COVID-19 Coma & Chronic Disorders of Consciousness

Neurorehabilitation of patients with severe brain injury during the Covid-19 epidemic

The growing emergency due to the Covid-19 pandemic has rapidly and abruptly stressed health systems in all involved countries. Post-acute rehabilitation wards are exposed to understandable pressure from intensive care units (ICU) with a progressive increase in admission requests to facilitate discharge from acute care facilities and to free valuable beds for people affected by Covid-19 related respiratory insufficiency.

The growing emergency due to the Covid-19 pandemic has rapidly and abruptly stressed health systems in all involved countries. Post-acute rehabilitation wards are exposed to understandable pressure from intensive care units (ICU) with a progressive increase in admission requests to facilitate discharge from acute care facilities and to free valuable beds for people affected by Covid-19 related respiratory insufficiency.
Rehabilitation professionals may be forced to choose between admitting patients with often unstable vital functions and poor recovery potential and discharging patients with severe disabilities in need of highly specialised rehabilitation. Meanwhile, caregivers are not able to care for their loved ones at home and, at the same time, may decline transfer to long-term care facilities that may be full of Covid-19 positive patients. Remote assistance and/or tele-rehabilitation as remote home-monitoring for patients unable to access rehabilitation hospitals can be suboptimal. Additionally, rehabilitation professionals are overwhelmed by conflicting tasks such as maintaining the safety of staff and patients on one hand and requests to relieve the pressure on ICUs from Covid-19 patients on the other.
Another unfortunate consequence of the Covid 19 epidemic is that caregivers are no longer allowed to visit hospitalized patients, which has many negative consequences including lack of emotional stimulation of patients by their caregivers (Formisano et al., 2019), an aspect for which remote information technologies cannot fully compensate.
Another lesson from this severe pandemic emergency is that the inclusion criteria for admission to highly specialised post-acute rehabilitation wards has to be revisited and rethought.
Patients with complex and severe neurological and cardiorespiratory diseases, irrespective whether or not they are in coma during the acute phase, require a multidisciplinary rehabilitation approach of high intensity, which is generally available only in post-acute rehabilitation wards. These wards have the necessary expertise in the management of tracheal tubes and enteral nutrition, oxygenation monitoring, tracheo-bronchial secretion management, respiratory and swallowing training, neuromotor and cognitive-behavioral rehabilitation and caregivers education and psychological support (Formisano, unpublished data).
Of note, the Italian Society of Neurorehabilitation has recently proposed recommendations on urgent measures for containment of the Covid-19 epidemic in Neurorehabilitation/Rehabilitation Departments (Bartolo et al., 2020).
References

Bartolo M., Intiso D., Lentino C., Sandrini G., Paolucci S., Zampolini M., On behalf of the Governing Council of the Italian Society of Neurological Rehabilitation (SIRN). (2020) Urgent measures for the containment of the Covid-19 epidemic in the Neurorehabilitation/ Rehabilitation Departments in the phase of maximum expansion of the epidemic. Frontiers Neurology.
Formisano, R., Contrada, M., Iosa, M., Ferri, G., Schiattone, S., & Aloisi, M. (2019). Coma Recovery Scale-Revised With and Without the Emotional Stimulation of Caregivers. Canadian Journal of Neurological Sciences, 46(5), 607-609.