Nearly 20% of all patients lost so much ability they could not live independently after discharge, a new study says.

Nearly half of COVID-19 patients left the hospital with significant functional decline post-discharge, a new study from Michigan Medicine found.

Of those survivors who suffered functional decline, 80% were referred for additional therapy after discharge. Nearly 20% of all patients declined to the point that they were no longer able to live independently, says the study, Functional Decline in Hospitalized Patients with COVID-19 in the Early Months of the Pandemic, published in PM&R.

"Rehabilitation needs were really common for these patients," lead author Alecia K. Daunter, MD, a pediatric physiatrist at Michigan Medicine, said in a media release. "They survived, but these people left the hospital in worse physical condition than they started. If they needed outpatient therapy or are now walking with a cane, something happened that impacted their discharge plan."

"These patients may have needed to move to a subacute facility, or they might have needed to move in with a family member, but they were not able to go home," Daunter says.

Researchers viewed charts of nearly 300 adult patients hospitalized for COVID-19 at Michigan Medicine during the pandemic's first wave between March and April 2020. They analyzed patients' discharge locations, therapy needs at time of release, and whether they needed durable medical equipment or other services.

Because the study period occurred in the early days of the pandemic, as healthcare providers focused primarily on minimizing exposures and managing patient overflow, about 40% of patients never had a rehabilitation evaluation by a therapist or PM&R physician while hospitalized.

"The things we do in the hospital to maximize functioning, like mobility interventions and assessing activities of daily living, were not happening as often," Daunter says.

That likely means the number of patients who are losing ability is underreported, she says.

COVID-19 can damage organs, causing neurological and musculoskeletal impairments. In response to ongoing COVID side effects, Michigan Medicine recently opened two clinics to address the growing population of "long COVID" patients.

However, the virus' effect on daily functioning is rarely discussed, which can't be ignored any longer, says Edward Claflin, MD, a Michigan Medicine physiatrist and study co-author.

"These results help to highlight the true impact of the COVID-19 disease on our patients," Claflin says. "They fill in that gap in knowledge about how patients with COVID recover and what kind of rehabilitation needs they have."

The study is a snapshot of acute therapy needs during a time when knowledge of the unprecedented virus was even more limited. While additional research examining the long-term effects of COVID on functionality is needed, health systems can use the current data to conduct rehabilitation assessments and prepare resources for this underserved population, Daunter says.

"These problems are frequent, and the stakes are pretty high if we miss them, or allow them to progress during hospitalization," she says. "Some of these people were working and many were living independently. To lose that level of function is meaningful. We want to make sure we're addressing those needs; not just looking at the black and white—survival or death."

Even as the COVID-19 pandemic winds down, nurse leaders are holding fast to rapid decision-making and the advantages it brought to their systems.

As COVID-19 began tightening its grip on U.S. hospitals and health systems, nurse leaders were forced to make rapid decisions about everything from diagnostic testing procedures to when to wear a mask to whether to allow visitors.

Now that vaccines continue to roll out, hospitalizations are decreasing, according to the Centers for Disease Control and Prevention (CDC), and normalcy looks to be on the horizon, some nurse leaders are holding fast to rapid decision-making and the advantages it brought to their systems.

At Emory Health System in Atlanta, Georgia, the chief nursing officer huddle, which began as a four-day-a-week meeting as the pandemic intensified, is now a scheduled weekly event, says Sharon H. Pappas, PhD, RN, NEA-BC, FAAN, the health system's chief nurse executive (CNE).

"We established [meetings] four days a week at the beginning and no one wants to let it go, so we're down to one day a week where we come together in what we call a huddle," Pappas says. "That is the place where, during the year of the pandemic, we used for more COVID decision-making, and now we use it for other things that need to be quickly communicated or things that need to have rapid decision-making."

Each of the health system's eight chief nurses sat on one of the incident command workgroups such as care model, clinical operations, or the emergency department, and "our huddle was a point where they could bring information in and take it back out," Pappas says.

One of the CNO huddle's earliest rapid decisions involved streamlining documentation.

"We realized early on that with the [COVID-19] volume we had, we might need to alter the requirements that we had for documentation," Pappas says, "and we used that huddle as a way for us to say to our CNIO (chief nursing informatics officer), 'What are the things that you would recommend to us that we remove from daily or maybe even twice-a-day documentation requirements, so that we're meeting minimal regulatory requirements but yet we also have information that the next shift will find useful?' And so, we would use that huddle to be able to turn on and turn off our crisis documentation plan."

Pappas was impressed with the efficiency of the huddle.

"That was an example [of decisions] that I could not believe we made in a 15-minute timeframe without a lot of discussion," she says. "We were confident that what our CNIO was bringing us was accurate, and we all trusted each other that we would speak up and say so if we disagreed with it and so that let us get to the deployment part of it."

Engaging governance groups in decisions

Rapid decision-making became essential as Emory's leaders realized that their unit for treating serious communicable disease, including Ebola, which the health system dealt with in 2014, wouldn't be able to contain COVID-19 patients.

"Initially we thought we could use that framework to care for these patients as we had successfully done with Ebola, so some of the first early decisions from my perspective were to begin broadening our thinking to something that exceeded beyond the capacity of that unit, and 'Where were we going next?'" says Nancye R. Feistritzer, DNP, RN, NEA-BC, vice president of patient care services and chief nursing officer of Emory University Hospital and Emory Wesley Woods Hospital. "And that roadmap for where we would go next was some of the toughest and most rapid-cycle decision-making we had to do."

Those decisions had to answer such challenges as how to maintain consistencies and standards of care for COVID patients spread across the health system's 11 hospitals, how to manage patients in the critical care and acute care units, how to get enough personal protection equipment (PPE), and how to conserve PPE, just to name a few.

Nurse leaders worked to answer those questions while also engaging the health system's professional governance groups so decision-making was more than top-down, Pappas says.

"It probably felt top-down because of the speed we were having to work, but if we made a decision, we kept ourselves loyal to circling back with those professional governance councils in getting their feedback on things, which really did help us to refine a decision that we may have had to make real very quickly," she says.

Rotating incident commanders of a six-member executive steering group—which led the entire Emory healthcare system's COVID-19 incident command response—were accountable for facilitating the rapid-cycle decision-making that needed to occur.

In some instances they made those decisions almost in real time, Feistritzer says.

A small group of clinicians within the hospital would be handed a particular problem or issue and charged with coming back later that afternoon with proposals to solve that issue. Decisions would quickly be made and communicated out, she says.

"It was very structured and consistently done," Feistritzer says. "People stopped in their tracks to devote the attention to the often very weighty decisions that needed to be made."

"That framework meant that we as nurse leaders could tap into our interprofessional partners in ways that was very facile; we were able to talk to someone else and hear what the impact of any given decision might be on that interprofessional partner and adjust accordingly," she says. "It was very well thought out and a framework we are using to this day as we keep our finger on the pulse of COVID."

Making good decisions for patients

Rapid decision-making also led to the creation of Emory's Care Partner program when the health system's chief nurses realized that having a "no visitors" policy like most other hospitals around country was not good for most patients, Pappas says.

The chief nurses realized that patients needed family members with them as part of their healing, so they came up with a concept called Care Partner, which was different than a visitor," she says.

Where a visitor comes to socialize and boost a patient's spirits, the Care Partner, who can be a family member or trusted friend, has a purposeful role and actually contributes to patient care, she says.

"It became very important to our frontline clinical nurses who were having to spend an extraordinary amount of time on FaceTime or on the phone, updating families," Pappas says. "The Care Partner could also, with a patient's permission as appropriate, communicate with broader family constituents who were interested and worried."

Better communication through technology

Pieces of Emory's rapid decision-making processes will remain long after the pandemic is a memory, both nurse leaders agree, particularly Zoom calls that helped facilitate the quick decisions

"I think we'll see ourselves beginning to come back together in some personal meetings, but the power of reaching across wherever someone is, whatever time of day, through Zoom is definitely something we'll keep," Feistritzer says. "That ability has enabled us to be more broadly informed and interactive with our teams through these open forums that there was just never any way to do previously. So, the technology has helped us be better informed, which contributes to rapid decision-making."
 

'Economic and social benefits of Medicaid expansion are immense,' says lead author of a new report.

Expanding Medicaid eligibility in the 14 remaining states under the American Rescue Plan (ARP) would create more than 1 million jobs and boost states' economies by $350 billion, says a new report from the Commonwealth Fund and researchers at the George Washington University’s Milken Institute School of Public Health.

The ARP encourages states to expand their Medicaid programs to cover adults up to age 65 with incomes at or below 138 percent of the federal poverty level—$30,305 for a family of three in 2021—according to a press release.

As of this month, 14 states have income limits well below that level: Alabama, Florida, Georgia, Kansas, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming. Missouri and Oklahoma passed ballot initiatives to expand coverage but have yet to implement expansion, and Wisconsin has a partial expansion covering adults up to 100 percent of poverty.

The ARP increases federal funding for states that adopt the Affordable Care Act’s (ACA) Medicaid expansion by paying 90 percent of the cost of covering newly eligible adults. It also adds a five-percentage-point “bonus” federal match on existing state Medicaid expenditures for two years, the release says.

The U.S. could see health, economic, and employment gains, both in the 14 states and in the nation overall, if the 14 states adopt Medicaid expansions, according to the report, The Economic and Employment Effects of Medicaid Expansions Under the American Rescue Plan.

Expanding Medicaid into the 14 states, the report says, would create:  

Job growth: In just the 14 states, employment would rise by 837,000 jobs in 2022, including 299,000 in Texas, 135,000 in Florida, 83,000 in North Carolina, 64,000 in Georgia, and 50,000 in Missouri. Some 209,000 more jobs would be created across the country as economic activity ripples through other states.

Most of the job growth would be in healthcare, but about 56% would occur in other sectors such as construction, insurance, retail, finance, and other industries.

Health insurance gains: In the 14 states, 4.45 million fewer people would be uninsured and Medicaid program enrollment would increase by 6.69 million in 2022.

The top five increases in Medicaid enrollment would be in Texas (1.75 million), Florida (1.38 million), Georgia (680,000), North Carolina (620,000) and Missouri (400,000), with the federal government covering almost all of the new healthcare costs.

Higher state and local tax revenues: Federal revenue to the 14 states would increase by $49 billion in 2022, leading to higher state and local tax revenues. That's because the additional federal Medicaid revenue stimulates economic activity, ultimately leading to higher state and local tax revenue.

The ARP five-percentage-point bonus federal match on existing state Medicaid spending would equal $8.5 billion for the 14 states in 2022 alone, coupled with the additional $43.8 billion in federal matching funds that the states would earn for covering newly eligible adults under Medicaid expansion.

Stronger state economies: With the inflow of federal funding, if the 14 states expand Medicaid, total economic activity will grow by more than $600 billion and personal incomes will grow by $218 billion in these states over the years 2022 to 2025.

"This study shows that with the additional federal support in the American Rescue Plan, Medicaid expansion in the remaining 14 states could revive state economies and create more than 1 million new jobs, in addition to helping millions of low-income Americans gain health insurance," Leighton Ku, Ph.D., director of the Center for Health Policy Research at the George Washington University Milken Institute School of Public Health and lead author of the report, said in the press release.

"The economic and social benefits of Medicaid expansion are immense," he says, "and would ripple through the broader U.S. economy."

Health system is focusing on new technology and new innovations to improve patient safety, quality director says.

Although observations showed a 90% hand hygiene compliance across the health system where he is director of quality, Bill Cox, RN, CPPS, CPHQ, was skeptical.

"I would say, 'How are we at 90% when I see many gaps across the 15 hospitals?' " he says.

Cox decided to trial a cloud-based electronic hand hygiene monitoring network in which badges with sensors communicate to the network when a user enters and exits a patient room and records whether the user cleans their hands.

Indeed, Cox is tapping into technology for better patient safety while, at the same time, fueling cultural change at Hospital Sisters Health System (HSHS), a nonprofit headquartered in Springfield, Illinois, that operates a network of 15 hospitals and other healthcare facilities throughout Illinois and Wisconsin.

The hand hygiene technology showed that Cox's suspicions about the high compliance rate were correct.

Some nurse leaders expected the new system to show compliance rates similar to the 80–90% rate when hand-sanitizing observations were done by staff. They were taken aback when the technology revealed numbers that were much lower.

"Now they're seeing more of them in the 50s and 60s or 70%, and it's kind of a shock to them," he says. "I stress to them that this information is a realistic timeframe activity with the organization, not a snapshot, which is what they were used to seeing."

Once Cox's team and nurse leaders saw the trial success, HSHS installed the system in all 15 hospitals. Although COVID-19 disrupted the rollout plans, by December 2020, all 15 hospitals had the technology in place.

Leading a culture change

"Back in 2019, we made a decision as a health system to really start to focus on new innovations to improve patient safety," Cox says.

Initiating culture change that comes with new technology—even one as small as hand sanitizing—requires engagement and buy-in by nurse leaders, Cox says. Leaders need to be fully engaged in and believe in the project in order to fully support it.

It also requires clear communication.

"We let not only the leaders know, but the frontline staff, what was about to happen, what was going to come up in the next few months, what they could expect to see, and how it would impact their current process for care," Cox says.

For instance, the nurses learned that new hand hygiene technology didn't change their handwashing flow; the badge attached to their main tag simply captures the data.

"We didn't change their process around that at all, and that was a big selling point to get them to buy into it," he says. "It wasn't telling them they had to do something different."

The nurse leaders also helped frontline staff ease any worries they had about the new technology.

Some nurses had heard that the badge gave off waves that caused breast cancer, so Cox's team got accurate information from the company to show that wearing the badge didn't put their health at risk.

Many nurses questioned why they were being tracked and resented such watchfulness, he says.

"We had to do a lot of training and a lot of reinforcement and a lot of reassurance that this isn't Big Brother; that our true goal behind it is patient safety and colleague safety," he says. "Once they started to grasp that and once the nurse leaders started to speak that same verbiage to them, they got the gist of it much quicker."

Reinforcing success

One nursing aide, in the first two weeks of the change, had more than 1,200 observations and was 94% compliant, Cox says. They have since established the 90s Club, where employees who hit 90% or higher compliance in a month are recognized through HSHS' systemwide communications.

"That's so they understand that we do pay attention, and that we are proud of what they're doing," he says. "That's key in showing that engagement with these initiatives is not put into place just to cause them to do more work, but it's actually being watched and trended for ways to show that we are providing high-quality care."

Nurse leaders are responding positively to the new technology, he says.

"They're starting to trust the data now that we've had it for a few months," he says. "They're starting to understand the importance of the data, and they're starting to hold the staff more accountable for compliance with our hand hygiene policies." 

Where, previously, 100 observations may have been captured for the month, a hospital may now be capturing 10,000 observations for a month from the new technology, he says.

"So it's really a very unique opportunity to capture a true picture of what we're seeing," Cox says.

The successful hand-hygiene program has also opened the door for other patient-safety technology, such as predictive analytics, which will first be applied to fall prevention, Cox says.

"We're hoping will go live in the next few months with predictive analytics within our electronic health record that will help us identify who's the fall risk, and as their hospital stay progresses, adjust it based on our care that we give them," he says. "So, if we give them a medication that is known to cause higher risks for falls, then the score automatically adjusts itself so we can change our plan of care for that patient."

His team also is considering video surveillance for patients who are at a high fall risk.

"Getting a sitter in the room with a patient is, as you can imagine, quite costly," he says. "Newer technology lets you put a robot in the room, and it's basically a video camera that you point at the bed, or the area, and you can talk and interact with the patient and not have to have somebody physically sitting there."

Such technology allows monitoring of multiple patients at a time so they remain safe and staff is used more effectively, Cox says.

With each technology advancement at HSHS, Cox and his team know it will require getting early buy-in from nurse leadership.