Members of ethnic and racial minority groups have been disproportionately affected in the coronavirus pandemic.
CVS Health is opening drive-thru testing sites for coronavirus in minority and underserved communities.
Preliminary data suggests ethic and racial minority groups are being disproportionately affected by the coronavirus 2019 (COVID-19) pandemic, the Centers for Disease Control and Prevention has reported. For example, a recent CDC Morbidity and Mortality Weekly Report examined data from 580 hospitalized COVID-19 patients. African Americans accounted for 33% of the cases but only 18% of the community population.
There likely are three primary reasons why ethnic and racial minority groups are at high risk of coronavirus infection, the CDC says:
Racial and ethnic minority groups tend to have housing conditions that are susceptible to spreading coronavirus such as living in densely populated areas and in multigenerational households.
Many members of racial and ethnic minority groups risk exposure working in essential jobs such as the service and agricultural industries, with few telecommuting opportunities. They also tend to work in jobs with no paid sick leave, which encourages employees to work during an illness.
Many members of racial and ethnic minority groups have underlying health conditions and poor access to clinical care. For example, African Americans and Hispanics are more likely to be uninsured than white Americans.
Photo credit: CVS Health
CVS Health opens coronavirus test sites in underserved areas
This month, Woonsocket, RI-based CVS Health has opened drive-thru coronavirus test sites in aimed at racial and ethnic minority group populations in five states.
"Testing identification and the subsequent linkage to care that people need is one of the easier strategies to try to impact the pandemic," says Gareth Graham, MD, MPH, vice president of community health and impact at CVS Health, and a former deputy assistant secretary in the Department of Health & Human Services' Office of Minority Health.
Identifying coronavirus infections benefits ethic and racial minority populations, he says. "We are offering rapid testing that allows individuals to get positive results in as little as 5 minutes, and negative results in as little as 13 minutes. The concept of identification is particularly valuable to underserved communities because it is the first step in getting care if needed."
To arrange for the free testing, people register for an appointment on CVS.com then drive to the testing site. Most of the tests are administered by MinuteClinic staff members who work at local CVS pharmacies. The tests are being offered at off-site locations such as libraries and college campuses in five states: Connecticut, Georgia, Massachusetts, Michigan, and Rhode Island.
Former Gateway Community College campus at Long Wharf, 60 Sargent Drive, New Haven, Connecticut.
Henry Ford Centennial Library, 16301 Michigan Avenue, Dearborn, Michigan
Twin River Casino, 100 Twin River Road, Lincoln, Rhode Island
"A patient does not need a doctor referral, which is particularly important in low-income communities, where people may not have access to a physician," Graham says.
Outreach and education are key ingredients in the CVS Health testing initiative, he says. "We reach out to communities, so they know where the test sites are, and we have culturally relevant information about other preventative factors that we know work such as social distancing. We have worked with the National Medical Association, which is the national African American physician organization, and local nonprofits in areas where we have our testing sites."
Next month, CVS Health plans to offer self-swab tests at drive-thru locations. The tests will be scheduled online then conducted in parking lots at select CVS pharmacy locations and drive-thru windows. By the end of May, the company anticipates having as many as 1,000 locations across the country for the self-swab tests.
Cancer clinics must take extensive coronavirus precautions because their patients are at high risk of serious illness.
Cancer clinics are making operational changes and launching other initiatives in response to the coronavirus disease 2019 (COVID-19) pandemic.
Patients with cancer are a high-risk group during the COVID-19 pandemic, according to a World Health Organization report published in February. The report, which is based on data collected in China, found that COVID-19 patients with cancer are more than five times more likely to die from the disease compared to COVID-19 patients who have no comorbid conditions.
There are three primary reasons why patients with cancer are at high risk during the pandemic, says Catherine Liu, MD, associate director of infection control at Seattle Cancer Care Alliance (SCCA) in Seattle, and associate professor of medicine at University of Washington School of Medicine in Seattle.
Patients with cancer receive treatments such as bone marrow transplants that can suppress the immune system
Certain types of cancer place patients at high risk, including hematologic malignancies such as leukemia and lymphoma
Cancer patients often have other underlying conditions that have been associated with increased risk of severe illness with COVID-19, including diabetes and high blood pressure
Delaying nonessential procedures and surgery
Like other healthcare providers across the country, SCCA has delayed nonessential procedures and surgery during the COVID-19 pandemic.
Cancer clinics have to carefully weigh which procedures and surgery can be delayed, Liu says. "Many cancer surgeries are not considered elective. We know that some of the more aggressive cancers such as pancreatic and colorectal cancer have a more immediate need for surgery. We have to be thoughtful about prioritizing some of these procedures. For example, there are some slower-growing cancers for which nonsurgical interventions may be appropriate."
SCCA has taken a team-based approach to these decisions, she says. "It has been a collaborative decision between oncologists, the care team, and patients to make a decision about moving forward with surgery. Everyone is involved in this process to determine whether surgery can be postponed, using other interventions in the meantime."
There are three primary considerations, Liu says. "It depends on the type of cancer, the type of procedure, and the clinical situation of the patient in determining whether a procedure can be delayed or needs to be performed right away."
Operational initiatives
SCCA has implemented seven operational initiatives to reduce exposure to the virus and increase the safety of patients and staff, she says.
1. All patients and staff are screened for respiratory symptoms when they enter the clinic. Symptomatic patients are masked and moved to a designated area of the clinic where they can be tested. Symptomatic employees are also given a mask, tested, and told to go home until their symptoms resolve.
2. Patients have been asked to call a nurse coronavirus triage hotline if they are experiencing any respiratory symptoms such as cough or shortness of breath. The nurses provide guidance to patients about whether they should come in for a scheduled appointment, postpone a visit until their symptoms resolve, or schedule a telehealth visit.
3. Symptomatic patients and employees can be tested at an off-site, drive-thru location. The service was established to limit exposure in the clinic.
4. Pre-visit screening phone calls are conducted about two days before a patient's clinic visit to see whether they have respiratory symptoms. Symptomatic patients are tested at the drive-thru location. If the test results are not available before the patient's clinic visit, a telehealth visit is set up or the clinic visit is rescheduled.
5. The use of a surgical mask is recommended for use by all staff in the clinic, primarily to limit the risk of infection from healthcare workers who have asymptomatic or pre-symptomatic infections.
6. Visitor restrictions to limit exposures include patients only bringing one additional person over age 12 to a clinic visit and no guests accompanying patients in the chemotherapy infusion rooms.
7. Nonessential staff have been restricted in clinic areas to reduce the density of people.
Treating coronavirus-positive patients
SCCA has developed guidelines for managing patients who test positive for coronavirus, Liu says.
"From a clinical perspective, the oncologist will discuss individual treatment plans with their patients and determine what aspects of their care need to be continued and what aspects should be delayed. In some cases, patients may need to continue their therapy or require some other types of essential care such as infusion."
Precautions are taken if a coronavirus-positive patient needs to have an essential care visit, she says.
"We developed infection prevention guidance to ensure that when these patients enter the clinic their care is carefully organized. We ensure that there is coordination between environmental services, the infection prevention team, and the treating team to allow for a controlled and safe environment for our other patients. We developed a process in which the patient is escorted into the clinic to a designated area, where they are seen and have their care managed."
Physician Support Line provides free counseling to doctors facing mental health challenges during the coronavirus pandemic.
More than 600 psychiatrists are volunteering to staff a hotline that is providing counseling services to physicians during the coronavirus disease 2019 (COVID-19) pandemic.
Healthcare workers are in a precarious position on the frontlines of the struggle against COVID-19. In China, Italy, Spain, the United States, and other countries, thousands of healthcare workers have been infected with the coronavirus. In hospitals where COVID-19 patients have surged, healthcare professionals have worked under disaster conditions for days and weeks with little respite.
On March 30, the Physician Support Line (888-409-0141) was launched to provide free counseling to doctors facing mental health challenges during the pandemic. In the first three weeks of the service, more than 3,000 minutes of counseling were logged.
Physician Support Line's founder says moderating a COVID-19 physician group on Facebook inspired her to start the hotline.
"From very early on in February, there were many medical and academic topics, but there also were a lot of posts about mental health. It was not just mental health as a concept for others and how we were going to deal with patients—it was mental health of physicians. There was a lot of anxiety, a lot of insomnia, and a lot of dread," says Mona Masood, DO, founder and chief organizer of Physician Support Line, and a practicing psychiatrist at Southampton Psychiatric Associates in Ivyland, Pennsylvania.
How the support line works
There are two options for callers to Physician Support Line. Non-physician callers can press 1 to be connected to the Disaster Distress Helpline, a first responders and healthcare workers support line, or the National Suicide Prevention Lifeline. Doctors can press 2 to be connected to a Physician Support Line psychiatrist, who are available from 8 a.m. to 12 a.m. Eastern Standard Time seven days a week.
The volunteer psychiatrists sign up for hour-long shifts, Masood says. "The service is based on psychiatrists who are working actively with their own patients. Sparing an hour is not a lot to ask of people doing volunteer work; and as a collective, we are having a big impact."
The cost of operating Physician Support Line is about $350 per month. Masood is paying for most of the cost.
'Physicians are running on empty'
Calls to Physician Support Line have evolved over the past three weeks, mirroring the progression of the pandemic, Masood says.
"At the beginning of the hotline, calls were about physicians not having cases yet, but they were feeling anxious. There was anticipatory anxiety about what was to come.
"In the second week, many of the calls were about the case load of patients increasing every day, hours being extended, and not having a break for a week. Physicians were working nonstop, sleeping at their hospitals, and being separated from their families. The calls were focusing on how physicians could survive the demanding schedule.
"In the third week, it became about death. Physicians were losing patients. Physicians could not get their patients to FaceTime with their families before they died.
"Now, physicians are running on empty. They have not had time to process grief or loss like they would have before the pandemic. They just have to keep going. It looks similar to war. Physicians have gotten the virus themselves—some are doing well, and others are waiting to see whether their condition is going to get worse and they are going to be hospitalized."
Dealing with regret
The pandemic has revealed a deep-seated vulnerability among physicians, Masood says.
"Almost every call is starting off with the physician saying, 'I'm so sorry for taking up your time.' There is regret. The physicians are feeling like they should not be calling and talking about their challenges. Physicians have an expectation that they have internalized—they are not supposed to be taking care of themselves, they are supposed to be taking care of other people. There is a lot of guilt that is associated with that.
"We have to remind physicians that we created this resource for them."
Rural areas of the country have vulnerabilities to the coronavirus and limited resources to respond to the pandemic.
The first wave of the coronavirus disease 2019 (COVID-19) pandemic inundated urban areas such as New York and Detroit, now rural areas are getting overwhelmed, two infectious disease experts say.
The United States has become a global hotspot in the COVID-19 pandemic, with the most confirmed cases and the most deaths in the world. As of April 23, the country had experienced more than 849,000 confirmed cases and more than 47,000 deaths, worldometer reported.
This week, the Infectious Diseases Society of America held an online media briefing on the impact of COVID-19 on rural areas of the country. The situation in Nebraska is emblematic of how the pandemic is affecting rural communities, said Angela Hewlett, MD, MS, director of the Nebraska Biocontainment Unit, and an associate professor at University of Nebraska Medical Center.
"Nebraska, as a whole, looks pretty good. We do not have a lot of positive cases here. But when you break the numbers down by county, a completely different picture emerges. It's alarming!" she said.
The pandemic is exposing the disparity of healthcare resources between urban and rural areas, said Andrew Pavia, MD, chief, division of pediatric infectious diseases, University of Utah School of Medicine. "We have to appreciate that the resources that we have to fight this epidemic are not evenly distributed. The bigger cities have major medical centers, a capacity of specialists, and ICU beds. But when you get 50 to 100 miles out from the big cities, the situation is very different."
Rural areas susceptible to COVID-19 pandemic
While rural areas of the country have some advantages in battling COVID-19 such as built-in social distancing from the geographic dispersion of populations, there are many significant disadvantages, Hewlett said.
Small towns are close-knit communities that often have large social gatherings such as family events drawing people from several towns.
Industries in rural areas including meat packing companies and power plants are considered essential and require most employees to work on-site, so the ability to telecommute from home is limited. "In these industries, there are often lots of people working in very close contact, which is a set-up for perpetuating a disease like this that is spread from person to person," she said.
Smaller communities have smaller hospitals with limited capabilities such as few ICU beds and small stocks of ventilators.
Rural communities have small local health departments, which constrains essential pandemic responses such as contact tracing.
Poor rural communities are particularly vulnerable to the coronavirus, Pavia said.
"We have known for a long time that poverty is a strong indicator of poor general health. Poor people are more likely to have worse diets; greater risk of diabetes, obesity, and heart disease; and they get less care for chronic diseases. We know that all of those factors are risks of dying when you get infected with the coronavirus," he said.
In addition, Pavia and Hewlett said air transport of severely ill COVID-19 patients from rural hospitals to larger medical centers poses serious challenges. The problems include the potentially large number of patients who will need this service and concern over virus exposure of flight crews transporting COVID-19 patients during long flights in small aircraft.
Rural hospitals ill-suited to treat coronavirus pandemic patients
Most rural hospitals are overmatched in the struggle against COVID-19, Hewlett and Pavia said.
"In a rural area, you may have a critical access hospital, which is a hospital that may have 20 beds and possibly one ventilator, if that. They are just not equipped to deal with an influx of sick patients. They are used to caring for individuals within their community with conditions that a small hospital can handle," Hewlett said.
"In the West, we have many hospitals that are critical access and frontier hospitals, and they may have fewer than 20 beds. They may have no ICU beds, or two or three ICU beds, and they are not staffed 24/7. Those beds are used to help patients in the postoperative period," Pavia said.
Beyond the physical limitations of rural hospitals, staffing is a daunting challenge during the COVID-19 pandemic, they said.
"At some of these hospitals, they have done a good job at gearing up, but the staff is quickly overwhelmed. They have to be able to staff 24/7 for weeks at a time, and many of these communities barely have enough doctors and nurses to provide good primary care, let alone 24/7 ICU care," Pavia said.
Shortages of key pandemic specialists are common in rural areas, Hewlett said, noting there are only two infectious disease physicians in western Nebraska.
"There are multiple hospitals that do not have infectious disease specialists or critical care specialists. These are hospitals that typically do not need a critical care specialist to operate 24/7, seven days a week, and that is the need we are seeing with this disease. We have patients who are very sick and require ICU care over an extended period. … These are patients who often require several weeks of ICU-level support; and in small communities, that is just not sustainable," she said.
Healthcare workers are crossing state lines to alleviate staffing shortages during the coronavirus pandemic. What are the legal implications?
There are several legal considerations when licensed healthcare workers cross state lines during the coronavirus disease 2019 (COVID-19) pandemic, a healthcare attorney says.
Last month, the Trump administration declared a state of emergency and changed federal rules to allow licensed healthcare workers to practice medicine across state lines. The move is designed to address shortages of healthcare workers as COVID-19 patients surge and hospital staff are sidelined by coronavirus infection.
To assess the legal implications of licensed healthcare workers crossing state lines, HealthLeaders recently spoke with Melissa Markey, JD, who is an attorney at Indianapolis-based Hall, Render, Killian, Heath & Lyman, P.C. In addition to specializing in healthcare law, she is a licensed paramedic.
The following is a lightly edited transcript of that conversation.
HealthLeaders: What is the new legal mechanism that allows licensed healthcare workers to cross states lines?
Melissa Markey: The federal declaration of emergency empowered state regulators to take the actions that are necessary to temporarily—during the emergency only—waive licensing rules so that licensed personnel from other states can come and help.
The reason why states maintain control over licensure is due to their desire to make sure that the healthcare professionals who are practicing in their state are adequately qualified and adequately trained, and they have not engaged in behavior that is not in the best interest of their citizens.
The waiver removes the ability of the state regulators to look at each professional individually and evaluate where they were trained, how long they have held a license, and what lawyers call character and fitness, which looks at things like whether healthcare workers have ever been convicted of a crime.
HL: How does the ability of licensed healthcare workers to cross states impact reimbursement for medical services?
Markey: On the federal level, the declaration of emergency allows Medicare and Medicaid to pay for the care that is provided by any licensed professional who has gone through the basic checks such as Drug Enforcement Administration registration.
The federal waiver is more about payment of services than licensure. Technically, states have the power to waive their own licensure laws under their own emergency management acts and other state laws. The challenge comes about because of the federal payment rules. If you don't have a federal order, then clinicians would have problems getting paid by Medicare and Medicaid. The federal declaration is mainly about dollars. The state declaration is mainly about the licensure law.
HL: How does crossing state lines impact healthcare worker liability?
Markey: There are a lot of different ways that you can volunteer to provide services, especially in this kind of disaster. Some of those ways of volunteering provide some immunity from liability and some of them don't provide any immunity.
You should check with your malpractice insurance carrier. You also should look at the laws of the state where you will be volunteering your services—you want to find out whether you would qualify under the Good Samaritan law for protection. You should also look at a state's emergency management law.
HL: How does crossing state lines impact workers' compensation?
Markey: It is important to check whether you will be protected through workers' compensation or some other protective scheme if you become injured or ill while you are providing services. This virus does not spare healthcare workers and they are becoming sick—sometimes very sick— with COVID-19.
Typically, a healthcare facility that is using volunteers from another state will confirm that their license is still valid, they will confirm any other criteria that they require to ensure that the healthcare worker is qualified, and they will try to confirm whether a physician holds hospital privileges. So, there is a process at the facility level.
Some volunteer healthcare professionals come through volunteer organizations such as the Medical Reserve Corps or the National Disaster Medical System. You volunteer ahead of time, you get cleared, your credentials are confirmed, then you can get to work right away because you have been pre-credentialed.
Depending on which pathway you go through, you may have liability and workers' compensation protections. For example, the National Disaster Medical System personnel are treated as temporary federal employees, and they are protected from liability and are provided with some workers' compensation protection.
HL: How do you check to see whether you have workers' compensation protection?
Markey: The most common place to find that information is under a state's emergency management act to see whether there is a provision for volunteers who come from outside the state to assist during a disaster.
HL: Would it be prudent to consult with a lawyer before volunteering your professional services in another state?
Markey: That's certainly an option. There also are resources available online from the federal Department of Health and Human Services—the assistant secretary for preparedness and response has some resources. The American Health Lawyers Association public interest group has resources that go through several considerations and outline some of the laws.
For healthcare workers, hospital grocery stores are a welcomed convenience during the coronavirus pandemic.
CommonSpirit Health is opening grocery stores at the organization's hospitals to help support healthcare workers during the coronavirus pandemic.
Many healthcare workers are under intense pandemic pressure, including work under stressful conditions in areas of the country where coronavirus disease 2019 (COVID-19) patients are surging, reassignment to critical care settings, and fear associated with possibly bringing the virus home to their families.
Chicago-based CommonSpirit, which operates hospitals and other healthcare facilities in 21 states, opened its first hospital grocery store on March 30. Since then, grocery stores have opened at two dozen CommonSpirit hospitals, and 22 more are set to open by the end of the month.
Deisell Martinez, PhD, MS, leader of nutrition services at CommonSpirit, says the health system launched the grocery store initiative to help support healthcare workers during the pandemic. "They were so strained and a lot of them found it hard to go to a grocery store at night. A lot of times, when they got to a grocery store, many of the items were gone."
Having grocery stores in hospitals also reduces possible exposure to the virus while shopping and helps address bias against healthcare workers, she says. "One nurse told me that when they get off work and go into a store in scrubs, they get looked at in a strange way. People feel they are bringing the virus with them."
Photo Credit: CommonSpirit Health
Establishing hospital grocery stores
The hospital grocery stores have been a low-cost venture for CommonSpirit because the stores have opened in existing cafés or dining areas, Martinez says. "These sites already had refrigeration, so we didn't have to bring in anything new."
The hospital grocery stores are financially neutral, she says. "What we are doing is taking our cost and transferring it to our employees. We are not making money or losing money. This is not about money. This is about fulfilling our mission. We have a mission of making sure we support our frontline healthcare workers."
CommonSpirit made three primary steps to establish hospital grocery stores, Martinez says.
1. The first step was ensuring there was a viable supply chain to stock the stores. "It started with making sure that we had a supply chain that would be able to sufficiently support the stores, so that the staff would not be disappointed with empty racks," she says.
2. Hospital food and nutrition service directors were contacted to see whether they were interested in providing the grocery store service. St. Joseph's Hospital and Medical Center in Phoenix volunteered to pilot the initiative.
3. A "playbook" was developed to help guide CommonSpirit hospitals through the process of opening and operating a grocery store.
Martinez says the offerings at the hospital grocery stores vary from site to site, but common items include toilet paper, disinfectant, paper towels, eggs, milk, pasta, tomato sauce, canned tuna, rice, flour, and sugar.
When the crisis level of the coronavirus pandemic passes, healthcare providers will need sophisticated strategies to restart elective surgery.
The American College of Surgeons (ACS) has released recommendations to guide healthcare providers when they resume elective surgery that has been put on hold during the coronavirus pandemic.
To boost resources for treating hospitalized coronavirus disease 2019 (COVID-19) patients, governors across the country have ordered hospitals to delay elective surgery procedures. Last month, ACS released guidance for determining which elective surgeries could be delayed appropriately.
Last week, ACS released a list of 10 issues that should be addressed before a healthcare organization resumes elective surgeries that have been delayed. "Evaluating and addressing each of these 10 issues will help facilities to not only optimally provide safe and high-quality surgical patient care, but also to ensure that surgery resumes and doesn’t stop again," the recommendations say.
The recommendations are highlighted below.
1. Know your community's coronavirus statistics
The maximum incubation period for the coronavirus is estimated at two weeks. There should be a decrease in incidence of COVID-19 cases for at least two weeks before elective surgery is resumed.
Monitor local COVID-19 statistics such incidence of new cases to detect a resurgence of the virus.
Consider setting a threshold for new cases of COVID-19 that would trigger putting elective surgeries on hold again.
2. Know availability of COVID-19 testing and craft testing policies
Monitor local COVID-19 testing availability and lab result times.
Craft testing policies for patients such as pre-operative testing of patients scheduled for surgery.
Craft testing policies for healthcare workers such as screening and testing guidance.
With false negative test rates as high as 30%, consider establishing retesting policies for patients and healthcare workers.
With fever and lung complications possible in the postoperative period, consider establishing retesting guidelines for symptomatic patients.
3. Personal protective equipment
Before elective surgery is resumed, there should be a stored inventory of PPE or a reliable supply chain for at least 30 days of operations.
PPE policies should be in place for COVID-19 positive patients, persons under investigation, and non-COVID-19 patients, including for high-risk procedures such as intubation.
Consider having all healthcare workers and staff wear appropriate PPE outside the operating room and having all patients wear cloth masks.
4. Know key healthcare facility capacities
A hospital's available resources should include peri-anesthesia units, critical care, diagnostic imaging, and lab services.
Consider new sites for elective surgery such as hospital spaces that were converted for COVID-19 care, including outpatient departments.
OR schedules should be set to accommodate a spike of electives surgeries such as performing procedures at night or on weekends.
Make sure there is sufficient capacity for preoperative, intraoperative, postoperative, and post-acute care.
5. Supplies capacity
Ensure there are adequate levels of surgical supplies and equipment such as implants and anesthesia-sedation medications.
Ensure a supply chain is in place for traditional or new vendors.
Conduct an inventory of existing supplies and check expiration dates.
There should be adequate cleaning supplies, particularly for areas where care is provided to COVID-19 patients and persons under investigation.
6. Healthcare worker staffing
There should be adequate multidisciplinary staffing for routine and expanded hours.
Assess coordination of key staff members, including surgeons, anesthesiologists, nurses, and housekeeping.
Have contingencies in place for staff members who test positive for the coronavirus.
Assess the level of stress and fatigue among healthcare workers who have been providing frontline care during surges of COVID-19 patients.
Consider mitigation efforts for workforce shortages such as enlisting retired surgeons to work as first assistants.
7. Create governance committee
A governance committee can make real-time decisions for several pivotal issues, including PPE, pandemic assessment, patient backlog, and safety and quality.
The governance committee should be multidisciplinary, including surgeons, anesthesiologists, and nurses.
At least during the elective surgery ramp-up period, the governance committee should meet daily.
8. Patient communication
Consider creating a multidisciplinary committee to manage patient communication.
There are several crucial patient communication topics, including procedure prioritization, coronavirus testing policies, PPE use, and advance directives.
9. Prioritization of surgery
Key stakeholders such as surgeons, anesthesiologists, and nurses should participate in ramp-up planning, including the collaborative formation of principles and frameworks for surgery prioritization.
The prioritization process should be adjustable to local, regional, and national epidemiological trends and changes in COVID-19 care. The prioritization process should also take a facility's resources, priorities, and patient needs into account.
The prioritization process, principles, and framework should be transparent to hospitals, healthcare workers, and the public. The benefits of transparency include reducing ethical dilemmas.
There are multiple considerations in developing the prioritization process, including a list of canceled and delayed procedures, a strategy for phased opening of ORs, PPE availability, and issues related to increased OR volume.
10. Ensure safety and high value in all five phases of surgical care
Optimal care in the preoperative phase includes considering the use of telehealth.
Optimal care in the immediate preoperative phase features reviewing surgery, anesthesia, and nursing checklists for possible revisions related to COVID-19 positive patients and other considerations.
Optimal care in the intraoperative phase includes guidelines for staff during intubation.
Optimal care in the postoperative phase includes adherence to standardized care protocols.
Optimal care in the post discharge phase includes post-acute care facility availability and safety.
When healthcare organizations administer drive-thru testing, they limit virus exposure inside their facilities.
A Philadelphia-based urgent care provider has a four-step process to offer patients drive-thru coronavirus testing.
Diagnostic testing has been a pain point in the country's struggle to manage coronavirus disease 2019 (COVID-19). Testing of individuals who suspect they have been infected with the coronavirus is crucial to limiting the spread of COVID-19. Testing also is widely viewed as a key component of any strategy to reopen the country's economy.
In Philadelphia and three communities outside the city, vybe urgent care started offering drive-thru coronavirus testing in mid-March, President and CEO Peter Hotz says. The service is billed to all insurance carriers, including Medicare, Medicaid, and commercial carriers, and most insurers have waived patient co-pays, he says.
"We wanted to make sure that our urgent care centers could continue to treat non-COVID-related patients. So, we wanted to make sure our centers were as safe as possible. By limiting the number of positive or suspected positive patients who are entering our centers, we can continue to see other patients," Hotz says.
There are four primary steps in vybe's drive-thru testing process, he says.
1. Telehealth triage
To start the process, patients go to vybe's website and register for a virtual visit. There are two teams of staff members who conduct the virtual visits.
"The first team does all the patient registration, check-in, and virtual triage—they get patient history and symptoms. Then a clinician—either a physician, physician assistant, or nurse practitioner—joins the call and conducts a clinical evaluation with the patient. The clinician determines with the patient whether testing is warranted, and we figure out the closest center for testing. Then a note is sent to the center notifying the patient is coming in for a test," Hotz says.
If it is determined that the patient has a non-COVID-19 condition, medication can be prescribed during the virtual visit, he says.
2. Administering coronavirus test
The coronavirus testing is conducted in an urgent care center's parking lot, Hotz says. "When the patient arrives, they call the center, and a staff member goes out to the car in full protective gear. The patient stays in the car, identification is checked, then the test is conducted."
Medical assistants administer the bulk of the tests, he says.
3. Lab work
Depending on the patient's insurance carrier, test samples are sent to one of two diagnostic testing companies for processing—Quest or LabCorp, Hotz says. "Initially, lab results were taking anywhere from five to seven days to come back to the urgent care center. Now, it is taking two to three days."
4. Communicating test results and treatment plans to patients
For negative results, the patient is contacted via phone call by a medical assistant or another staff member. For positive results, a clinician makes the call, Hotz says.
"Our clinicians call back with positive results because patients tend to have more questions. The clinicians give specific guidance and follow-up instructions as if the patient had come in to see us physically. We send them information on COVID-19 and the things to watch out for—we make sure they are monitoring their ability to breath and their fever."
He says many coronavirus patients self-quarantine at home and do not require further care. Most patients whose symptoms progress are directed to go to the hospital, but some patients without underlying conditions have chest X-rays at an urgent care center to check for pneumonia, Hotz says.
"The overwhelming majority of patients are just staying home, self-monitoring, and self-treating, Fortunately, only a small percentage of patients are seeking care in a hospital. Those who are seeking that higher level of care are typically older, typically have underlying health conditions, and need to have a hospital level of care."
Surges of coronavirus patients, patient deaths from the virus, and hospital cutbacks due to financial pressures during the pandemic strain workforces.
As the coronavirus disease 2019 (COVID-19) pandemic threatens to surge hospital patients in Missouri, Children's Mercy is launching initiatives to support the wellbeing of the organization's employees.
With coronavirus patients surging beyond New York, the COVID-19 pandemic is straining healthcare organization workforces from coast to coast. The United States has more reported COVID-19 cases and deaths than any other country, at more than 644,000 cases and more than 28,000 deaths as of April 16, according to worldometer.
Kansas City, Missouri-based Children's Mercy established its COVID Employee Wellness Support Team to address a pressing need during the coronavirus pandemic, says Jennifer Bickel, MD, a practicing neurologist and COVID employee wellness officer at the hospital.
"The wellbeing of our caregivers is directly related to the wellbeing of our patients. There have been repeated studies showing that when healthcare providers—whether they are physicians or nurses—have problems with depression or burnout they are more likely to make safety errors and less likely to engage in a meaningful way with the patient," she says.
The wellness initiative is designed to formalize efforts to support the wellbeing of staff members during the coronavirus pandemic, Bickel says. "For everybody who goes into healthcare, one of our biggest callings is to be able to take care of people, and many of our colleagues are being drawn into taking care of each other. So, by developing the COVID Employee Wellness Support Team, we were able to develop an umbrella for how our employees can support each other."
How wellness support team works
Bickel says the COVID Employee Wellness Support Team features two dozen psychologists, clinical social workers, chaplains, and hospital leaders who have launched several initiatives.
Clinical specialty teams can set up virtual support groups
Mental health professionals can meet with employees one-on-one virtually or in-person to help them cope with fear, anxiety, and managing change
The Ronald McDonald Respite Room in the hospital is available to all employees from 11 a.m. to 11 p.m. to provide access to food, aromatherapy patches, meditation services, workout equipment, and wellbeing support services
Hospital mindfulness experts are leading employees through virtual guided meditation three times per day
A 10-minute meditation is conducted at the start of a daily COVID-19 planning call attended by about 100 hospital leaders
All of the hospital's information on wellbeing has been placed on a single web page that is available to the entire staff
Psychologists, social workers, and chaplains are conducting wellness rounds in the hospital emergency department and the neonatal intensive care unit
Planned initiatives include expanding respite rooms beyond the main hospital, offering one-on-one counseling sessions to affiliated community physicians, and conducting an American Medical Association COVID-19 wellness survey.
Wellness support team building blocks
Senior leadership was the key to creating the COVID Employee Wellness Support Team at Children's Mercy, Bickel says.
"Having executive leadership has allowed us to put together a team of our own compassionate experts—including psychologists, social workers, and chaplains—to help our employees. Then, we divided those experts to develop teams to work on initiatives," she says.
Drawing on internal experts at the hospital is an essential ingredient of the program, Bickel says. "This is not a time to bring in external consultants. Every hospital has established wellbeing initiatives, and you should build on those rather than break them down to form entirely new initiatives."
Hospitals in areas of the country that have not experienced a surge of coronavirus patients yet have the advantage of time to prepare themselves.
While coronavirus hotspots such as New York and Detroit are coping with patient surges, Valleywise Health is preparing for the challenge.
The coronavirus disease 2019 (COVID-19) pandemic is affecting states with varying intensity, with patient surges expected to roll out across the country in different time frames. For example, as of April 15, New York had nearly 200,000 confirmed COVID-19 cases compared to more than 3,800 cases in Arizona, according to Johns Hopkins University.
"We have been very blessed in Arizona to have the time. We have not seen the large influx of patients like they have in New York or Detroit. So, we have been able to benefit from their experience to make sure that our plans are ready if we experience that type of surge," says Michael White, MD, executive vice president and chief medical officer of Phoenix-based Valleywise Health.
The health system features an academic medical center and 11 community health clinics.
Current modeling predicts Valleywise Health will be able to accommodate a COVID-19 patient surge, he says.
"In the models that we are seeing in Arizona, as a community in Maricopa County we would be able to handle that volume of patients both from a personal protective equipment and a ventilator perspective. If the models change, then my answer will change."
The health system has been preparing for an expected surge of COVID-19 patients for several weeks, focusing primarily on Valleywise Health Medical Center's emergency department and critical care capabilities.
Emergency department preparations
In response to the COVID-19 pandemic, screening and triage protocols in the emergency department are crucial, White says. "We are planning for how we can efficiently screen and triage individuals who may be able to have their care maintained in an ambulatory environment or at home, versus those who may need admission to the hospital for further care," he says.
The medical center's emergency department has established two tracks for incoming patients—one track for patients with respiratory symptoms that could indicate coronavirus infection and another track for patients with non-respiratory acute complaints, White says.
"If a patient has a respiratory complaint, they get triaged into a track where we have staff who have elevated levels of personal protective equipment who can perform COVID-19 testing," he says. Patients who have other acute medical conditions see clinicians who treat "routine patients" who need emergency care.
In addition, the medical center has reconfigured emergency department space to have a designated area to provide critical care to seriously ill COVID-19 patients, White says.
Critical care preparations
The medical center has also concentrated on increasing ICU capacity, he says. "We have already begun to identify new spaces within the acute care hospital to keep patients together who have COVID-19 so we can treat them with ventilators in a critical care capacity."
White says the medical center has already converted the facility's step-down pediatric unit to an adult unit that can treat COVID-19 patients. Other areas that can be converted to provide critical care to COVID-19 patients include procedural space, pre-operative areas, post-anesthesia care units, operating rooms, and ambulatory clinics embedded in the hospital, he says.
In addition to repurposing space for critical care, the medical center is preparing to expand the facility's critical care workforce, White says.
"We will work very closely with our critical care partners and our medical staff to develop a team-based approach. We will have intensivist teams that could supervise hospitalists who could provide basic critical care. The same approach will apply to nursing, where nurses with intensive care training and experience will work with nurses who may not have critical care experience but can do some of those functions while being overseen."
Supporting medical staff
At Valleywise Health, another key facet of preparing for a COVID-19 patient surge has been initiatives designed to support the healthcare workforce, White says.
"We have done a lot of work preparing our staff in relieving their anxieties [such as] making sure there is adequate personal protective equipment. We have done a lot of education on the use of PPE."
Communication is an essential factor in supporting the healthcare workforce, he says.
"We have been transparent with our COVID-19 incident command—we do a daily briefing. We also do a daily newsletter that goes out to the entire staff."
He continues, "One of the early teams we created was an employee engagement and morale team that has done a number of events and other outreach to the staff within the medical center and all of our outlying clinics to make sure we are able to provide support to them. We are entering our third week of that outreach."
Other supportive efforts include displaying employee artwork and deploying mobile tool kits and carts that have snacks and supplies, White says.
Preparing for the worst
If a COVID-19 patient surge is overwhelming, Valleywise Health has established protocols for transferring patients to other health systems and rationing care, White says.
The care rationing protocol has been developed in consultation with other Arizona health systems and Valleywise Health's ethics committee, he says.
"We have that protocol in place in case we need to use it. Most of it is evidence-based around what has been established by the Society of Critical Care Medicine and previously published for these types of situations. There is some modified scoring about what the chance of recovery is based on presentation and comorbid conditions to determine medical utility."
White views care rationing such as a shortage of ventilators as a doomsday scenario that he hopes never comes to pass. "There would be some really tough decisions that we would have to make and grapple with. They would be terrible decisions for us to have to make to decide whether we are truly overwhelmed and how we are going to deliver care."
