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Implementation considerations for delivering inpatient COVID rehabilitation: A qualitative study

Abstract Rationale Patients recovering from significant COVID‐19 infections benefit from rehabilitation; however, aspects of rehabilitative care can be difficult to implement amidst COVID infection control measures. Aims and Objectives We used the Consolidated Framework for Implementation Research (CFIR) to evaluate the rapid implementation of a COVID zone in an in‐patient rehabilitation hospital at the onset of the first wave of the pandemic. Methods Semistructured interviews were conducted with health care providers (n = 12) supporting the COVID zone, as well as with patients (n = 10) who were discharged from the COVID zone and their family caregivers (n = 5). The interviews explored the successes and challenges of working on the unit and the quality of care that was delivered to patients recovering from COVID. Results Rapid implementation of the COVID zone was supported by champions at the middle‐management level but challenged by a number of factors, including: conflicting expert opinions on best infection control practices (outer setting), limited flow of information from senior leaders to frontline staff (inner setting), lack of rehabilitation equipment and understanding of how to provide high quality rehabilitative care in this context (intervention characteristics), willingness and self‐efficacy of staff working in the COVID zone (individual characteristics) and lack of time to reflect on and assess effectiveness (process). Conclusions While there was an apparent need for rapid implementation of a COVID rehabilitation zone, senior leadership, middle management and frontline staff faced several challenges. Future evaluations should focus on how to adapt COVID rehabilitation services during fluctuating pandemic restrictions, and to account for rehabilitative needs of people recovering from significant COVID infections.


| Study setting and intervention
This evaluation was conducted at an IRH located in Toronto, Canada.
The hospital offers in-patient and outpatient rehabilitation services to people recovering from a range of illnesses and injuries. The COVID zone was implemented on the Musculoskeletal and Geriatric Rehabilitation Unit. Seven of the units' 39 beds were designated to the COVID zone, with an additional 15 beds available if needed. The unit was staffed by a hospitalist physician, physiatrist, consulting psychiatrist, nurses and allied health professionals. They also had direct support from the Infection Prevention and Control (IPAC) team. The COVID zone provided rehabilitation to a total of 45 patients between March 2020 and July 2021.

| Data collection
A convenience sample of HCPs working in or supporting the COVID zone were recruited using the hospital's COVID unit listservs (n = 12; see Table 1 for sample characteristics). We also recruited a convenience sample of family caregivers (n = 5) and patients (n = 10) who were discharged from the COVID zone between March and September 2020 (see Table 2 for sample characteristics). All patients were contacted by telephone or email to share information about the study, and each patient was asked for their caregiver's contact details for the research team to follow-up. Eligible patients and caregivers included those who spoke English and were cognitively able to provide consent. Additionally, caregivers were eligible if they were a friend or family member of a patient who was discharged from the COVID unit during the abovementioned period. Thirteen patients and caregivers were eligible for the study but were not interested (n = 9) or could not be reached (n = 4). One family caregiver (CG10) also worked as a frontline nurse at the IRH, and relevant quotes that pertained to implementation are included in the current analysis.
Data were collected through single, semistructured, one-to-one interviews conducted via Zoom or telephone between August 2020 and Occupational therapist (OT) Uses everyday activities and occupations to treat the physical, mental, developmental and emotional ailments that impact a patient's ability to perform day-to-day tasks 3 (35) Patient care manager (PCM) Supervises a clinical team and are responsible for the direction of patient care 2 (17) Registered nurse (RN) Assesses, identifies, plans, implements, and evaluates the nursing care required to assist patients in meeting their physical, social, spiritual and psychological needs 2 (17) Pharmacist Prepares and dispenses prescription medications and educates patients and families on the safe and effective use of medications 1 (8) Medical department head (MDH) Responsible for medical supervision and overseeing daily operations in their respective departments 2 (17) Professional practice leader (PPL) Oversees and supervises clinical and professional practice, and develops and supports patient care and education through mentorship, consultation, and acting as a resource for staff 2 (17) focused on successes and challenges working on the unit, supports received, and the quality of care delivered to patients. Data were collected until saturation was reached. 18 All sessions were audiorecorded, transcribed verbatim and uploaded into NVivo for data management and collaborative coding. Ethical approval for this study was granted by Sunnybrook Health Sciences Centre, and informed consent was obtained from all participants before data collection.

| Data analysis
We used a qualitative descriptive approach to elicit a rich description of the implementation of the COVID zone to inform the development of actionable policy and practice recommendations that were reflective of our participants' views. 19 We conducted a deductive thematic analysis 20 guided by a coding framework based on the CFIR (see Table 3). All transcripts were coded independently and then jointly by two researchers (Z. S. and S. G.), and three additional researchers (C. S., R. S. and M. W.) participated in the thematic analysis. Rigour was established by double coding, keeping audit trails, recording memos and regular team meetings.

| RESULTS
Although participants recognized the need for a COVID zone, several implementation challenges were identified. Participants' insights fell into several CFIR constructs that spanned all five domains of the framework (see Table 3). As one health care provider described:

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'My concern is that they wouldn't be getting enough rehab she would always say that she will be there and seeing us. And she was. We had questions, she tried to answer them as best as she could […] we were all anxious to work in the unit, but she reassured us. We did our huddles, we vented, we got our concerns out'.
External change agents reflecting and evaluating: Quantitative and qualitative feedback about the progress, quality, and experience of implementation.
Participants reported a lack of feedback regarding the progress and quality of implementation.  Provision of rehabilitation was strained by a lack of resources (e.g., PPE shortages) and inaccessible rehabilitation equipment (e.g., gym). Conversely, rehabilitation was facilitated by the extra time that HCPs had with patients, which was necessary, as rehabilitation took longer to deliver and patients had more complex psychosocial needs due to visitor restrictions.
As one health care provider reflected:

| DISCUSSION
At the onset of the pandemic, rehabilitation institutes across the globe struggled to provide care to patients recovering from significant COVID infections. 21 While emerging research has explored rehabilitative outcomes for these patients, 7,[22][23][24][25] this is the first study to examine the challenges of rapidly implementing a COVID rehabilitation strategy in an IRH. 13  Secondly, efforts must be made to promote staff competencies providing care to this population. While our data did not explore the nature and extent of rehabilitation provided, it was clear that the pandemic created a nebulous and unfamiliar environment that generated feelings of uncertainty as to the best way to provide rehabilitation to patients recovering from COVID. Therefore, more research is needed to understand if and how patients recovering from significant COVID infections require a more nuanced rehabilitation approach, and how best to deliver this in situations where usual resources (e.g., rehabilitation gym) are restricted due to ongoing outbreaks. 11 Given ongoing restrictions to community-based rehabilitation services, staff may also require supports to train patients to selfmanage recovery at home. 25 As the pandemic progresses, staff will also need to become competent providing care to patients with long COVID; while this population experiences a wide range of persistent health challenges that benefit from rehabilitation 1,34 they are frequently dismissed by HCPs, 35,36 highlighting the need to build skills among staff to recognize and support long COVID symptoms.
Third, our findings suggest that implementation of a COVID

| STRENGTHS AND LIMITATIONS
The major strength of this study was the ability to rapidly evaluate the implementation of a COVID zone at the onset of the pandemic, using a robust theoretical framework. 13 Importantly, our findings add to the growing body of literature exploring the challenges implementing health interventions during a crisis like the COVID pandemic. [15][16][17][30][31][32] However, this study did not explore the implementation of specific rehabilitation therapies for patients recovering from COVID and additional research is needed to understand both the types of therapies and how best to implement them in this adapted context for patients recovering from acute infections as well as long COVID. 1,8,10,[41][42][43] The COVID zone was adapted in July 2021 once it was understood that cohorting patients recovering from COVID was no longer needed. While changes in IPAC measures will address some implementation barriers identified in the current study (e.g., increased access to equipment and reintroduction of family caregivers into the hospital setting), others (such as access to information and staff selfefficacy) will require additional considerations. As the pandemic progresses and emerging viral variants create new 'unknowns' that amplify crisis circumstances or lead to outbreaks on units within the facility, our findings offer valuable insights to ensure that rehabilitation services can continue.