilitation care indicators for poststroke users with (COV+) and without (COV−) COVID-19 infection in designated rehabilitation centres compared with those admitted in the previous year (pre-COV).
Method A retrospective analysis of 292 medical files was performed in 3 rehabilitation centres. Demographic characteristics were collected, as well as indicators routinely collected in acute care and rehabilitation such as length of stay (LOS), the Functional Independence Measure and a number of physical/occupational therapy (PT/OT) sessions. Non-parametric statistical tests were used to compare variables among the three groups.
Results COV+ users were older than COV− and pre-COV ones (p<0.01) and were more disabled on admission to a rehabilitation centre (p<0.01). They also exhibited longer LOS in acute care prior to rehabilitation (p<0.001) and were more often rehospitalised (p<0.002) during the course of their stay in the rehabilitation centre. Despite longer rehabilitation stays (p<0.001) and more PT/OT sessions, COV+ users remained more disabled at discharge (p<0.002). COV− users showed rehabilitation care indicators resembling the ones of pre-COV despite spending less time in rehabilitation.
Conclusions Patients who had a stroke infected with COVID-19 exhibited greater vulnerability on admission to rehabilitation. They required more care and services during their rehabilitation period. However, this additional support did not enable them to achieve the same level of recovery as COV− and pre-COV users. This underscores the added impact of the disease on already impaired patients and highlights the specific needs of COV+ users undergoing rehabilitation.
- Stroke
- COVID-19
- Quality in health care
- REHABILITATION MEDICINE
- PUBLIC HEALTH
- Health Services
Data availability statement
No data are available. Not applicable as we could not ask participants if they accepted that their data could be shared.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The study focuses on the initial two waves of the COVID-19 pandemic, when more stringent sociosanitary measures were implemented and before mass vaccination took place.
A wide variety of rehabilitation care indicators were extracted to obtain a holistic view of the outcome of stroke rehabilitation during the pandemic.
The rehabilitation care duration for the COVID+ group might be underestimated due to transfers to non-COVID-19 facilities.
Based on data from Québec’s urban rehab centres, the findings may not apply to other regions with different healthcare systems.
Background
In Canada, stroke users receive rehabilitation care that follows high-quality standards to achieve optimal functional recovery from stroke-related disabilities (cognitive/sensory/motor).1 However, during the first two waves of the pandemic, mandatory infection control measures added complexity and time-consuming procedures to rehabilitation services.2 3 These disruptions in care services highlight the need to comprehensively examine the impact of the pandemic on the rehabilitation care of poststroke users.
The WHO declared COVID-19 a global pandemic on 11 March 2020.4 In Québec (Canada), a public health emergency was announced on 13 March 2020.5 COVID-19 can affect multiple body systems, causing complex health conditions.6–8 Few individuals were vaccinated before the vaccination peak (May–July 2021),5 leading to more hospital admissions andintensive care unit (ICU) care.9–11 Over the first two waves (from 25 February 2020 to 20 March 2021), there were over 300 000 confirmed cases and 14 000 deaths.5
To prioritise the prevention of disease transmission, COVID-19 designated rehabilitation centres were established at the beginning of the pandemic.2 These designated centres reallocate beds to dedicated rehabilitation care COVID-19 units, or ‘hot zones’,12 for patients identified as confirmed or suspected COVID-19 cases (COV+). In these units, staff was dedicated and trained to the strict Infection Prevention and Control guidelines.13 Patients diagnosed with COVID-19 were confined to their rooms, with resources limited to what was available within the unit. Comprehensive protective equipment was mandatory (N95 masks, gloves, goggles, face shields, gowns, caps and shoe covers), and entering or exiting the hot zone of the COVID-19 unit required passing through a dressing-undressing neutral zone. During this period, there was also a staff shortage due to staff absenteeism caused by illness and highly skilled healthcare providers were also redeployed to front-line COVID-19 units.13 14 Meanwhile, routine admission and care of asymptomatic and non-infected COVID-19 patients (COV−) continued in separate units: the ‘cold zones’. In these, the use of less intensive personal protection equipment (PPE) was mandated and required occasional preventive isolation. Isolation protocols further restricted the ability to bring therapy equipment and tools into isolation rooms and prevented families from visiting.12 14 Visitation was limited across all units to control virus spread within the community.
In addition to these new protocols, stroke users were at higher risk of experiencing more severe disease or adverse outcomes when infected with COVID-19 due to their underlying health conditions.15 16 The presence of comorbidities such as diabetes, hypertension and obesity, which are risk factors for both stroke and COVID-19 infection, further increased the prevalence of the infection among this population,3 15 17 contributing to a higher mortality rate18 19 as well as aggravated sensory and motor deficits due to neurological damage.12
While it is understood that significant modifications were made to inpatient rehabilitation care, the full impact of these changes on high-risk poststroke individuals during the first two waves of the COVID-19 pandemic in Québec remains unclear. This study seeks to describe how COVID-19 infection and rehabilitation under the restrictions and guidelines in place during the pandemic’s first two waves affected the quality-of-care indicators and functional outcomes for these patients. This knowledge is crucial not only for evaluating the impact of pandemic-related changes on rehabilitation care but also for informing future crisis preparedness strategies.
Objectives and hypotheses
The main objective was to determine the impact of the COVID-19 pandemic on rehabilitation care indicators extracted from the medical files of poststroke users, with and without COVID-19 infection (COV+ and COV−), in comparison to the pre-pandemic scenario (pre-COV). More specifically, we wanted to determine the impact of being: (1) COV+ on rehabilitation care indicators in comparison to COV− and pre-COV users and (2) admitted to a rehabilitation centre without contracting the COVID-19 virus on rehabilitation care indicators compared with the pre-COV scenario.
We hypothesised that (1) COV+ users would demonstrate impacted rehabilitation care indicators compared with the COV− and pre-COV ones. This would be attributed to the worsening of their health conditions and exacerbated poststroke deficits due to a COVID-19 infection. In addition, since they were admitted in the hot zone, COV+ users would have experienced challenges in receiving rehabilitation care and (2) COV− users would demonstrate impacted rehabilitation care indicators compared with the pre-COV scenario. This would be attributed to challenges in receiving rehabilitation care when they were admitted to a cold zone.
Methodology
A multicentres retrospective cross-sectional study was performed on medical files (Dossier Santé Québec) of in-patient stroke rehabilitation users admitted to COVID-19 designated rehabilitation centres in the province of Québec. The study focuses on the initial two waves of the COVID-19 pandemic, before mass vaccination took place and more stringent sociosanitary measures were implemented.
Inclusion and exclusion criteria
The study included adults (>18 years. of age) with a diagnosis of stroke who were admitted to a COVID-19 designated rehabilitation centre in the province of Québec between March 2020 and March 2021. The COV+ group consisted of stroke users who tested positive for COVID-19 either on or after their admission to a rehabilitation centre (rehab-nosocomial), which was confirmed by a reverse transcription-PCR test. The COV− group included stroke users who did not have a COVID-19 infection during the same period. The pre-COV group consisted of poststroke users admitted to a rehabilitation centre the year before the pandemic, specifically from March 2019 to February 2020. The rehabilitation centres provided the research team with a complete list of COV+ users. A semirandom selection of medical charts for the other two groups was performed to obtain a similar sex ratio (female/male). COV+ and COV− users were excluded if they did not meet the specified admission timeline to rehabilitation care between March 2020 and March 2021.
Patient and public involvement
None.
Data extraction
Out of the 15 centres designated for poststroke rehabilitation for adults who contracted COVID-19 in the province of Québec,2 3 were included in the study, namely Hôpital de réadaptation Villa Medica, CISSS Laval-Jewish Rehabilitation Hospital Site and CIUSSS Montreal West Island—Catherine Booth and Richardson Sites. The other sites were excluded either because they did not admit stroke COVID+ individuals during the period of interest or because they were emergency sites (eg, hotels or community centres converted for COVID+ care), which did not answer to the usual definition of a rehabilitation centre such as employing a team of rehabilitation expert professionals. Eight research assistants (RAs) were involved in the data extraction. An interjudge double-blinded scoring methodology was employed to ensure the quality and reproducibility of the extracted data. Each RA independently scored a subsample of approximately 10 charts, and consensus was reached through discussion. The data extracted were inputted into a REDCap data frame using encryption techniques to safeguard confidentiality. Furthermore, all collected data from various sites were securely stored on password-protected USB flash drives, following strict measures to maintain confidentiality throughout the entire process of data extraction, collection and analysis.
Data collection was guided by the postacute care rehabilitation quality-of-care framework.20 This framework provides a comprehensive structure for analysing rehabilitation quality of care, guiding the collection of key components known to impact rehabilitation care quality. As part of a larger study where data were extracted for users in all rehabilitation programmes, over 200 variables were initially extracted from participants’ medical charts. Indicators relevant to the stroke population were selected a priori based on previous literature and recommendations from the Canadian Stroke Best Practices. Discussions with clinical partners helped reach a consensus on the most typical and standardised poststroke rehabilitation care indicators, as well as those most frequently reported in medical charts. The study ultimately reports 13 stroke rehabilitation care variables. Baseline characteristics included age, sex and comorbidities (diabetes, hypertension and obesity were selected as known risk factors for both stroke and COVID-19 infection). Care process indicators prior to rehabilitation stay included length of stay (LOS) and intubation in acute care (acute LOS). Rehabilitation care processes were captured by LOS in rehabilitation care (from admission to discharge—Rehab LOS), rehospitalisation to acute setting during rehabilitation stay (Rehosp), a number of physical/occupational therapy (PT/OT) sessions and COVID status (COV+, COV− and pre-COV). The primary rehabilitation outcome indicator was the Functional Independence Measure (FIM) score—a validated assessment tool in rehabilitation care21–23 recommended by the Canadian Stroke Best Practices23 to assess the improvement in functional status from admission (FIM pre) to discharge (FIM post).13 The FIM scale scores from 1 to 7 across 18 items and measures functional abilities in rehabilitation, with a maximum score of 126. The higher scores indicate greater independence, and lower ones reflect higher dependence.22
To assess the overall impact of rehabilitation interventions on the functional outcomes (FIM score), Rehabilitation Impact Indices24 were calculated, which consisted of:
Rehabilitation effectiveness (RE) expressed as a percentage reflecting the proportion of potential improvement in FIM score during rehabilitation, using the formula:
Rehabilitation efficiency (REy) regarded as the average increase in the FIM score per day during rehabilitation, using the formula:
Absolute functional gain (AFG) expressed as the difference in FIM score before and after rehabilitation:
The therapy dose was also calculated for PT/OT by dividing the total number of sessions by the total Rehab LOS:
Statistical analysis
Only outcomes with less than 35% of missing data were analysed, to allow for proper analysis and interpretation. The numerical variables were described using median and IQR (ie, the difference between the upper and lower quartiles) due to their non-normal distribution (Shapiro-Wilk normality test: p<0.05). Categorical variables were presented as frequencies in percentages. Group comparisons were conducted using the non-parametric Kruskal-Wallis test for independent samples using numerical variables and Pearson’s χ2 test for categorical variables to evaluate how likely it is that any observed difference between the sets arose by chance. Post hoc pairwise comparisons were done using Wilcoxon rank-sum tests (to compare the median ranks of two groups when they follow a non-normal distribution) and pairwise Proportion tests (to compare the proportion of successes in two groups). Bonferroni correction was performed to counteract the problem of multiple comparisons, reducing the chances of obtaining false-positive results (type I errors).
Results
Stroke users characteristics
Data were extracted from 292 poststroke files and included 85 COV+, 107 COV− and 100 pre-COV users (table 1). Within the COV+ group, 26 users (31%) were already positive for COVID-19 on admission to a rehabilitation centre, while 59 users (69%) contracted the virus during their rehabilitation stay (rehab-nosocomial).
Statistical comparison of demographic characteristics and acute care indicators between groups
Demographic characteristics and acute care indicators
The demographic characteristics and the comorbidities of the individuals are presented in table 1. There were significant differences observed in terms of age and comorbidities (obesity) among the three groups (p<0.05). The COV+ group was significantly older than the COV− and pre-COV ones (p<0.02) and had a significantly lower percentage of obesity compared with the other groups (p<0.007). Regarding other comorbidities, there were no significant differences in the prevalence of diabetes and hypertension among the three groups (p>0.05). The type of stroke differed significantly between groups (p=0.01), with a higher proportion of non-specified aetiology during the pandemic and a tendency for fewer ischaemic strokes before the pandemic. The COV+ group had significantly longer LOS in acute care prior to rehabilitation admission compared with the COV− and pre-COV ones (p<0.001) (table 1 and figure 1A) and a higher percentage of intubation compared with the pre-COV scenario (p<0.01).
Comparison of rehabilitation care indicators between groups. (A) LOS in acute care, (B) LOS in rehabilitation care, (C) FIM score on admission, (D) FIM score at discharge, (F) # PT sessions, (F) # OT sessions. *p<0.05, **p<0.01. #, number of sessions; FIM, functional independence measure; LOS, length of stay; OT, occupational therapy; PT, physical therapy.
Rehabilitation care indicators
The rehabilitation care indicators of the three groups are presented in table 2. The COV+ group had longer LOS in rehabilitation (p<0.001) (figure 1B). On admission to the rehabilitation centre, the COV+ group had lower FIM pre compared with the other groups (p<0.003) (figure 1C). The COV+ group also had lower FIM post compared with the other groups (p<0.002) (figure 1D). They received more PT and OT sessions (PT: p<0.006, OT: p<0.02) (figure 1E,F) but had lower OT dose compared with COV− users. In addition, the COV+ group had a higher proportion of users requiring rehospitalisation to acute care (p<0.002) than the COV− group during their rehabilitation stay. The COV+ group also had lower RE compared with the COV− one (p<0.05), and lower REy (p<0.001) compared with both the COV− and pre-COV groups. The AFG was not significantly different among the three groups.
Statistical comparison of rehabilitation care indicators between groups
The COV− group had similar care indicators in terms of LOS in acute care, proportion of those being intubated, FIM score on admission, FIM scores at discharge (p>0.05), a number of rehospitalisation and PT and OT sessions compared with the pre-COV group (p>0.05). The COV− group had significantly shorter LOS in rehabilitation compared with the pre-COV one (p<0.02) and showed higher REy score (p<0.02).
Discussion
This descriptive study provided valuable retrospective insights into the impact of the COVID-19 pandemic on rehabilitation care indicators among poststroke users with and without COVID-19 infection compared with the prepandemic scenario. Consistent with our first hypothesis, COV+ users showed impacted rehabilitation care indicators, including longer stays in acute and rehabilitation care, higher rates of intubation and rehospitalisation. Importantly, COV+ users had lower functional status on rehabilitation admission than COV− and pre-COV users. They were also more impaired at discharge even though they stayed longer in rehabilitation care and underwent a greater number of therapy sessions compared with COV− users.
COV− users had acute care profiles that resembled the prepandemic scenario, including days spent in acute care, rate of intubation care and rehospitalisation. Contrary to our second hypothesis, COV− users achieved similar functional gains at discharge compared with pre-COV users despite spending less time in rehabilitation care and receiving a similar number of PT/OT sessions.
Impact of being infected with COVID-19 on rehabilitation care indicators
Although the COV+ group had longer rehabilitation stays and received more PT/OT sessions, their level of functional recovery did not match that of the pre-COV one. The gain in FIM score per day (REy) was less in COV+ compared with to both COV− and pre-COV groups. Consequently, COV+ users were more disabled at discharge (lower FIM post and RE) than the COV− and pre-COV ones. In fact, only 42% of COV+ users achieved the minimally clinically important difference25 (FIM post–FIM pre (AFG)≥22) in FIM scores, while 51% of COV− and 47% of pre-COV users did. This is in line with the fact that in addition to their stroke-related deficits, COV+ individuals ended up facing a multisystem affection due to the infection of the virus COVID-19 itself, including cardiorespiratory system and fatigue leading to a slower recovery curve,6–8 in addition to impairments caused by the stroke. COV+ individuals were also more frequently rehospitalised to acute care. This aligns with previous studies demonstrating the adverse effects of acute care unit readmission (ACUR) on rehabilitation outcomes. Rehospitalisations to acute care were more common among COV+ individuals, interrupting the rehabilitation process. This observation is consistent with previous studies highlighting the negative impact of ACUR on rehabilitation outcomes.26
In this study, the COV+ group had lower OT intensity compared with the COV− group. This may be attributed partly to the stricter mandatory infection control measures used for COVID-19 individuals in the hot zone, such as heavy PPE and restrictions on the therapy equipment that could enter isolation rooms.12 14 Adding time-consuming procedures might have affected the actual time spent providing one-to-one care to the infected COVID-19 users.12 14
In this study, 69% of the COV+ users were rehab-nosocomial, which means they caught COVID-19 during their rehabilitation stay. As a group, COV+ users were older, making them more at risk of catching the COVID-19 virus and experiencing more severe symptoms.15 16 COV+ individuals who contracted the disease before their admission to the hot zone of the designated centre spent more time in acute care, with a higher proportion requiring intubation than COV− and pre-COV groups. Individuals admitted with COVID-19 exhibited higher levels of functionally disabled on admission in rehabilitation.
Impact of being admitted to rehabilitation care without infection during the pandemic on rehabilitation care indicators
Contrary to our hypothesis, being COV− in the cold zone of COVID-19 designated rehabilitation centres did not seem to impact the rehabilitation continuum of care. COV− individuals had similar profiles compared with the pre-COV ones regarding LOS in acute care, frequency of intubation and rehospitalisation, as well as functional status on admission in a rehabilitation facility. The COV− users also underwent a comparable number and doses of PT/OT sessions. The main difference is that they spent less time in rehabilitation care than in the prepandemic scenario. Remarkably, they achieved similar functional status at discharge compared with pre-COV users. This aligns with the fact that daily FIM score gain (REy) was higher for the COV− group (0.7±0.62) compared with pre-COV one (0.5±0.45). This suggests that the cold zone’s restrictive infection control measures in place did not significantly impact their rehabilitation outcomes. There is also the possibility that COV− users received longer treatment sessions or different quality than in the prepandemic scenario, but this information was not available in the medical files. Contrary to individuals who contracted the COVID-19 disease, the rehabilitation care provided to COV− users in designated centres seemed sufficient to reach the expected functional status at discharge.
Study limitations
Only 3 of the 15 COVID-19 designated rehabilitation centres were included in this study. These centres were all located in urban areas in the province of Québec. Therefore, caution should be made when generalising the results to other provinces, countries or rural areas with different healthcare systems and/or practices. Furthermore, the time spent in rehabilitation care for the COV+ groups may have been underestimated due to transfers to non-COVID designated rehabilitation centres once users tested negative for COVID-19. In addition, during the pandemic, stroke users experienced a lower probability of being transferred to an in-patient rehabilitation facility,13 27 further limiting the representativity of the present study for both groups.
In addition, this study focused on the most commonly reported rehabilitation quality of care and functional outcome indicators from medical charts to provide a general overview of care quality and functional outcomes. While other motor and cognitive clinical outcomes could have been valuable to examine, many variables in our initial dataset of 200 measures had missing data rates above 35%. We excluded these variables from the study since such high rates of missing data preclude meaningful statistical analysis and interpretation.28 During the pandemic, these data loss may have been partly due to infection control measures that prohibited external objects in COVID-positive patients’ rooms, preventing on-the-spot recording of test results and the use of standardised testing equipment. Beyond the pandemic context, medical charts generally lack standardisation in data collection, leading some researchers to advocate for a standard registry to support rehabilitation research.29 Future research would thus benefit from more comprehensive variables, including standardised physical and cognitive assessments. In the context of missing quantitative data, qualitative data from stakeholders in a mixed-methods follow-up of this study will contribute to the understanding of how the pandemic’s first waves affected rehabilitation care through their lived experiences.
Conclusion
This study reveals significant differences in rehabilitation outcomes for poststroke patients infected with COVID-19 and admitted to a hot zone of a COVID-19 designated rehabilitation centre during the pandemic. This may be related to the deterioration in health associated with COVID-19 infection, as well as the additional challenges posed by strict infection control measures during rehabilitation in the hot zones. On the other hand, non-infected COVID-19 users admitted to a cold zone did not show significant differences in functional recovery compared with the prepandemic cohort, suggesting fewer disruptions in standard rehabilitation care. These findings underscore the importance of tailored rehabilitation resources during pandemics, such as acute medical care and rehabilitation specialists, to optimise recovery and minimise rehospitalisations for all patients, including those admitted for or treated alongside an infection. Further studies are needed to better understand the factors influencing these differences and to confirm the underlying mechanisms contributing to the observed differences in recovery in the context of a global health crisis.
Data availability statement
No data are available. Not applicable as we could not ask participants if they accepted that their data could be shared.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and ethical approval was obtained from CRIR/CIUSSS Centre intégré universitaire de santé et de services sociaux de l’Ouest-de-l’Île-de-Montréal du Center-Sud-de-l’Île-de-Montréal on 13 July 2021 (MP-50-2022-1297). Institutional suitability was obtained for each of the COVID-19-designated rehabilitation centres before data extraction took place. This is a retrospective study where variables were extracted from medical charts.
References
Footnotes
Contributors MHB acted as guarantor of this study. MHB and PF conceived the study. MHB, PF, MHM, JH and L-DB acquired funding. MHB, PF and PV were responsible for data acquisition. PV and PF performed data analyses. MHB, PF and PV wrote the manuscript. MHM, JH and LDB were involved in the revisions of the manuscript. All authors approved the final version for publication.
Funding This work was supported by the Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR) as part of the New Initiatives Program Provincial Adaptation-Rehabilitation Research Network (REPAR) as part of a call for projects targeted at COVID-19. At the time of the study, MHB held a Research Scholar Award Fonds de recherche du Quebéc–Santé (FRQ-S) and PF a Postdoctoral Fellowship from FRQ-S and Unité Système de Santé Apprenant (SSA). PV received MSc scholarships from CRIR, REPAR and McGill Faculty of Medicine and Health Sciences.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.