Photobiomodulation therapy has been an FDA-approved treatment for inflammation and pain since 2011.
The first U.S. patient to receive photobiomodulation therapy for severe coronavirus disease 2019 (COVID-19) pneumonia responded positively to the treatment, according to the principal investigator of the pilot study.
Pneumonia and acute respiratory distress syndrome in COVID-19 patients are potentially deadly conditions. As of Sept. 10 in the United States, there had been more than 6.5 million confirmed cases of COVID-19, with more than 195,000 associated deaths, according to worldometer.
Details about the first treatment of a COVID-19 patient with photobiomodulation therapy (PBMT) was published last month in the American Journal of Case Reports.
The patient was a 57-year-old African American man presenting with a serious case of COVID-19 pneumonia at Lowell General Hospital in Massachusetts. The patient was placed in a prone position during the laser therapy for 28 minutes once a day for four consecutive days.
After the treatment, the patient's oxygen saturation increased from 93%-94% to 97%-100%, oxygen support was decreased from 2-4 liters per minute to 1 liter per minute, and the radiological assessment of lung edema score improved from 8 to 5. The patient also reported significant improvement in the Community-Acquired Pneumonia assessment tool. "Respiratory indices, radiological findings, oxygen requirements, and patient outcomes improved over several days and without need for a ventilator," the case report says.
The principal investigator for the PBMT pilot study, which features 10 patients, says the laser therapy had a significant impact on the first patient to receive the treatment. "It was remarkable watching him going through these four treatments and being discharged to a rehab facility the day after his last treatment," says Scott Sigman, MD, a practicing orthopedic surgeon at Orthopedic Surgical Associates of Lowell and team orthopedic physician at UMass Lowell.
Healthy dose of skepticism
A pair of critical care experts told HealthLeaders that much more research needs to be done before PBMT can be viewed as a viable treatment option for COVID-19 patients.
The improvements in the first patient to undergo PBMT may be related to the prone positioning during the treatment, says Abhijit Duggal, MD, assistant professor, Department of Pulmonary Critical Care and Allergy, Respiratory Institute, Cleveland Clinic, Cleveland.
"The data should be presented in terms of what the oxygen levels of patients were at four- to six-hour intervals after the photobiomodulation therapy. The improved oxygenation that was reported could have been a result of the therapy, but it is more likely that the improvement is associated with the prone positioning. What you need to know is what happened to the patient's oxygenation four hours later, eight hours later, or 12 hours later. If there was a trend in improved oxygenation without proning, that would be interesting to see. But that is not being reported in the case study."
The overall trajectory of COVID-19 patients with pneumonia or acute respiratory distress syndrome also must be considered, Duggal says. "We know that COVID-19 patients who are on 1 to 6 liters of oxygen usually have trajectories that improve around day three or four. Looking at the data in the case report, I did not see anything that I can say, 'Yes, this therapy by itself is showing a direct correlation with patient outcomes.'"
Until there are randomized controlled trials involving many patients, any new treatment for COVID-19 acute respiratory distress syndrome (ARDS) should be viewed skeptically, says David Kirk, MD, director of Pulmonary and Critical Care Medicine and director of eICU Service at WakeMed Health & Hospitals in Raleigh, North Carolina.
"At WakeMed, we believe that unproven therapies like hydroxychloroquine may have led to worse outcomes based on our internal data. Because of these facts, we have been very conservative to not jump on any unproven novel therapies unless they are done under research protocols. So, in general, we are skeptical of ARDS therapies, and we are worried that unproven therapies may make things worse instead of better."
Journey of discovery
So, how does an orthopedic surgeon with no experience treating lung injury become the principal investigator of a study on the use of laser technology in the treatment of COVID-19 pneumonia?
PBMT has been an FDA-approved treatment for inflammation and pain since 2011. Sigman has been using PBMT to treat inflammation and pain associated with acute joint injuries and chronic joint pain for nearly three years, with a success rate of about 78% in improvement of patient pain and inflammation.
"I wondered whether we could try the laser for the acute lung inflammation associated with COVID-19. I wondered whether it could work because it works well in orthopedic conditions," Sigman says.
Sigman's next step was to consult with his PBMT mentor, Professor Monica Monici of the University of Florence in Italy, one of the world's leading authorities in the study of the biology of laser treatment.
"She educated me on the process of the laser treatment, so I became much more comfortable using it for my patients. I called her in March and went over the details of what I was thinking about doing. She thought it was a good idea, and she gave me some initial parameters. But she is a molecular biologist, not a clinician, and she did not have experience in laser treatment of the lung fields," Sigman says.
The second step was finding clinicians who were familiar with the concept of using PBMT in the treatment of injured lungs. Sigman used a common research tool when doctors are unsure of their direction—Google.
"I was able to identify that there were two doctors—Soheila Mokmeli and Mariana Vetrici—who were MD-PhDs in Canada who were in the process of writing a paper about the theoretical use of laser treatment for COVID-19. I direct messaged Dr. Mokmeli, and she got back to me within an hour. I told her my idea and she said it was amazing," he says.
After consulting with Mokmeil, Sigman was able to determine the laser wavelength dose and duration of the laser treatment for COVID-19 patients with pneumonia or ARDS.
The next step was to convince the institutional review board at Lowell General Hospital to approve a pilot study. While the local IRB members were intrigued, they wanted to know whether the Food and Drug Administration would designate PBMT as a nonsignificant risk in the treatment of lung injury in COVID-19 patients, Sigman says. "I picked up the phone and called the FDA. Six hours later, the FDA called me back."
After several days of sending email back-and-forth with the FDA, Sigman got the greenlight. "The FDA was able to provide us with the documentation that my laser was a nonsignificant-risk device, which then allowed the IRB to give us permission to use this laser in a randomized trial."
Sigman and his colleagues at Lowell General Hospital are poised to publish results from a second COVID-19 patient in the Canadian Journal of Respiratory Therapy. "The case has been accepted for peer review—we are putting together the galley at this point. We will be able to announce the findings for that patient soon. The laser had a profound positive impact on that patient," he says.
The research team is compiling data from the pilot study and plans to submit that data to the New England Journal of Medicine, Sigman says.
Tower Health's flagship hospital promotes executive with cardiovascular and thoracic surgery background to top clinical leadership role.
The new chief medical officer of Reading Hospital is confident that the expansion of telemedicine services will continue after the coronavirus disease 2019 (COVID-19) pandemic passes.
Reading Hospital is the flagship hospital of West Reading, Pennsylvania–based Tower Health. Ron Nutting, MD, was appointed CMO of Reading Hospital in July. He succeeded Gregory Sorensen, MD, who had been serving in a dual role as CMO of Reading Hospital and Tower Health. Sorensen remains as the CMO of the eight-hospital health system.
Nutting, who is also serving as vice president for medical staff services at Tower Health, started his medical career as a cardiovascular and thoracic surgeon at Reading Hospital in 1992. He transitioned from clinical care to medical staff administration in 2013, when he became director of medical affairs at Reading Hospital.
Nutting shared his perspectives on telemedicine, patient safety, and other healthcare topics in a recent interview with HealthLeaders. The following is a lightly edited transcript of that conversation.
HealthLeaders: Telemedicine has experienced explosive growth during the coronavirus pandemic. Which telemedicine services has Reading Hospital adopted or expanded recently?
Nutting: Telemedicine areas where we have had success include outpatient screening—particularly individuals suspected of respiratory illnesses that could possibly be COVID-19. The telemedicine screening has allowed us to direct these patients to locations where they can be safely and effectively evaluated.
With telemedicine, we have also been in a better position to monitor our COVID-19 patients who have been staying at home. We have been doing remote monitoring utilizing pulse oximetry and screening questions. In the past, we have done telemonitoring of congestive heart failure and chronic obstructive pulmonary disease patients as part of our population health management strategy. The onset of the pandemic allowed us to amplify many of those activities.
We have done a lot of ongoing patient care with telemedicine—particularly for patients who need continued monitoring for chronic illnesses during the pandemic when they are concerned about coming in for office visits. For example, we have used telemedicine to monitor patients with diabetes and anticoagulation needs.
Perioperatively, we have been able to conduct pre-operative screening via electronic means to a larger extent than we have before. And we have taken advantage of being able to monitor our postoperative patients with telemedicine. This is an area of telemedicine that is likely to continue after the pandemic—it is a significant patient satisfier. If we have a patient who travels from the next county to undergo a surgical procedure, we can have a postoperative visit and our ability to evaluate a wound electronically can save the patient a car ride that can be uncomfortable. We can screen the patients to determine which ones we need to see in person.
We have been able to set up virtual ICU care with our sister facilities. We are a hospital system with eight acute care hospitals, and several of the hospitals have adult ICUs that have relatively small critical care teams compared to Reading Hospital. We have been able to utilize Reading Hospital's ICU team to render virtual ICU monitoring to help several of our sister facilities with coverage of acutely ill patients. This has helped us standardize some protocols and to identify patients earlier in the phase of decompensation.
Telemedicine has been available for many years; but, as a society, we had allowed the strategies around what was allowable for billing to prevent us from doing things that patients would prefer us to do remotely. It is nice to see this logjam open up, and I am very optimistic that many of these telemedicine advantages that have been gained will be maintained in the future.
HL: Since the publication of To Err Is Human two decades ago, where have healthcare organizations made the greatest strides in patient safety?
Nutting: This is an interesting issue, and it serves to highlight how complicated healthcare delivery is.
Unlike many manufacturing processes, healthcare is extraordinarily variable at the biologic level, both in terms of the individual variability of our patients and the wide array of maladies that they are presenting with that require us to discover the underlying ills and make an accurate diagnosis.
The strides that we have made in patient safety are around elements that reduce variability such as universal protocols like central line protocols, how we don gowns, and rituals for handwashing.
Medication safety is another area that stands out. This is one area where we have reaped some gains from information technology in terms of being able to track what medications we are giving patients in the inpatient environment and ensure we are giving medications safely through methods such as barcodes and multiple forms of identification.
We also have made progress in the engagement of patients and family members in care—they are participating at the level of decision-making and timeouts to verify that we are operating on the right site and performing the correct procedure.
Infection control through various bundles has also been a big win.
HL: How can health systems and hospitals help address physician burnout?
For physicians and clinicians of all stripes including allied health professionals and nurses, burnout is one of the big issues of our time.
Addressing burnout is not about making clinicians more resilient—it is about looking at the root causes of the burnout problem. Physicians feel overworked. Sometimes, they feel underappreciated. They are mourning the loss of autonomy. They feel they spend too much of their time on activities that are not aligned with their sense of purpose such as the impact of the electronic medical record.
When we look at the EMR, many of them are designed to limit the variability of care, but limiting variability of care drives a sense of loss of autonomy if the clinicians have not been involved in the process of standardizing care at the outset. There also are ways that clinicians must work through the EMR interface that are primary drivers of career dissatisfaction. Those drivers include the diminishing time of eye-to-eye contact with patients because of the distraction of needing to click fields in the EMR. Overall, interface optimization is going to be important in moving forward and reducing those distractions.
The inefficiencies of EMRs contribute to causing work hours beyond clinic time and into the evening for many medical professionals. As a result, there is diminished access to outside interests, which can cause hopelessness and a sense of depersonalization, which are hallmarks of burnout.
Other clinical inefficiencies are created by nonclinical agents that are mandating requirements for data input from clinicians that may be important but really are not good uses of clinician time. Clinicians feel they are not creating value in the clinic because they are working more in the role of a clerk. This is related to requirements from government regulators, insurers, and health system management. My colleagues and I need to be careful about what we are asking clinicians to do.
The antidote to burnout is to engage physicians and enlarge their sense of joy in work by involving them in clinical redesign that leads to performance improvement through lean-process improvement efforts and lean management. That approach will allow clinicians to have a sense of autonomy and to make sure a greater fraction of their time is spent on higher-value activities such as interacting with patients.
Influenza vaccination is more important than ever because of the overlapping threat of the coronavirus pandemic this fall and winter.
With the coronavirus disease 2019 (COVID-19) pandemic showing no signs of going away, influenza vaccination has taken on increased gravity.
There is widespread concern among healthcare professionals that the United States could be facing two infectious disease emergencies this flu season. For example, the California Immunization Coalition and the California Chronic Care Coalition are urging Americans to get flu vaccination to avoid a deadly "twindemic" this fall and winter.
"We are facing a dangerous double whammy in the coming months. Contracting the flu and getting COVID-19 on top of it can be deadly, so don't wait—vaccinate. Make plans to get a flu shot now to keep you and your family protected from influenza during the pandemic," says Catherine Flores Martin, executive director of the California Immunization Coalition.
Niket Sonpal, MD, a board-certified gastroenterologist and an assistant professor at Touro College of Osteopathic Medicine in Harlem, New York, says there are two pressing reasons to promote flu vaccination.
"The first and foremost reason is because the flu is a deadly disease. So, we want to protect everyone from flu regardless of COVID-19. The second most pressing issue is the coronavirus pandemic. I was in the forefront here in New York City for 43 days straight treating COVID-19 patients when we were bombarded by the pandemic. We were overwhelmed. And if you consider a COVID-19 resurgence in the winter along with a flu resurgence, we could not only overwhelm physicians and other healthcare workers but also resources and hospitals."
Just as in past years, health systems, hospitals, physician practices, and healthcare workers should actively encourage flu vaccination, he says. "Healthcare organizations do a great job of promoting flu vaccination to begin with. There are vaccination drives. Healthcare workers post on social media that flu vaccination is the right thing to do."
Government leaders also have a role to play, Sonpal says. "What is equally important is to see leaders of the country promote flu vaccination as well. Part of the reason masks have become political, part of the reason masks have been flouted, and part of the reason why some people think COVID-19 is a hoax is because the coronavirus was not taken seriously by the Trump administration to begin with."
People should not be concerned about contracting influenza from a flu shot, he says.
"The flu vaccine absolutely—without a doubt—does not cause the flu. It is a very common mistake to think the vaccine causes the flu, which is why some people do not get it. You may feel a little something, but that is your body accommodating the vaccine and building antibodies. You may feel a little achy, feel some pain in your shoulder where you got the shot, or feel a little warm for a day, but there will be nothing that a little bit of Tylenol can't fix."
Diagnosis challenge
Distinguishing between influenza and COVID-19 symptoms is difficult, Sonpal said.
"We don't know how people are going to present when they have both the flu and COVID-19. But what we can say is that the symptoms for both conditions are essentially similar. What we are telling people to do in the fall is to take the flu vaccine to take it out of the equation and to consult with their doctors if they are feeling unwell. Clinicians will go through your travel history, your contacts, and whether you have been exposed to people with COVID-19. Then, it comes down to testing."
Most flu and COVID-19 symptoms such as fever, aches, sniffles, and cough are common to both conditions. The only symptoms that are unique to COVID-19 and not unique to flu are the loss of taste and the loss of smell, he says.
A nonpunitive safety event reporting regime is likely to encourage staff to participate in reporting and to focus on systemic deficiencies.
A punitive approach to safety event reporting at healthcare organizations is counterproductive, a recent research article concludes.
Two decades after the dawn of the patient safety movement in healthcare with the publication of "To Err Is Human: Building a Safer Health System," medical errors remain a vexing challenge at healthcare settings. Encouraging staff to participate in safety event reporting is a primary strategy in fixing systemic problems that jeopardize patient safety.
The co-authors of the recent research article, which was published in Annals of Emergency Medicine, conclude that safety event reporting regimes that focus on punishing individuals are self-defeating.
"Punitive reports have important implications for reporting systems because they may reflect a culture of blame and a failure to recognize system influences on behaviors. Nonpunitive wording better identifies factors contributing to safety concerns. Reporting systems should focus on patient outcomes and learning from systems issues, not blaming individuals," the co-authors wrote.
The research, which was conducted at Richmond, Virginia-based VCU Health, examined more than 500 safety event reports from January to June 2019. The study includes several key data points.
25% of the safety event reports were designated as punitive and 68% of the reports were designated as nonpunitive
Punitive safety event reports compared to nonpunitive reports were more likely focused on communication (41% vs. 13%), employee behavior (38% vs. 2%), and patient assessment (17% vs. 4%)
Nonpunitive safety event reports compared to punitive reports were more likely focused on equipment (19% vs. 4%) and patient or family behavior (8% vs. 2%)
More nonpunitive safety event reports involved patient harm than not (5% vs. 2%)
"A high frequency of punitive reports may reflect a culture of blame and retribution, rather than a just culture focused on learning and improvement," the research article's co-authors wrote.
They wrote that there are two primary strategies to promote a nonpunitive safety event reporting regime. First, training staff to use safety event reporting to focus on creating a high-reliability organization and a just culture. Second, using alternative resources or tools rather than safety event reporting to disclose problematic behavior by colleagues such as intimidation.
Crafting an effective safety event reporting regime
One of the co-authors of the research article—Robin Hemphill, MD, chief quality and safety officer at VCU Health—told HealthLeaders that an effective safety event reporting system has five components.
1. Leadership: A good safety reporting system is supported by leadership. There needs to be an expressed desire from leadership that they do not want to punish people—they want to understand vulnerabilities in the healthcare organization's system.
2. Accessibility: A good safety reporting system is easy to access. If you must go searching on the intranet of your healthcare organization to find the patient safety reporting system, people are not going to use it. There should be a desktop icon that makes it easy to find—you log on to your computer and there it is.
3. Ease: Safety reporting should not be lengthy and onerous when people want to report. You may offer a lot of detail that people can report, but you must limit the computer system fields in a required reporting form to the bare elements. A busy healthcare worker should be able to get into the safety report and give enough information in the report so someone can understand the concern. The safety report should include the location of the safety event, a brief description of the event, and the perceived level of seriousness of the event.
4. Receptivity: Management needs to be responsive to safety event reports. If people put safety event reports into the system and it feels like a black hole, then few people will use the reporting system.
5. Training: Healthcare organizations need to train staff on how to use a safety reporting system and help them understand why the safety reporting system is important. Management should remind staff that safety reporting is about fixing systemic problems.
When to focus on individuals
There are circumstances when focusing on an individual's actions related to a safety event is appropriate, Hemphill said.
"There are times when you must look at the individual. But what we try to do before we leap to whodunit is to try to find out why it happened. Most errors, adverse events, and near misses have an individual at the sharp end of the processes that lead up to that moment in time. So, it is uncommon that people are not involved in these events. But, if you fundamentally believe that people don't go to work to hurt patients, then you need to understand everything around a healthcare worker that may have contributed to a bad choice or a wrong decision," she said.
When a patient safety event occurs, managers should conduct a rigorous investigation before laying blame on an individual, Hemphill said. Four key questions should be addressed, she said.
What is the action that we see? The patient safety event could be an innocent mistake.
Was there a low or moderate level of risk involved? For example, a nurse could have given a medication without using the barcode scanner, but there could be extenuating circumstances. If the barcode scanner is wireless and unreliable, then it could be rational behavior to not use the device, particularly if management has been alerted to the problem and failed to fix it.
Was there an unacceptable level of risk involved? To use the barcode example, if the nurse says the barcode scanner works fine but she just decided not to use it because she is smart enough to know which medication to administer, that would be an example of the kind of overly risky behavior that is inappropriate.
What is the performance of the individual? A just culture cannot tolerate repeated errors. If someone is making the same error week after week, maybe they are just bad at their job and maybe they need to be fired or reassigned to a different area where they can be more successful. Eventually, the competency of the individual must be questioned, but it is not the first step in a just culture.
"Safety reporting that is designed to detect systems deficiencies is complicated and very difficult to conduct. Situations must be managed fairly. You must make sure that you have a complete picture of what is going on if someone is being singled out for a behavioral problem," Hemphill said.
In the health system of the future, there are multiple opportunities for clinical care improvement and reform such as patient safety and quality improvement.
Clinical care is a hotbed of innovation in the healthcare sector. There are not only opportunities for improvement and reform, but also a shift in the delivery of care from the inpatient setting to the outpatient setting.
Quality improvement and boosting patient safety are primary objectives for clinical leaders, says Julian Schink, MD, chief medical officer of Boca Raton, Florida-based Cancer Treatment Centers of America. "This is our day-to-day job. This is our No. 1 priority: quality and safety within our workspace. I look at it as three spheres. There are the tools that make it easier for us to be safe and practice quality medicine. There are the incentives to practice quality medicine. Then there are the barriers."
At healthcare organizations, establishing a just culture is foundational for patient safety, says Sarah Garber, MD, chief medical officer of the Swedish Medical Center Ballard Campus in Seattle.
"Part of a just culture is reporting problems. Physicians and other caregivers need to be able to report on themselves, and they need to feel that they will be supported by colleagues and the organization. We are all human and we all make mistakes—we all need to be able to step back together to acknowledge that. If caregivers feel that they can raise their hands in the moment and say, 'I see a problem,' that would be a huge opportunity and a place to improve before bad things happen to patients," she says.
With the rapid expansion of telemedicine during the coronavirus disease 2019 (COVID-19) pandemic, healthcare leaders need to be cognizant of patient safety and quality challenges, says Joe Kimura, MD, MPH, chief medical officer of Newton, Massachusetts–based Atrius Health.
"We do need to understand where telemedicine strategies could raise patient safety or quality of care issues. The recent Sciencepublication highlighting racial bias in risk stratification algorithms shows where unintended care disparities may be propagated as we funnel more and more care through digital platforms. For the broad use of telehealth during the COVID-19 pandemic, there are questions about the quality of communication and the interaction between clinicians and patients. While it may seem natural and easy, it may take people time to learn how to best use this mode of care appropriately," he says.
The ongoing shift of care delivery from the inpatient setting to the outpatient setting also raises patient safety concerns. Patient ownership of care is a significant factor in outpatient care safety, says Donald Whiting, MD, chief medical officer of Pittsburgh-based Allegheny Health Network. "In the outpatient setting, safety is much more about the patient and their family's ownership of safety. You aren't watching them as inpatients, and patients are just starting to really want to own their own health, particularly the younger generation."
Chicago-based CommonSpirit Health has established a partnership with a direct primary care provider that will eventually be rolled out in several states.
Primary care services boost health condition prevention and improve clinical outcomes. A 2007 study published by the International Journal of Health Services found increasing the primary care physician supply reduced mortality for cancer, heart disease and stroke; decreased the incidence of low birth weight; and improved life expectancy.
CommonSpirit, which operates more than 700 care centers in 21 states, has established a partnership with direct primary care provider Paladina Health. Paladina, which is based in Denver, has more than 130 clinics that operate under value-based contracts with employers, unions, and other organizations. The partnership is launching in the Las Vegas area.
Paladina clinics are financed through per-member-per-month (PMPM) fees paid by employers and other organizations, says Paladina Chief Revenue Officer Kirk Rosin.
"We can tailor the financial arrangement based on several factors. Those factors include the hours of operation of the primary care center, the staffing that an organization wants to have in the primary care center, and the scope of clinical services. We have expanded the clinical scope in our primary care centers to include behavioral health, physical therapy, occupational therapy, dental, and vision," Rosin says.
The range of the PMPM fee is also linked to whether an organization contracts primary care services for an entire population of employees or members, or just contracts for the employees or members who utilize a Paladina primary care clinic. For contracts that cover an entire population of employees or members, the PMPM fee ranges from $40 to $55, and the fee is higher for the walk-in model, he says.
CommonSpirit has teamed up with Paladina to boost population health and lower total cost of care, says Rich Roth, MHA, senior vice president and chief strategic innovation officer at the health system.
"The opportunity for direct primary care is for an employer, a union, or any organized group to pay for primary care for all of their employees or members to effectively engage individuals in better preventive care and high-access services that avoid complications down the line. The uniqueness of the model is the business approach, which is having employers, unions, and other organizations invest in their employees or members through dedicated payment for primary care services. The goal of these organizations is to keep their employees or members healthy and avoid unnecessary healthcare service utilization," Roth says.
From the patient perspective, direct primary care is free, Roth says. "Patients do not have extraneous costs for the use of primary care services because the employer, union, or organization is invested in the health of patients. In theory, there are greater primary care interventions, which results in lower costs down the line for specialty care and other avoidable care costs."
For example, employers and other organizations contracted with Paladina reduce total cost of care by about 25% and decrease specialty care costs by about 50%, Rosin says. "We avoid exorbitant specialist visits, emergency room visits, and urgent care visits. We have seen a reduction in inpatient admissions over time because what we are able to do is meaningfully move the health risk of our patient populations in a positive way."
How Paladina's direct primary care clinics work
Rosin says there are five key elements of a Paladina direct primary care clinic.
1. Data: "What we have seen is that when 80%–85% of the employees and their family members start to use our centralized health service, the information on that population becomes a lot richer. So, we bring individuals into our clinics who typically would not have pursued any kind of primary care relationship. We can uncover clinical conditions that would have gone unchecked or undetected, then intervene at a point where the conditions are not severe," he says.
2. Small patient panels: Paladina primary care physicians typically see no more than a dozen patients per day, Rosin says. "When you think about the quality of the discussion that can happen in 90 minutes versus the seven to 10 minutes that is allotted for a fee-for-service visit, our physicians are able to get much deeper into not only a health concern on a specific day but also have conversations about closing gaps in care and healthy lifestyle coaching. We have the luxury of time because we are maintaining smaller patient panels."
3. Tight referral network: With a concentrated patient population, Paladina can work with employers and other organizations to establish and direct a referral network that is often "tighter" than the traditional insurance network, he says. "With that referral network, we can co-manage the patient within the specialty realm, so that once a patient has been diagnosed and has an established treatment protocol, we are able to perform ongoing care in our health center with a primary care physician."
4. Individualized care: Largely through examining claims data, Paladina primary care clinics can take an advanced approach to patient engagement, Rosin says. "It is a matter of absorbing claims data from every employer we work with and running that claims data through technology such as predictive analytics, which helps identify preventive care gaps. … We tailor every message to the individual. We account for demographic factors, health factors, and attitudinal segmentation, so that the messages and reminders that each individual receives are put into language they understand and reflect their views on health and healthcare."
5. Access: Paladina patients have 24/7 urgent care access to primary care physicians, including video visits and text messaging. "If something comes up and the primary care center is not open, that allows patients the leeway to always get ahold of one of our primary care physicians. Patients have a trusted resource they can go to and have a meaningful conversation," he says.
More research is needed to determine why the disparity in black newborn mortality exists.
Black newborns have a significantly higher mortality rate if their attending physicians are white rather than black, recent research indicates.
In the 2018 America's Health Rankings Annual Report, the United States ranked No. 33 out of 36 Organization for Economic Co-operation and Development (OECD) countries for infant mortality. In 2018, the U.S. infant mortality rate was 5.9 deaths per 1,000 live births, and the average infant mortality rate in all OECD countries was 3.9 deaths per 1,000 live births.
The recent research examined 1.8 million hospital births in Florida from 1992 to 2015. The study includes several key data points.
When black neonates are cared for by black physicians as opposed to white physicians, their in-hospital death rate is a third lower
This disparity manifests more strongly in more complicated cases and when hospitals deliver more black babies
The extent of the mortality rate reduction when black physicians care for black babies would correspond to preventing the in-hospital deaths of about 1,400 black newborns nationally each year
Physician race was not associated with an effect on the mortality rate of white neonates
The next step for researchers is to determine the mechanism that determines why black newborns have a lower mortality rate when cared for by black physicians, the lead author of the recent study told HealthLeaders.
"What this research calls for is getting into the primary setting and saying, 'What is it that these doctors, teams, and organizations are doing differently in higher and lower quality locations, and promulgating the successful behaviors from the high-quality locations to those that are struggling," said Brad Greenwood, PhD, MBA, MIT, associate professor of information systems and operations management sciences at George Mason University in Fairfax, Virginia.
"There are a lot of potential explanations—most likely it is not just one. What this work calls attention to is the fact that we need to look at locations that are performing higher and locations that are not performing as well, and figure out what the organizational team and individual behaviors are that are resulting in these disparities."
The finding that there was no significant impact on newborn mortality for white babies based on the race of the attending physician may be related to medical training in the United States, Greenwood said.
"Most medical training and most knowledge generation happens with white patients. So, you have a situation where the knowledge generation is happening with white patients—doctors are educated specifically with the presentations of white patients."
The recent study should not be interpreted as calling for black newborns to only have black physicians, he said. "This perspective calls for creating some type of Jim Crow medical system, which is exactly the wrong interpretation. … The important question is what is driving this disparity. What are black doctors doing differently than their white colleagues? That might come down to the individual level, it could come down to the team level, or it could come down to the organizational level."
Research articles indicate there are several effective decontamination methods for N95 respirator masks, including vaporized hydrogen peroxide.
N95 respirator masks have been in limited supply since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, and sterilization is a primary strategy to address shortages of this key personal protection equipment.
N95 respirator masks, which filter at least 95% of 0.3-μm particles, are the gold standard for protection against airborne pathogens such as the novel coronavirus. To conserve supplies of N95 respirator masks, the Centers for Disease Control and Prevention recommends that the masks be used by healthcare workers at highest risk of contracting infection or experiencing complications of infection.
Research on sterilizing N95 respirator masks for reuse includes four recent articles.
Used N95 respirator masks treated with ethylene oxide or vaporized hydrogen peroxide maintain their filtration efficiency, according to a study published by JAMA Internal Medicine. Steam sterilization distorted 1860 N95 respirator masks, rendering them unsuitable for reuse; however, steam sterilization of 1870+ Aura face masks was effective, with the masks retaining more than 95% fitted filtration efficiency after a single sterilization cycle, the study found.
The JAMA Internal Medicine study also found that N95 respirator masks as many as 11 years past their expiration date maintained their filtration efficiency.
A recent research article, which was published in JAMA Otolaryngology—Head & Neck Surgery, identifies four decontamination methods that can recycle N95 masks without compromising the fit of the masks or the filtering material. The sterilization methods identified are ultraviolet germicidal irradiation, vaporized hydrogen peroxide, steam treatment, and dry heat treatment.
Two recent studies show steam can effectively decontaminate medical masks including N95 respirator masks.
A research team in China published a study in the Journal of Medical Virology on using steam to sanitize surgical masks and N95 respirators. The sanitization process, which used avian coronavirus of infectious bronchitis virus to mimic the novel coronavirus, was simple. Contaminated masks were placed in plastic bags and steamed over boiling tap water in a kitchen pot.
Researchers at Houston Methodist Research Institute in Houston published a steam sanitization study for N95 respirator masks in the journal Infection Control & Hospital Epidemiology. The study featured five test subjects to verify mask fit after the decontamination process and a more sophisticated steam treatment method than the Chinese study.
Opening a new hospital during a pandemic involves several difficulties, including staff training with infection prevention measures in place.
How do you open a new hospital in the middle of a deadly pandemic?
That has been the challenge faced at St. Louis-based SSM Health, which is set to open SSM Health Saint Louis University Hospital on Sept. 1. The new $550 million, 802,000 square foot facility has been in the works for five years.
The coronavirus disease 2019 (COVID-19) pandemic has created several hurdles for the project, says Kelly Baumer, MBA, vice president of clinical services at SSM Health Saint Louis University Hospital.
Training more than 2,000 staff to occupy the new academic medical center during the pandemic was particularly vexing, she says.
"Prior to the COVID-19 pandemic, we had plans for how we were going to train masses of people. When the pandemic became a reality for us and we still needed to get all of these people trained, we had to reconsider how we were going to do training because we could not have large groups of people in classrooms. We moved as much of our training as possible to virtual training."
Baumer says there is a wide range of training needs when opening a new hospital, including learning about physical plant features such as oxygen shut-off valves, practicing patient evacuation plans, and training physicians and nurses how to use new equipment.
"There is also training for workflows. We put teams together over the past couple of years to design playbooks for the various departments. The playbooks define how employees will function in their new spaces. We had to take staff members to the new facility and let them role play with the new workflows. We had to walk through the work processes and walk through how patients enter the facility," she says.
The workflow training and staff tours of the new facility had to be broken down into multiple small groups for infection control safety, Baumer says. "Everybody had to wear masks, social distance, and practice good hand hygiene."
In addition to altering training plans, SSM Health had to make changes to waiting rooms and workspaces, she says. To promote social distancing, some furniture was removed from waiting rooms and changes were made to crowded work areas. "In some areas of the hospital, several people work together sitting close to each other. We have installed Plexiglas so staff can work safely in their normal workspaces."
The pandemic made it impossible to have celebration events with crowds, Baumer says. "We have a lot of excitement in our community and among our staff, but we couldn't have traditional ribbon cuttings because we couldn't have large groups of people present. We looked at what kinds of celebrations we could do virtually but still maintain the excitement."
Hospital designed for infectious disease emergencies
The new hospital has features that are designed to cope with infectious disease outbreaks, she says.
"We have gone through earlier outbreaks such as Ebola and H1N1; so, as an academic medical center, we are constantly thinking about infectious diseases. The design of the new facility includes having separate areas of the hospital if we need to quarantine some patients. We have areas in our emergency department and some of the patient floors where we can isolate patients."
During the COVID-19 pandemic, many hospitals across the county have struggled to have enough patient care space with negative air pressure to avoid the airborne spread of the novel coronavirus. SSM Health's new hospital has extensive negative pressure capabilities, Baumer says.
"This new facility has a very sophisticated building automation system, so we can make several areas of the hospital negative pressure relatively easily. It's not only patient rooms that need to have negative pressure but also operating rooms and the morgue area. In the new facility, we can have all of those things in place."
Although there is a looming nationwide physician shortage, the more pressing clinician workforce problem is the distribution of doctors, a Stanford researcher says.
Recent research on rural emergency physicians reflects a maldistribution of physicians nationwide, the lead author of the study told HealthLeaders.
Physician demand will grow significantly higher than supply through 2033, according to a report published earlier this year by the Association of American Medical Colleges. The AAMC report projects the shortfall at as many as 139,000 physicians by 2033.
The recent research, which was published in the Annals of Emergency Medicine, shows there is a shortage of emergency physicians in rural areas of the country. The study includes two key findings:
Compared to 2008, the total number of clinically active emergency physicians has increased by nearly 10,000, but emergency physician density per 100,000 of U.S. population has decreased in large rural (-0.4) and small rural (-3.7) areas.
This year, most (92%) emergency physicians practice in urban areas, with 6% practicing in large rural areas and 2% practicing in small rural areas.
"In the context of the work that we have done, there is a maldistribution of physicians in the United States. We see compared to the 2008 data, the situation in 2020 is more pronounced, with a decrease of physicians in the large rural and small rural areas," said the lead author of the study, Christopher Bennett, MD, MA, an assistant professor of emergency medicine at Stanford University School of Medicine in Stanford, California.
The study also found there are more emergency physicians approaching retirement age in rural areas compared to urban areas. This year, the median age of emergency physicians in urban areas is 50, and the median age of emergency physicians in large rural areas is 58 and 62 in small rural areas.
"The thing that is concerning about the number of emergency physicians in rural areas who are approaching retirement age is that you would presume to see in 10 to 20 years in the future that these are physicians who will no longer be working clinically. Given that there is concurrently a tendency for newer medical school graduates to work in more urban areas, that will likely compound the density difference in rural areas," Bennett said.
Although his team's research shows there is a mainly a distribution problem now in the U.S. physician workforce rather than a nationwide shortage, Bennett said several factors such as the aging of the general population will likely result in a widespread shortage of clinicians.
"The AAMC's projected shortage is in the context of a growing population, a growing population of older people who are going to see doctors more often, a population of people who need both primary and specialty care, and limited support for graduate medical education," he said.
Addressing the rural emergency physician shortage
It will take a multifaceted approach to increase the number of emergency physicians practicing in rural areas of the country, Bennett said. He said those strategies include:
Training more emergency physicians in rural areas, with the hope that more young doctors will end up practicing in rural areas
Offering financial incentives to practice in rural areas such as student loan forgiveness and higher salaries
Federal support to incentivize emergency physicians to work in rural areas
"The number and distribution of doctors is a complex national issue; and if we are going to increase the number of emergency physicians practicing in rural areas, it is going to take national-level interventions. It is a complex problem, and it is going to take a complex solution to fix it," Bennett said.
