The coronavirus is taking a heavy toll on nursing home residents and workers.
During the coronavirus disease 2019 (COVID-19) pandemic, patient transfers between nursing homes and hospitals require heightened consideration, a recent journal article says.
People who are at least 65 and people living in nursing homes are at high risk of serious illness during the COVID-19 pandemic, according the Centers for Disease Control and Prevention (CDC). Nursing home residents face high risk because the facilities have a "congregate nature" and serve older adults with chronic medical conditions, the CDC says.
One-third of COVID-19 deaths in the United States have been residents and workers at long-term healthcare facilities, the New York Timesreported this week.
"Many older Americans who require assistance with Activities of Daily Living (ADLs) live in some type of congregate setting. These patients are particularly vulnerable to outbreaks of infectious disease, given close proximity of living quarters, frailty, functional dependence, and co-morbidities," the recent journal article says.
The co-authors of the journal article provide five recommendations for nursing home residents being considered for transfer to a hospital:
1. Medically stable patients who can be properly isolated from other nursing home residents and staff should not be transferred to an emergency department. For these patients, effective communication between nursing home clinicians and the ED can ensure adequate care in the nursing home setting.
2. During the COVID-19 pandemic, nursing homes should encourage residents and their families to complete advance care planning documents.
3. For nursing home residents with a fever and respiratory symptoms, staff should weigh the risks and benefits of transferring the individual to an ED. "This includes an evaluation of the patient's current state of health, patient-centered goals, and an assessment of prognosis in the context of the COVID-19 illness," the journal article says.
4. Nursing home staff should conduct "forward triage" when residents are considered for transfer to an ED. Key elements of forward triage include determining the resident's acuity and the best setting for meeting the resident's needs. An ED physician should be consulted.
5. Warm hand-offs are essential, such as effective communication between nursing home and ED staff before a transfer, and discussions about medical decisions such as the capacity of the nursing home to accept a patient back from the ED. Procedures should be in place that promote communication between EDs and nursing homes.
Care considerations
Nursing homes are equipped to provide care to ill residents, including treatment of pneumonia, urinary tract infections, skin infections, and fevers, a co-author of the journal article told HealthLeaders last week. "We take care of sick residents all the time in nursing homes," said Kathleen Unroe, MD, MHA, an associate professor of medicine at Indiana University School of Medicine and a research scientist at Regenstrief Institute in Indianapolis.
Nursing home residents should only be transferred to another care setting when treatment cannot be provided at the skilled nursing facility, she said.
"This is most often because they are or have gotten sicker—such as needing more oxygen and showing signs of severe infection such as a low blood pressure. It is important to know the resident's goals for care. Many residents, for example those with advanced dementia, have goals of care focused on comfort. When we can treat the symptoms of their illness, then we can care for them in the facility and avoid hospital transfer, including at the end of life."
In many cases of severe illness, transfer of nursing home residents to hospitals is appropriate, Unroe said. "When their clinical condition and goals of care are consistent with needing hospital-level care, we transfer them. Clear communication with the emergency medical service providers and the clinical providers in the emergency department is essential, especially if COVID-19 is suspected."
Forward triage screens nursing home residents prior to transfer to help direct them to the most appropriate resources, she said. "This requires direct, proactive communication between the ED and nursing home providers prior to transfer. For example, a patient who needs a blood transfusion due to worsened anemia found on labs could go directly to a transfusion center, bypassing the ED."
Communication between nursing homes and EDs is pivotal to achieve warm hand-offs of patients, Unroe said.
"Some health systems have secure communication systems, but you can always pick up the phone, call the emergency department, and ask to speak to the physician. In my experience as a nursing home physician, the ED docs are grateful for the call—especially now. We let too much information get dropped during transfers, which has consequences for our frail patients, and this is even more unacceptable now. These warm handoffs can be promoted by simply doing them, over and over, until it becomes our standard practice."
Photo: Kathleen Unroe, MD, MHA, meets with a nursing home resident. Photo credit: Regenstrief Institute
Social determinants of health (SDOH) such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. In 2018, an estimated 11.1% of U.S. households were food insecure at some point during the year, with food insecurity defined as household members having their eating patterns disrupted because financial and other resources were inadequate to obtain nutritious food.
To address patient food insecurity, healthcare organizations should focus on three steps, the recent report says.
1. Screening and assessment
The first step is determining which patients and populations in your service area are food insecure.
"To identify who may need targeted support, healthcare organizations can integrate screening strategies into standard care. Screening for food insecurity as part of broader efforts to integrate SDOH into healthcare conversations will enable healthcare organizations to better meet their patients' needs and improve population health," the report says.
Success strategies to support screening include:
Incorporating consistent screening as part of routine care, which decreases prejudice, accounts for chronic and episodic food insecurity, and helps track positive changes in nutrition
Utilize a screening tool that identifies food insecurity in both individuals and families
Enlist a multidisciplinary team to design screening methods that decrease strain on healthcare workers
Success strategies for screening individuals include:
Work with community-based organizations (CBOs) to identify food insecure individuals who are in your service area but are not receiving services from your organization—these individuals could be at risk for negative health outcomes
Pair food insecurity screening with other SDOH screening to develop a comprehensive view of an individual's social needs
Train healthcare workers about food resources in your service area to promote screening—some healthcare workers may be reluctant to screen individuals unless they are familiar with community resources
2. Clinical action
Once screening and assessment methods have identified individuals or families as food insecure, the next step is matching these people with the best resources. "The level of effort, investment, and impact of the various food insecurity interventions can vary across organizations and communities," the report says.
The primary focal points for clinical actions are public programs, food access, and access to supporting resources.
Public programs: Federal, state, and local public programs help food insecure people access food but often do not provide food directly. "Assisting individuals to participate in these programs can be a first step toward moving them into food security. Public program strategies should be paired with strategies that supply food to individuals and families in need," the report says.
Food access: An inability to access nutritious food is a key factor in food insecurity. Healthcare organization interventions to promote food access include the "Food is Medicine" strategy, which matches food to a patient's specific health condition, and establishing partnerships with CBOs to provide direct food delivery or financial assistance to overcome food access barriers such as limited mobility.
Access to supporting resources: People who are food insecure often face related SDOH challenges such as housing instability and unemployment. "Providing access to food alone will not help those who are food insecure overcome the circumstances that led to their food insecurity. Giving individuals access to resources they need will help them overcome barriers and challenges to sustainable food security," the report says.
3. Tracking and evaluation
Monitoring metrics demonstrates which food insecurity interventions are effective or generate negative unintended consequences. "Organizations can use data to show return on investment through improved health outcomes, lowered costs, reduced care utilization, and positive changes in other metrics of interest, such as patient satisfaction and number of healthy days reported," the report says.
Technology is an essential element of tracking and evaluating interventions. "When considering which strategies to implement, healthcare organizations should conduct an analysis of both their own technological infrastructure and the patient's ability to access various types of technology and the Internet," the report says.
Success strategies to support tracking include:
Adding food insecurity workflows to electronic health records (EHRs) to ease data management and increase productivity
Understanding the capabilities and needs of CBOs to support their data collection and evaluation efforts
Learning what is most important to patients, and creating methods to track and report data in ways that do not alienate, prejudice, or encumber food insecure patients
Success strategies to track food insecurity and evaluate the results of interventions include:
Setting follow-up appointments during the screening process
Using your EHR to identify food insecure patients and monitor health outcomes linked to food insecurity
Obtaining consent for data sharing, which can boost continuity of care between healthcare practitioners and settings
Targeting interventions
Food access interventions need to be tailored to community circumstances and the specific needs of patients, Kathleen Giblin, RN, senior vice president of quality innovation at the National Quality Forum, told HealthLeaders.
"Patients living in communities with few grocery stores, food pantries, or food banks, or those with mobility challenges, lacking reliable and affordable transportation, or facing financial barriers may need to be referred to in-house interventions to provide direct access to food to have their needs met. In areas with strong community resources and programs, it may be more effective for healthcare providers to connect patients to CBOs that can provide access to nutritious food," she said.
Social determinants of health factors do not exist in a vacuum, Shantanu Agrawal, MD, MPhil, president and CEO of the National Quality Forum, told HealthLeaders.
"Our Food Insecurity and Health Implementation Guide, developed in collaboration with Humana, is a critical step in addressing an essential social determinant. Other SDOH such as transportation, housing, and social isolation are issues that healthcare providers are beginning to tackle through both direct investments and community partnerships," he said.
Regardless of whether healthcare organizations pursue direct investments or community partnerships, SDOH initiatives require teamwork, Agrawal said.
"Bringing together patients, communities, healthcare providers and organizations, and community-based workers to discuss goals, resources, and values can help to build trust, prevent duplication of efforts, and establish shared ownership of actions to address food insecurity and other social determinants of health," he said.
Extracorporeal membrane oxygenation provides life support for coronavirus patients suffering respiratory failure.
After all other conventional treatments have failed, extracorporeal membrane oxygenation (ECMO) life support can be a coronavirus patient's last hope for recovery.
ECMO is a form of life support that features a machine that performs essential functions of the heart and lungs. The ECMO machine is connected to a patient through plastic tubes that are placed in large veins and arteries in the legs, neck, or chest, according to the American Thoracic Society. Blood flows through the ECMO machine, which adds oxygen to the blood and removes carbon dioxide, then the blood is returned to the patient.
ECMO technology has advanced significantly since it was developed in the early 1970s, but it is a high-risk intervention, says Jonathan Haft, MD, ECMO medical director at Michigan Medicine, and an associate professor in cardiac surgery at University of Michigan Medical School.
"ECMO still is a last-ditch effort. ECMO is a challenging therapy. It requires expertise, experience, carefully established policies, teamwork, and quality assurance reviews. Centers that do not have a lot of experience doing ECMO are unlikely to have a lot of success. You can't just buy the equipment and start doing it," he says.
Michigan Medicine recently discharged the health system's first coronavirus survivor who underwent ECMO, Haft says.
"It was a typical ECMO course. The patient was gravely ill and at imminent risk of death when the ECMO decision was made. He was supported well on ECMO and eventually liberated from ECMO, then he was liberated from a ventilator and was eventually well enough to go home independently to his family. The belief is that his long-term life expectancy will be close to normal."
So far, 15 adult coronavirus patients have undergone ECMO at Michigan Medicine, and Haft predicts at least half of the patients will survive. "I expect our survival rate will be over 50%—probably over 60%. That survival rate would be consistent with what we have seen in other adult patients who are treated with ECMO for all-cause respiratory failure."
Most ECMO patients are on the life support machine in an ICU for about nine days, and the average hospital length of stay is more than a month, Haft says.
He says there are four primary complications:
Clotting that can form on artificial surfaces
Bleeding because patients are given high levels of blood thinners
Skin infections where the large-bore tubes are inserted
At Michigan Medicine, Haft says five main factors are considered before a coronavirus disease 2019 (COVID-19) patient is placed on ECMO:
Advanced age can be disqualifying. "We do not have an age cutoff for ECMO; but the older you get, the more discerning we are about appropriateness in candidacy," he says.
Co-morbidities are assessed. "We factor in other medical problems—does the patient have diabetes, chronic kidney failure, or cirrhosis of the liver? Does the respiratory failure represent an exacerbation of an established and irreversible chronic lung disease? In other words, if a patient has baseline emphysema or baseline pulmonary fibrosis with COVID-19, they may not be an appropriate candidate."
Overall functional status, which is a surrogate for other medical problems and age combined, is a factor. Elements of functional status include debilitation, ability to live independently, and dependence on assistive devices.
Duration of mechanical ventilation can be a contraindication. "Once we get beyond seven days on mechanical ventilation, the likelihood of survival starts to drop," he says.
Physicians also consider the lung injury score, which assesses the dependence on mechanical ventilation, the stiffness of the lungs, and the appearance of the lungs on chest X-ray. "These are all markers of the severity of lung injury," he says.
ECMO is resource-intense and the COVID-19 pandemic is resource-draining, so patient selection requires rigorous consideration, Haft says. "In the context of COVID-19 and the volume of patients, the resources have become scarce—not just ECMO resources, but also ICU beds, ventilators, nurses, and blood bank supplies. With scarcity throughout the institution, we are trying to be even more thoughtful about ECMO candidates."
The patient selection process involves life-or-death calculus, he says. "You do not draw a line on patients, but you put all of the factors together and they give you a likelihood of recovery. Our selection criteria are based on the likelihood of meaningful recovery. The alternative is death, but the one thing that can be worse than death is futility—depending on life support for a long period of time without meaningful benefit of survival."
At Michigan Medicine, the decision to place a COVID-19 patient on ECMO usually involves at least two physicians, Haft says. "When I am not on call, the ECMO physician who is on call will contact me to discuss the individual case. If we are borderline on whether ECMO is appropriate, then I will typically call two or three of my senior partner colleagues and we will have a group discussion about the case."
Role of ECMO in the pandemic
With limited resources, ECMO will not play a pivotal role in the COVID-19 pandemic, Haft says.
"From an epidemiologic perspective, ECMO's impact will probably be too low to measure. The number of people in the U.S. who have COVID-19 are in the hundreds of thousands, and the number of patients who are going to get ECMO is in the hundreds. So, epidemiologically ECMO is not going to be a solution. However, on an individual basis, there is no question that ECMO will save lives."
The primary steps Margaret Mary Health took to address a surge of coronavirus patients included formation of a response team and expansion of telemedicine.
In response to the coronavirus pandemic, an Indiana-based rural hospital succeeded in boosting staff, increasing bed space, and securing essential equipment such as ventilators.
Rural hospitals are facing multiple challenges during the coronavirus disease 2019 (COVID-19) pandemic, including limited ICU beds, shortages of key specialists such as infectious disease experts, and narrow patient surge capacity. Unlike well-resourced medical centers in urban areas, admission of COVID-19 patients can quickly overwhelm a rural hospital.
Batesville, Indiana–based Margaret Mary Health, which features a 25-bed critical access hospital (CAH) and two health centers, started planning for the pandemic in early March and admitted its first COVID-19 patient on March 13. At the peak of the rural hospital's COVID-19 surge, nearly 20 coronavirus patients were admitted.
"The big question was: What do we need to have? That is when we figured out how to rent hospital beds, find ventilators, and what we were likely to run out of," says Tim Putnam, president and CEO of Margaret Mary.
There were six primary steps that enabled Margaret Mary to cope with its COVID-19 patient surge, he says.
1. Response team formation
Margaret Mary's senior leadership started forming a coronavirus response team on March 4 and had the panel in place on March 12, Putnam says. "When we started, the response team was staffed by about 20 leaders from the organization."
Margaret Mary's chief nursing officer and vice president of patient services, Liz Leising, was picked to lead the response team because of her inpatient nursing and ER background, Putnam says.
The response team has six subcommittees: communications, community hotline, space, staffing, supplies, and testing, he says.
2. Increasing bed capacity
After Indiana officials lifted the CAH's 25-bed limit, the response team played a key role in expanding the rural hospital's bed capacity. "They created opportunities to create negative air flow rooms. They also looked at our inpatient capabilities and got as many patients into the hospital as possible. Now, we have phasing to go up to 60 beds," he says.
Finding space for new patient rooms was manageable, Putnam says.
"We were lucky to be in an older facility that was designed for larger patient volumes. A lot of critical access hospitals are in that situation, where they were 70-bed hospitals then came down to the 25-bed critical access hospital limit. What happens over time is that many of those patient rooms turn into offices, but they still have oxygen and other critical components."
3. Securing equipment
The two primary equipment challenges at Margaret Mary were finding adequate supplies of personal protective equipment (PPE) and procuring ventilators, he says.
The Margaret Mary purchasing staff was able to find PPE, but a larger measure of creativity and help from the organization's CFO, Brian Daeger, was necessary to increase the stock of ventilators. Before the pandemic, Margaret Mary had four ventilators. Daeger and the purchasing team were able to find an additional 12 ventilators, Putnam says. "The ventilators were in Tennessee on a used market. They were not new ventilators, but they were completely functional."
4. Boosting medical staff
Margaret Mary's anesthesia team played a pivotal role in staffing ventilator-equipped hospital beds, he says.
"Since we cancelled all elective surgeries, the anesthesia team became a great resource. That is what you see in rural hospitals—a lot of us can do a lot more than what is in our job description. So, we had nurses who used to work in the inpatient setting volunteer to work inpatient again. We had anesthesiologists who helped with airway issues when they arose. It was a strong teamwork effort."
In addition, medical assistants from outpatient offices and hospital departments with low volume due to the pandemic were redeployed to work as inpatient nurse assistants and nurse aides.
Several of the staff redeployment efforts required a training component, Putnam says. "We brought people in who had backgrounds in the inpatient setting—they had either worked in inpatient or were familiar with the setting. They went through an abbreviated orientation, then worked with experienced med-surge nurses."
5. Working with tertiary partners
Having solid relationships with tertiary partners was critically important for Margaret Mary, he says.
"They know the types of care that we deliver and which patients we will be sending to them. So, they know when they receive patients from us that the patients have been worked up appropriately and the information flows. They do not have to repeat anything, so the patient is not being set back to the starting point where they run all the tests again."
With these partnerships in place, Margaret Mary was able to transfer the hospital's most critically ill patients to tertiary centers and receive some less acute patients from tertiary centers, Putnam says.
6. Expanding telemedicine
Margaret Mary was able to expand an existing telemedicine relationship with an infectious disease expert, Stephen Blatt, MD, medical director for infectious diseases at Cincinnati-based TriHealth.
"He has been a big resource for how we prepared for COVID and how we treat the disease. Our medical staff has a conference call with him weekly to discuss the latest in treatment, testing, and resources," Putnam says.
Margaret Mary also bolstered an existing primary care telemedicine service, he says. "We have worked with several other community hospitals in Indiana to develop a primary care telehealth network that has expanded tremendously during the pandemic. The groundwork for it was already established."
Ernesto Vazquez shares his perspectives on value-based contracting, improving quality, controlling costs, and harnessing data analytics.
Ernesto Vazquez, MD, is set to play the top clinical leadership role at MercyOne Population Health Services Organization (PHSO).
MercyOne PHSO was launched in 2012 and has a portfolio of direct-to-employer, commercial, and government value- and risk-based contracts covering more than 300,000 patients of the MercyOne health system. The PHSO's Partnered Provider Network has decreased healthcare spending by more than $150 million, according to the Clive, Iowa-based health system.
Vazquez is taking on the CMO position at MercyOne PHSO following the retirement of David Swieskowski, MD, who played a broad leadership role at the PHSO including CMO responsibilities. Vazquez joined MercyOne in 2011, serving as a physician at MercyOne Clive Family Medicine Clinic and a member of the MercyOne Clinics quality committee.
Before joining MercyOne, Vazquez was a primary care physician at Summit Medical Center in Hermitage, Tennessee, where he served in several leadership roles such as a member of the medical executive committee. He earned his medical degree at the University of Texas Southwestern Medical School in Dallas.
Vazquez recently spoke with HealthLeaders to share his perspectives on PHSO operations. The following is a lightly edited transcript of that conversation.
HL: From a clinical viewpoint, what are the key elements of successful value-based contracting?
One important clinical element is having the right information. Every health system is very complex, and we need to make sure that we have the right information.
Another important aspect of value-based contracting from a clinical perspective is making sure you have the infrastructure to take care of patients from a holistic standpoint. It's not enough to take care of a patient medically. You have to be able to provide needed resources. For example, if there are gaps in housing, you need to have a social support system or social work system to be able to help the patient.
You also need to communicate with the payers to make sure that what we are doing is appropriate and that our services are being considered fairly. Payers need to be able to give feedback on a real-time basis; so that if there are deficiencies, we are given the opportunity to correct them. This feedback not only improves patient care but also allows us to benefit from value-based contracts.
HL: At MercyOne, what are the primary challenges of advancing quality and reducing cost of care?
Vazquez: The primary challenge in improving quality is setting a high standard of care for each patient in each clinical encounter. We can have all the data on the patient and all the gaps that need to be filled; but, ultimately, we are still dealing with a human being, and that can be a challenge. No two people are the same.
In controlling costs, the difficulty is that patient care may not align with cost containment. We need to do what's best for the patient, and sometimes that results in higher costs of care. The cost of care can be more than we projected. The PHSO can look for redundancies and unnecessary costs.
HL: Give an example of unnecessary costs.
Vazquez: One example in the clinical setting for primary care physicians is with complex patients, who require extensive monitoring. These patients see multiple physicians in multiple specialties frequently. Many times, the communication between the providers is delayed. So, the PCP may not know that the patient had a test the day before an office visit and repeats the test. These are repetitive tests that serve no purpose.
HL: How does the PHSO intervene when there are unnecessarily repeated tests?
Vazquez: We have a good infrastructure of data analysis and claims analysis that gets filtered through our health coaches, who are employed by the PHSO and work in clinics. The health coaches help communicate unnecessary tests to the clinicians. We are working on better communication. It takes a team approach. It takes technology. It takes awareness among clinicians.
HL: What aspects of MercyOne PHSO do you find most intriguing?
Vazquez: As a science and number guy, what I find most intriguing is the data analytics capability. As a clinician, it's intriguing to use our data to identify patients who are at higher risk and to prioritize them to get the best care in a timely fashion.
We believe that we are trendsetters. With good information we can not only affect the lives of our patients but also enhance the ability of clinicians to work at their best and take care of the patient.
HL: Give an example of data analytics at the PHSO.
Vazquez: We can analyze how many of our patients have been hospitalized recently. One big goal of Medicare is to minimize rehospitalizations. With the data that we have and the processing we can do, we have algorithms that can identify patients who are at risk for readmission. Then we can get them in to see their doctor to try to prevent a readmission.
The pandemic has increased stressors on physicians such as being redeployed to new care settings and anxiety over potential virus exposures.
Already an at-risk group, doctors are at increased risk of suicide during the coronavirus pandemic, a physician suicide researcher says.
Physicians and other frontline healthcare workers on the frontline of the coronavirus disease 2019 (COVID-19) pandemic are under physical and psychological strain. As of April 9, more than 9,000 healthcare workers had tested positive for coronavirus, the Centers for Disease Control and Prevention reported.
The April 26 suicide death of a New York emergency room physician appears to be related to the pandemic, according to the New York Times.
Lorna Breen, MD, was the medical director of the emergency department at New York-Presbyterian Allen Hospital. She died in Charlottesville, Virginia, where she was staying with family, the Times reported.
Breen's father, Philip Breen, MD, told the Times that his daughter was afflicted with COVID-19 and returned to work after recuperating for about a week and a half. He told the Times his daughter had witnessed grim conditions at Allen Hospital and appeared detached the last time he spoke with her. "She was truly in the trenches of the frontline," he told the Times.
The COVID-19 pandemic is placing doctors at higher risk of suicide, says Mirret El-Hagrassy, MD, a postdoctoral research fellow at Spaulding Rehabilitation Hospital's Neuromodulation Center and Harvard Medical School in Boston.
"It has increased the risk, considering all the risk factors and underlying mental health vulnerabilities. The pandemic increases the social stressors. The career-associated stressors are being exacerbated in a way that they were not before," says El-Hagrassy, co-author of a research article on physician suicide published by JAMA Psychiatry in March.
The research article found that female physicians have a higher suicide risk than the general female population by two statistical measures. Male physicians were found to have a higher suicide risk than the general male population by one statistical measure.
Physician suicide and the pandemic
The pandemic is associated with several physician suicide risks, El-Hagrassy says.
The risk of physicians exposing themselves and vulnerable family members to the virus
Physicians isolating themselves from others to lower the risk of spreading the virus
Physicians being redeployed to work in unfamiliar care settings such as anesthesiologists being reassigned to work in ICUs, which heightens concern over legal liability
Pressure from the business aspects of medicine, including physician practices being pushed to the brink of financial ruin
Layoffs, furloughs, and cutbacks in pay and raises as healthcare organizations teeter from the financial blows of the pandemic such as cancelation of elective surgery
Some residents and fellows are struggling to find jobs, which heavily impacts physicians in the United States on visas
In their JAMA Psychiatry article, El-Hagrassy and her co-authors found physicians who were divorced, widowed, or single faced higher suicide risk, and the pandemic will likely exacerbate this risk
There are ways to ease physician suicide risk during the coronavirus pandemic, El-Hagrassy says.
Provide adequate PPE: "The biggest factor is making sure physicians and other frontline workers are protected. Physicians need to get their personal protective equipment, so there is less risk of them getting infected or infecting their families. It is not just the fear of getting infected—it is the fear of spreading the virus to patients," she says.
Lenders could put physician's student loan debt on hold during the pandemic.
Mitigate legal liability: "The judicialization of medicine should be eased because it is a major factor for physician mental health disorders and suicide," El-Hagrassy says.
Employers could reduce or eliminate requirements for physicians to disclose mental health history on job applications.
Privacy should be enhanced for physicians for who want to seek mental health help. "Telemedicine psychiatry can be helpful for physicians because they don't have to go into an office, where they can be seen in a waiting area," she says.
Prejudice against those who seek mental health services in general and among physicians particularly should be addressed.
Physicians can conduct virtual daily check-ins with their colleagues on mobile devices or home computers.
"If we use this time of the pandemic to establish measures that protect physicians, it might lead to better outcomes down the line. We should move in that direction. There are a host of factors that could be improved during this period that might reduce the stressors and the potential for physician suicide both for the short-term and the long-term," El-Hagrassy says.
Doctors can call the Physician Support Line (888-409-0141) for free and anonymous psychiatric counseling.
Virtual visits are a safe way for families to stay in contact with hospitalized patients during the coronavirus pandemic.
AdventHealth is connecting hospitalized patients and families with virtual visits, including coronavirus patients.
To curb the spread of coronavirus disease 2019 (COVID-19), hospitals across the country have placed strict limits on visits to hospitalized patients. Visitation restrictions have been troublesome for COVID-19 patients, with families unable to see their loved ones for many days or weeks, and seriously ill patients dying without contact with their families.
For COVID-19 patients, virtual visits at AdventHealth have generated significant benefits, says Pam Guler, MHA, vice president and chief experience officer at the Altamonte Springs, Florida-based health system. "This has been meaningful for our patients, their families, and our caregivers. Many caregivers have told stories of creating a moment that has deep meaning not only for families and patients but also has touched their hearts."
AdventHealth features nearly 50 hospitals in nine states. During the COVID-19 pandemic, physical visits to hospitalized patients have been limited to a single loved one in the case of an end-of-life situation, childbirth, and a child in the hospital.
Virtual visit basics
AdventHealth recently launched virtual visits for hospitalized patients with the distribution of 1,000 Chromebooks and some iPads throughout the health system's hospital campuses, Guler says. The cost of the initiative was minimal because the Chromebooks were already in hand for another project, which has been delayed, she says. "The investment has been more about helping our team members to understand what they need to do."
With help from the health system's information technology staff, Guler has a team of 65 experience leaders who facilitate the virtual visits. In one recent week, the health system conducted 1,350 virtual visits. "Our information technology staff loaded the Chromebooks in a way to make it as easy as possible to use Google Hangouts, Facebook Messenger, and Facetime. We are using Google Hangouts quite a bit for video chats."
Coronavirus patient virtual visits
AdventHealth has put protocols in place for hospitalized COVID-19 patients to have virtual visits with loved ones, including for end-of-life situations, Guler says.
There are three primary considerations for virtual visits with all COVID-19 patients:
To limit the number of people in a patient's room for infection control, a bedside caregiver in full personal protective equipment brings a Chromebook or other device into the room
The device can be held by the bedside caregiver or placed on a bedside table if the family requests privacy for the virtual visit
After the virtual visit, a disinfectant is used to sterilize the Chromebook or other devices
The protocols for end-of-life situations are more involved, she says. "We have to facilitate calls more when there is an end-of-life scenario and the patient is not able to be an active participant."
The first step is for an experience leader to contact the family and to see whether they want to have a virtual visit. Then the family is asked whether they want to have a hospital chaplain included in the virtual visit.
Once a virtual visit has been arranged, an experience leader initiates the call to the family and hands off the device to a bedside caregiver outside the patient's room. In most cases, the bedside caregiver holds the device so the family gets a full view of the patient.
Although ICU bedside caregivers are experienced in working with the families of dying patients, they have received training to help them facilitate virtual visits, Guler says.
"This is a very deep and meaningful situation and interaction, and we have shared some words the caregivers might say. They may ask the family whether there is anything they can do to be the family's hands as the family is talking with their loved one, such as, 'Can I touch your loved one's hand?' They have protective equipment on, but they can be the hands of the family. The caregivers try to do anything they can to bring a human touch to this virtual experience."
Many family members can participate in an end-of-life virtual visit, she says.
"In one end-of-life situation, we had 15 family members on the virtual chat, along with their family pastor. The patient could not respond, but the family was able to say some last words. They said how much they loved the patient. Their pastor prayed with them. It was deeply meaningful and facilitated by a caregiver who held the device. In that situation, the caregiver did not need to say anything."
The new normal
AdventHealth plans to continue providing virtual visits for hospitalized patients after the COVID-19 crisis is over, Guler says.
"We want to continue virtual visits in the future. Even in a non-COVID-19 scenario, we often have patients who have family across the country. With this platform now in place, contact does not just have to be through telephone. We are already exploring ways that we can have virtual visits in the future in a non-COVID-19 world."
Researchers in China and Houston show that steam sterilization processes do not damage surgical masks or N95 respirator masks.
Two new studies show steam can effectively decontaminate medical masks including the N95 respirator mask.
Shortages of personal protective equipment (PPE) such as N95 respirators have plagued the U.S. response to the coronavirus disease 2019 (COVID-19) pandemic. On Feb. 22, testimony before Congress asserted that 3.5 billion N95 masks were needed for healthcare workers during the pandemic, and there was about 1% of that figure available.
"With each attempt to safely don a contaminated N95 mask, the risk for infection of vital clinicians grows. In countries where equipment shortages have progressed, healthcare workers are currently being infected with COVID-19 at three times the rate of the general population, reducing the ability of hospitals to provide adequate care, and increasing COVID-19 patient death rates. Thus, it is essential to create a protocol for sanitizing masks without reducing efficacy."
A research team in China published a study in the Journal of Medical Virology on using steam effectively to sanitize surgical masks and N95 respirators.
The sanitization process, which used avian coronavirus of infectious bronchitis virus to mimic the new coronavirus, was simple. Contaminated masks were placed in plastic bags and steamed over boiling tap water in a kitchen pot.
"The avian coronavirus was completely inactivated after being steamed for 5 minutes," wrote the Chinese researchers, who conducted the study at the College of Veterinary Medicine, Qingdao Agricultural University, Qingdao, China.
The effectiveness of the masks was unaffected by exposure to steam as long as two hours, the Chinese researchers wrote. "In this study, mask decontamination with steam on boiling water is without abrasive physical or chemical action. This can account for its excellent performance in maintaining the masks' blocking efficacy."
In addition to not damaging the masks, the steam treatment has other benefits, they wrote. "This measure has other advantages including safety, not requiring special agents or devices, and rapid inactivation of most microbes potentially attached to the surface of masks."
Houston steam sanitization study
Researchers at Houston Methodist Research Institute in Houston published a steam sanitization study for N95 respirators in the journal Infection Control & Hospital Epidemiology. The study featured five test subjects to verify mask fit after the decontamination process.
The immediate-use steam sterilization (IUSS) procedure was more complex than the Chinese research team's steaming method.
Used N95 respirators were placed in paper-plastic sterilization peel pouches manufactured by Mechanicsville, Virginia-based Medical Action Industries Inc.
The N95 respirators were steamed in a Steris Amsco Evolution HC1500 PreVac Steam Sterilizer autoclave
Chemical and biological indicators were used to ensure there was no contamination after the steaming procedure
The N95 respirators were not damaged in the steam sterilization procedure, the Houston-based researchers wrote. "Five test subjects were used to begin to account for individual differences between faces. For each subject, a fit test was performed before the IUSS cycle to serve as a control value. Fit tests were performed after three IUSS. In all cases, masks retained their structural integrity and efficacy."
A study involving more than 1,000 patients finds remdesivir speeds coronavirus recovery and lowers mortality rate by 3.6 percentage points.
Remdesivir is the first medication shown to have a therapeutic effect on the coronavirus, the National Institutes of Health reported today.
Since the coronavirus disease 2019 (COVID-19) outbreak began in Wuhan, China, in December, there has been no scientifically proven treatment and no vaccine for the deadly illness.
Preliminary data from a randomized, controlled trial featuring more than 1,000 patients indicates that severely ill COVID-19 patients with lung involvement recovered faster than similar patients given placebo, NIH reported. The clinical trial was sponsored by NIH's National Institute of Allergy and Infectious Diseases.
The preliminary data from the clinical trial includes two key results:
Patients given remdesivir recovered 31% faster than patients who received placebo. Recovery was defined as being fit for hospital discharge or returning to normal activity level. The median time to recovery was 11 days for remdesivir patients and 15 days for the control group.
Patients given remdesivir experienced a lower mortality rate—8.0% compared to 11.6% for the control group.
The clinical trial was conducted in 68 sites—47 in the United States and 21 in European and Asian countries.
Remdesivir, which has shown promising results in animal models for treating coronavirus, was developed by Gilead Sciences Inc. The investigational broad-spectrum antiviral medication is administered through daily infusion for 10 days, NIH reported.
Physician assistants need more leeway to practice medicine because of the coronavirus pandemic, a PA organization says. But a physician group is skeptical.
Particularly during the coronavirus pandemic, a national physician assistant organization is calling on states to drop laws that require collaborative or supervisory agreements between physicians and PAs.
At hospitals and other healthcare facilities, staffing shortages are one of the primary challenges of the coronavirus disease 2019 (COVID-19) pandemic. For example, to adequately staff new ICUs that have been created to address surges of seriously ill coronavirus patients, the Society for Critical Care Medicine is recommending tiered staffing that includes personnel redeployed from other hospital departments.
"These agreements are mainly relics of the past because most of the legislation establishing these arrangements was written 45 years ago, when PAs and nurse practitioners were much more of an experiment," says David Mittman, PA, president and chair of the Alexandria, Virginia–based American Academy of PAs (AAPA).
There are two primary reasons to drop the collaborative and supervisory agreement laws, he says.
"First, it is important to lift any agreement that is mandatory because they are barriers to care. They prevent PAs, physicians, and healthcare teams from practicing the way we need to practice. … Second, during the COVID-19 pandemic, it is even more important to eliminate these barriers because clinicians have to go to areas of need. It is important to allow PAs to practice at the highest level."
The collaborative and supervisory agreement laws are inappropriate during the COVID-19 pandemic, Mittman says. "The limitations on PAs don't make sense under normal conditions; and in a crisis where we need all-hands-on-deck, the limitations make much less sense. This is about saving lives, and legislation written decades ago to make sure that PAs and nurse practitioners were not dangerous in any way are barriers that need to be removed."
Last week, Virginia Gov. Ralph Northam issued an executive order allowing PAs with at least two years of clinical experience to practice medicine without a practice agreement during the commonwealth's COVID-19 state of emergency.
According to the AAPA, seven other states have waived physician supervision or collaborative agreements for PAs in executive orders related to the COVID-19 pandemic: Maine, Michigan, New Jersey, New York, Louisiana, South Dakota, and Tennessee.
Up to the task
PAs provide the same services as physicians, and the differences between the clinicians are based mainly on specialty rather than training, Mittman says.
"For example, a PA who works in an emergency room and is comfortable doing procedures would be a lot more able to go to the ICU and function there than a PA or even a physician who is a psychiatrist. A PA in family practice could probably move to urgent care during the pandemic. A PA in urgent care could definitely move to the emergency room."
PAs are well-suited to work with COVID-19 patients, he says. "PAs are trained as generalists first. So, they all do rotations in emergency medicine and primary care. They are qualified to diagnose and treat patients in primary care, urgent care, emergency rooms, and hospital settings for patients who either have or could have COVID-19."
Many PAs are already on the frontlines of the pandemic in supervisory roles, Mittman says. "Drive-thru testing sites at large health systems are frequently staffed by and—in many cases—run by PAs. Drive-thru test sites operated by the military and public health departments have PAs in command positions."
PAs also are being called upon to utilize their primary care training to free up primary care physicians to work in urgent care and emergency rooms, he says.
"PAs are very flexible because of their training and clinical experience. They can function in almost any area. PAs are not only freeing up physicians to provide COVID-19 care. They are freeing up other PAs who have experience working in hospitals to treat pandemic patients."
Physician group skeptical
Physicians for Patient Protection—a grassroots organization of practicing and retired physicians, residents, medical students, and assistant physicians—is opposed to dropping the supervisory and collaborative agreement laws for PAs.
"Physicians for Patient Protection believes that physician-led care is the gold standard and is what patients expect and deserve. PAs right now, under current state laws, can absolutely assist in this COVID crisis to the full extent of their education and training. There is nothing stopping them from working right now and treating patients as part of a team," says Carmen Kavali, MD, a board member of the group and practicing plastic surgeon in Atlanta.
The COVID-19 pandemic should not be used as a justification for rescinding supervisory and collaborative agreement laws, she says. "During a pandemic is not the time to experiment with unsupervised practice by PAs, who have 27 months of medical education, compared with seven to 11 years of physician education. PAs are a valuable part of the team, but the profession was never intended to work independently of physicians."
Clinician liability is a concern, Kavali says. "We are unaware of any mandates that would ensure equitable malpractice limits for PAs, which should match those of physicians if a PA is practicing independently, so physicians would not have the 'deepest pockets' for attorneys to pursue."
