Liselotte "Lotte" Dyrbye, MD, MHPE, delivered a keynote address at a national summit on promoting well-being and resilience in healthcare workers.
A Mayo Clinic expert says there are more than a dozen ways to promote well-being and limit burnout at healthcare organizations.
Healthcare worker burnout was at epidemic proportions before the coronavirus pandemic, and a Stanford Medicine burnout researcher expects a new national survey will show the pandemic has exacerbated the problem. A study published in October 2018 found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction.
Last week, Liselotte "Lotte" Dyrbye, MD, MHPE, a professor of medicine and medical education at Rochester, Minnesota–based Mayo Clinic, was one of the keynote speakers at the second national Summit on Promoting Well-Being and Resilience in Healthcare Professionals. In her presentation, Dyrbye said there are at least 14 methods to address healthcare worker burnout:
Appointing a chief wellness officer
Securing commitment to tackle burnout from top leadership
Having governing boards hold healthcare organizations responsible for creating a positive work environment
Holding leaders at every level of healthcare organizations accountable for improving the work environment
Creating a workplace culture that supports change management, psychological safety, and peer support
Establishing clear alignment between organizational values and workforce values
Including well-being in decisions, policies, mandates, and resource allocation
Redesigning clinical systems so that they meet the needs of healthcare professionals
Targeting known systems factors that affect the balance between job demands and job resources
Building infrastructure and culture that supports accountability
Improving electronic medical record usability
Having strong relationships between healthcare professionals to increase social support
Providing professional coaching for clinicians
Promoting the ability of healthcare workers to seek help if they are experiencing burnout
After Dyrbye delivered her keynote presentation, she spoke with HealthLeaders in greater detail about some burnout prevention efforts. The following is a lightly edited transcript of that conversation.
HealthLeaders: How do healthcare organization leaders play a role in curbing burnout?
Liselotte "Lotte" Dyrbye: It is really systems factors that are contributing to workplace stress, which leads to burnout. So, healthcare organization leaders need to look at the work demands and the work resources, then get them into a better balance.
Practically, this means that healthcare organization leaders need to do some measurement using validated instruments, so they know what is going on. They need to find out about the levels of burnout and satisfaction. They need to understand the contributing factors for burnout in the workplace. Then leaders need to get that data down to the work units to help identify hotspots for burnout. They need to engage in a dialogue with the "boots on the ground" to identify the drivers of burnout and identify the solutions.
Other important factors that healthcare organization leaders can influence are culture, values, meaning in work, and leadership skills. We need to be thoughtful that the people we put in leadership roles have good leadership skills and seek opportunities to refine their leadership skills. Local leadership makes a difference.
HL: Give an example of how clinical systems can be redesigned to promote clinician well-being.
Dyrbye: One example is having a medical assistant in the exam room with the clinician in the primary care setting. Under this model, the medical assistant goes into the room first, collects the medical history, makes sure the patient's medications are in the medical record, and gets the patient prepared for the visit.
When the clinician comes into the room, the medical assistant summarizes the medical history, the clinician can ask targeted questions, and the medical assistant can enter notes into the medical record as well as prepare any equipment that will be used during the visit such as throat swabs. The clinician and the medical assistant work together collaboratively to meet the needs of the patient. The clinician can focus on the patient, and the medical assistant can focus on clerical tasks.
At the end of the visit, the clinician can sign the medical orders that the medical assistant has put into the medical record, and the clinician can provide some counseling then leave the room. The medical assistant can finish up with patient education, make sure the patient understands the plan of care, then finish up the notes for the clinician to review and sign.
Under this model, the clinician is working at the top of his or her licensure, and the medical assistant is working at the top of his or her licensure. Patients are satisfied. Quality metrics go up. The medical assistant is satisfied. And the physician is more satisfied.
HL: Give examples of where electronic medical record usability needs improvement.
Dyrbye: These systems are incredibly complex. The interface has multiple different colors, font sizes, and there is so much busyness going on. It is hard to figure out where information is, where you need to enter information, and how to get tests done. The whole work process is very difficult.
I am fortunate. I work in one health system that has one electronic medical record. But there are many other healthcare professionals who work in multiple hospitals, and each hospital has its own electronic medical record that is set up differently. There is no standardization.
One concern is when nurses must enter data into different boxes, and they cannot advance to the next field if they leave a box blank. There are some situations where information is not available or not applicable. So, the nurses get stuck, which is incredibly frustrating.
There are innumerable opportunities to improve the usability of electronic medical records.
HL: How does professional coaching boost clinician well-being?
Dyrbye: We did a randomized controlled study where physicians received three-and-a-half hours of professional coaching over a six-month period. That coaching led to improvements in burnout, increased quality of life, and more resiliency.
This is a low-cost, feasible intervention that can be done during the pandemic. Physicians mostly get coached on factors that fall into the professional sphere. Although some physicians got coached on overcoming barriers to physical fitness and those types of issues, most were coached on how to have crucial conversations, how to lean into change at work, and how to make meaningful differences at work.
Coaching is different than mentoring. It is focused on listening, being curious, and not giving advice. The coach asks a series of open-ended questions that get clinicians to clearly identify their goals, help them to understand their options, and determine where there is the will to change.
HL: How can healthcare organizations encourage staff to seek help for burnout?
Dyrbye: Psychological safety is a big issue. Organizations must make seeking help safe. You must change the culture to make seeking help a sign of strength rather than weakness.
Many organizations have various versions of employee assistance programs that keep confidential records—these records are not part of an employee's work file to try to reduce barriers to seeking help.
At Mayo Clinic, we have an Office of Staff Services, which is a place where clinicians can go and talk with a physician who can refer them to an internal psychologist if necessary, to help with burnout or other work-related issues.
What is great about the Office of Staff Services is I can go there for help with my 401(k) or I can go there because I am burned out. There are a variety of reasons why I would go to that office. So, it feels safe to go there.
A new COVID-19 recovery program focuses on long-term symptoms after acute illness with individualized and expedited treatment.
A New York-based medical center has established a clinical program for coronavirus "long haulers"—patients who experience symptoms for weeks or months after the acute phase of their illness.
Since the first case of COVID-19 was diagnosed in the United States, the disease has perplexed clinicians at several turns. For example, during the spring coronavirus patient surge, clinicians placed seriously ill patients on ventilators relatively quickly as they are inclined to do with other patients suffering with acute respiratory distress syndrome (ARDS). However, proning and nasal high flow therapy have emerged as better courses of treatment for many coronavirus patients who develop ARDS.
Gary Rogg, MD, an attending physician in internal medicine and co-director of the Post-COVID-19 Recovery Program at Westchester Medical Center in Valhalla, New York, says coronavirus long haulers can have a range of long-term symptoms.
Cough
Shortness of breath
Constitutional symptoms such as numbness and tingling
Cardiac issues
Deconditioning
Hair loss
Anxiety and depression
Brain fog: "They will understand what you are asking them and they know the answer, but it takes them a while to formulate the answer, which is very different from these people's baseline," he says.
"What became apparent through the pandemic is that COVID-19 is very different from the flu. With influenza, pretty much everyone has fever and body aches for a week or two, then it just resolves. With COVID-19, patients are having ongoing symptoms for week after week," Rogg says.
He says about 10% of Westchester Medical Center's coronavirus patients are long haulers, but the percentage could be higher. "As time goes on, that number could increase, particularly in the younger and healthier group. Those patients recover and have symptoms, but they go to work, go about their lives, and maybe have some denial hoping the symptoms will go away. So as time goes on, we will probably see more long haulers. It could go up to 15% of all coronavirus patients."
Caring for long haulers
Westchester Medical Center launched the Post-COVID-19 Recovery Program after Labor Day.
"During the first COVID-19 patient surge, I was asked to organize the coronavirus response for the medical center. One of the things we developed was a rapid response team, where we had dedicated physicians from each of several specialties. When we had hospitalized patients, they would not go through the standard mechanism for consultation—the physicians would be called directly, which provided expedited specialty care. We modeled the Post-COVID-19 Recovery Program along those lines," Rogg says.
Primary care physicians play a key role in the recovery program, he says. "What we try to do with the program is to personalize and individualize the care of these patients. We have set up a dedicated group of primary care providers who serve as a gateway."
Physicians in several specialties also are participating in the recovery program, including neurology, pulmonology, cardiology, rehabilitative medicine, and infectious disease.
Patient navigators are a unique aspect of the recovery program, Rogg says. "This program is not one-size-fits-all. It is individualized. The patient navigators are a resource and extension of the physician to expedite any issues that arise. The patient navigators schedule patients for appointments in the recovery program and they expedite specialist appointments. They are basically an appointment contact person."
The patient navigators help ensure that care is provided on a timely basis, he says. "We see patients in an expedited manner. For specialty care, we can get patients in to see a clinician within a week or two. If necessary, we can set those appointments faster."
Once a coronavirus patient is enrolled in the recovery program, the first step is an initial evaluation, Rogg says. "We look for other contributing or secondary causes of symptoms, we see what was done on the patients during the acute phase of their illness, then we refer patients for testing and for specialty evaluation. … We do a blood panel, check inflammatory markers, and conduct tests looking for secondary issues."
Some long haulers are evaluated for blood clotting, he says. "Many patients who have an issue with shortness of breath either have emboli and are given CT scans, or they have diffusion abnormalities such as scarring or inflammation in the interstitial space—the air spaces in the lungs. In the latter cases, air cannot get into the lungs adequately. For patients with diffusion abnormalities, we conduct pulmonary function testing."
For long haulers with suspected cardiac issues, echocardiograms are conducted, Rogg says.
In search of a cause
The cause of long hauler symptoms remains a mystery, but Rogg has a theory. "The thought is that COVID-19 is causing persistent changes in a person's immune system—there is an immune system-mediated process driving the long-hauler symptoms."
The course of symptoms also points to the immune system, he says. "A pattern we see with long haulers is waves of symptoms. A patient will wake up and say, 'This is the first day that I'm starting to feel better.' Then a couple of days later or a week later, their symptoms recur. We have seen that in the acute illness, too. The symptoms seem to fluctuate. The only thing that can cause that kind of fluctuation is some kind of dysregulation of the immune system."
The biennial conference, which met virtually this year, is designed to share best practices and evidence-based approaches to curb burnout.
Last week, nearly 400 healthcare professionals participated in a national summit on healthcare worker well-being and resilience.
Research indicates that nearly half of physicians are experiencing burnout symptoms, and a study published in October 2018 found that burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction.
Formed in 2017, the collaborative has launched several initiatives and resources, including resources to support clinician health and resilience during the COVID-19 pandemic, a clinician well-being knowledge hub, publications, and events and webinars.
Dzau reflected on the accomplishments of the action collaborative over the past four years.
"We have convened key players and entities to address burnout. That includes many stakeholder organizations, many commitment statements, and many activities. We have created webinars and convened a summit of CEOs to affirm the importance of clinician well-being and to look for solutions. We have created an art form of expression that is a gallery that has been presented across the country. We have collected data and conducted analysis. We have been active, with 65 member organizations. This is collective action, where we cannot make progress alone."
Pandemic as catalyst
Perry Gee, PhD, RN, nurse scientist at Salt Lake City, Utah-based Intermountain Healthcare, discussed how the health system seized on the coronavirus pandemic as an opportunity to launch a bevy of well-being and resilience programs for healthcare professionals. "We had to react. We had to implement programs that were in development or in pilot phases," he said.
Intermountain launched several programs:
A major campaign for marketing and communications to provide transparent information for caregivers
A compassionate connections program to help healthcare professionals learn to speak and listen about difficult challenges such as changes in patient visitation during the pandemic
A 24/7 call-a-chaplain program for family members, patients, and caregivers
Wellness rounds by health system leaders that include bringing a cart or basket with treats to medical units that provide an opportunity talk with caregivers
Facilitated peer support groups
Checklists such as a going-home checklist and family safety checklist
Respite rooms close to COVID-19 treatment centers that are manned by employee assistance program staff
A crisis response program developed by the EAP to provide a range of services including psychological first aid
Daily virtual mindfulness sessions that are led by experts in behavioral health and the EAP
"The pandemic gave us an opportunity to implement programs that we had been considering, and we are going to continue to circle back and make improvements on those programs. We quickly learned what our caregivers needed, and we reacted to adapt our programs to those needs," Gee said.
Strengthening relationships
Diana McMahon, MSN, RN, director for professional practice at The Ohio State University Wexner Medical Center—James Cancer Hospital in Columbus, Ohio, discussed her organization's approach to relationship-based care.
"Relationship-based care is the conceptual framework and roadmap that we use to stay focused on our mission. Relationship-based care focuses on four caring relationships: care of the patient and the family, care of self, care of colleagues, and care of the community. It provides consistent coherence in a world that is ever changing. What COVID-19 has taught us is that when everything is changing, relationships bring stability. The pandemic has also taught us that being part of a team builds security and decreases stress," she said.
Examples of programs developed to foster relationships include relationship-based resilience. The one-day retreat is designed to introduce staff to the four key relationships of relationship-based care and to learn how to leverage relationships to increase personal and organizational resilience.
With a positive approach to change, healthcare workers and their organizations can emerge from the pandemic stronger and more resilient.
At the individual and organizational levels, posttraumatic growth can be a positive response to the coronavirus pandemic at healthcare organizations, a recent journal article says.
COVID-19 has wreaked havoc on the healthcare sector. At the individual level, healthcare workers have faced a range of adversity from shortages of personal protective equipment to the strain of losing patient lives to the virus. At the organizational level, health systems, hospitals, and physician practices have endured many disruptions, including financial distress and the suspension of elective surgeries during coronavirus patient surges.
Posttraumatic growth features positive psychological change achieved after severe adversity and the establishment of a "new normal." The recent journal article, which was published by the Journal of the American Medical Association, says posttraumatic growth has five spheres.
Development of stronger relationships
Willingness to embrace new possibilities
Improved perception of personal strength
Heightened sense of spirituality
Increased appreciation of life
Although posttraumatic growth is challenging for individuals, who must engage in deliberate reflection and dedication to improvement, the process can be significantly beneficial, the co-authors of the recent journal article wrote.
"Typically, posttraumatic growth develops following a physical or psychological trauma that is disruptive enough to the affected individual's perspectives and values that it stimulates reassessment and rebuilding of psychological and philosophical beliefs and approach to living. Such traumas often force affected individuals to recognize they are not invincible, consider what they do and do not control, and reassess their personal and professional priorities."
Posttraumatic growth can be equally beneficial for organizations, the journal article's co-authors wrote. "When organizations are affected by adversity, they often use crisis management with the goal of restoring the system back to its normal level of functioning. In contrast, organizational posttraumatic growth refers to a process by which organizations are not only restored, but achieve a higher level of functioning as a result of addressing and learning from a traumatic event."
Promoting posttraumatic growth
Healthcare workers and organizations can take five steps to promote posttraumatic growth as a response to the coronavirus pandemic, the journal article and its lead author say.
1. Assessment and learning
Individuals and organizations should assess the impact of the pandemic and determine what can be learned from the experience. At the organizational level, the assessment and learning process should include creation of a team of leaders and frontline healthcare workers to reimagine a new normal.
Posttraumatic growth is a method for individuals and organizations to get through the pandemic and not only bounce back to where they were but also be better and stronger than where they started, the lead author of the journal article told HealthLeaders.
"The process of reimagining a new normal starts with recognizing the loss of the old normal and acknowledging the loss of the old normal. Then you need to set upon finding new ground and the new normal. A major part of the concept of posttraumatic growth is you have lost the ground under your feet—there has been a seismic shift—and you want to move into the new normal," said Kristine Olson, MD, MS, chief wellness officer at Yale New Haven Hospital in New Haven, Connecticut.
2. Role models
Individuals and organizations should seek out role models that have improved because of the pandemic. Role models show that posttraumatic growth is possible, how posttraumatic growth can be achieved, and how individuals and organizations can respond to the pandemic in a way that makes them stronger and more resilient.
For individuals, a good role model is someone who has risen to the challenge, Olson said. "For example, if you were afflicted by COVID-19, you may see somebody who has gone through ECMO and three months of intubation and survived. You can see that this other patient is now joyful and productive. That can help you in your recovery."
For organizations, leaders should look for other organizations that are exemplary of best practices, she said. "You need to look for role models who have tackled the pandemic well. When you are looking for a role model, you are looking for organizations that have been impacted and tackled the pandemic and can be exemplary of how your organization can tackle the pandemic."
3. Creativity
Individuals and organizations should view the pandemic as both a traumatic experience and an opportunity for improvement. A key question to ask is how the pandemic can serve as a driver of change. Creativity is crucial because it can spur new ideas, attitudes, procedures, and structures that can fuel growth.
Healthcare organization leaders should create a workplace climate that supports creativity among groups of individuals, Olson said. "If you can make people feel in control, make sure that their needs are being met, provide a safe environment for cultivating optimism, and reimagine the new normal, then you can do it faster as a group than you can as individuals."
4. Altruism
Individuals and organizations should assess how the pandemic has fostered connections to humanity and the broader society as well as promotion of altruistic solutions. At the organizational level, leaders should reconsider how to show genuine commitment to healthcare workers and reaffirm altruistic values.
To emerge stronger from the pandemic, healthcare organization leaders should be grounded in the mission to provide high-value care to their communities, Olson said. "When we decide to come together to solve problems, we find that we are more creative, and we find new ways to reframe and create the new normal. We find out that we are not alone and are in this together. All of that is easier when we are oriented to our altruistic mission."
5. Loss and grief
In the process of coping with loss and grief, organizations should reassess priorities and seek out reasons for gratitude. Leaders should reflect on whether they are supporting healthcare workers appropriately and look for reasons to be optimistic.
Healthcare organization leaders can play a pivotal role in helping their workers deal with loss and grief, Olson said.
"When I ask our bereavement counselors about this topic when we have a community shaken by loss, they say that leaders need to acknowledge the trauma, the loss, the goals that have been disrupted, and the passing of the old normal. Leaders need to promote self-compassion and compassion for others as well as gratitude for one another. Leaders need to foster optimism."
Particularly for patients who are older and frail, home-based medical care is often a viable alternative to urgent care centers, emergency rooms, and hospitalization.
The coronavirus pandemic has increased demand for home-based medical care, according to Michael Le, MD, chief medical officer at Landmark Health.
During the coronavirus disease 2019 (COVID-19) pandemic, patients have been reluctant to visit healthcare facilities due to concerns over coronavirus infection. In April, a Medical Group Management Association survey found that physician practices had experienced a 60% average decrease in patient volume.
Huntington Beach, California–based Landmark Health specializes in providing home-based medical care such as medical interventions and behavioral healthcare to older patients with multiple chronic conditions. The COVID-19 pandemic has been driving demand for this type of in-home care, says Le.
"There has been a dramatic increase in the interest for our services—about a 33% increase in demand for our type of in-home services since the pandemic began. We think that is only going to grow as the year continues, especially as we get back into the flu season in the fall," he says.
The increased demand for in-home services has boosted Landmark's finances, Le says. "From a financial standpoint, the pandemic has grown revenue. We forecast revenue will increase about 230% for this year."
Landmark focuses on risk-based and value-based contracts, mainly with Medicare Advantage health plans. The organization employs about 450 healthcare professionals such as doctors, nurse practitioners, physician assistants, dietitians, and social workers. Landmark operates in 14 states, including 46 metropolitan service areas.
Focusing on frail seniors
There is untapped potential to provide home-based medical care to homebound seniors, a recent article published in Health Affairs says.
According to estimates in a 2015 JAMA Internal Medicine article, there are about two million homebound seniors in the United States and about five million seniors who can only leave home with assistance or significant difficulty.
The Health Affairs article is based on survey data collected from more than 7,500 community-dwelling, fee-for-service Medicare beneficiaries. The study includes three key data points.
Almost 5% of the Medicare beneficiaries had received home-based medical care during the study period from 2011 to 2017
Among the Medicare beneficiaries who received home-based medical care services, 75% were homebound
Compared to non-homebound Medicare beneficiaries who did not receive home-based medical care, non-homebound beneficiaries who did receive this kind of care had more chronic illnesses, more functional impairment, and higher healthcare utilization
For healthcare providers, there is a golden opportunity to provide home-based medical care to homebound seniors and medically complex non-homebound seniors, the Health Affairs article's co-authors wrote. "The significant unmet needs of this high-need, high-cost population, and the known health and cost benefits of home-based medical care should spur stakeholders to expand the availability of this care."
Frail seniors are good candidates for home-based medical care, says Nancy Guinn, MD, medical director of Healthcare at Home, a division of Albuquerque, New Mexico–based Presbyterian Healthcare Services.
"This population is well served by being seen at home for many reasons. Even traveling to a clinic can be difficult or impossible. Patients with cognitive decline or mobility issues may be especially challenged by a clinic visit. In terms of hospital at home, patients avoid exposure to any potential hospital-based infections and are less likely to fall in a familiar setting. Seeing a patient in the home offers significant insight into their environment," she says.
Landmark's mobile care model
The average age of a Landmark patient is 79, and the average patient has eight chronic conditions, Le says.
"For the frail population, they need someone laying hands on them and looking around at the home environment, especially in this time when family members are afraid of visiting and getting their loved ones sick with the coronavirus. Our patients are even more isolated and lonely than they were before the pandemic, and having someone come to examine them and bring treatment to them helps keep them out of emergency rooms, urgent care centers, or hospitals that are full of COVID-19 patients."
Landmark's mobile geriatric care model has four primary elements, he says.
1. "Complexivist" care features a multidisciplinary team. "Complexivist care includes our doctors, nurse practitioners, physician assistants, psychiatrists, pharmacists, dietitians, and social workers. It is a full care team wrapped around the patient. It takes a village to manage the frailties of these patients," Le says.
Complexivist care is provided 24/7 in the patient's home, and caregivers spend a significant amount of time with patients, he says. "As opposed to a 10- or 15-minute office visit, our initial visits are an hour long and our follow-up visits are 50 minutes long."
2. Urgent care services are provided to patients. "We do not just lay hands on the patient and take vital signs. If we find a health problem, we can make an intervention immediately—we are like a global urgent care or emergency room. We can draw blood and check labs. We can administer medications such as Lasix, IV antibiotics, and steroids to treat and stabilize patients. We can insert catheters, perform suturing, and check X-rays or ultrasound imaging," Le says.
3. Behavioral health services are provided to patients because about 50% of Landmark's patients have behavioral health comorbidities that negatively impact their quality of life and healthcare outcomes. "We have our own behavioral health team to help address behavioral health needs and social determinants of health," he says.
4. Palliative care and advanced care planning are provided to patients because they are statistically approaching their last years of life, Le says.
"We train our providers to have end-of-life conversations with patients. As a former hospitalist, I can say there is no worse place to have those kinds of conversations than in an emergency room or an ICU. There is no better place to have those kinds of conversations than in a patient's living room while they are surrounded by their family. That way, the whole family can have discussions about goals and values."
Geared for the pandemic
Landmark's in-home service model is well-suited to rising to coronavirus pandemic challenges, Le says.
"Whether it is a direct impact from the pandemic or an inability to get out and get medications, we have seen worsening behavioral health severity among patients. Our behavioral health team—our psychiatrists, nurse practitioners, and social workers—has seen about a 180% increase in visits during the pandemic."
Landmark caregivers are serving as a "pre-frontline" during the pandemic, he says.
"We are able to go into homes and treat our patients so they do not have to go into a hospital and be around symptomatic patients who could be spreading the coronavirus. We can alleviate some of the frontline stress in the emergency rooms, so they are not overwhelmed."
Treating frail, elderly patients in their homes limits their exposure to possible infection with coronavirus, Le says.
"Many of our patients have diabetes, heart failure, and cancer, which puts them at higher risk if they contract COVID-19 at a healthcare facility. If they catch coronavirus, these patients will likely have a bad outcome. Our patients have another option to receive care other than just dialing 911 and being transported to an emergency room."
Bright future
Landmark focuses on the sickest and frailest patients now, but healthcare is moving in the direction of the home, he says. "Whether it is for convenience, safety, or good outcomes, more and more healthcare will be shifting toward the home. We believe there is a gap in this area."
As a care delivery method, home-based medical care is likely to follow a similar trajectory as telemedicine, Le says. "Just like telemedicine has surged and will be part of the healthcare landscape for years to come, the shift to more home-based medical care has been accelerated and will continue to grow long after the pandemic."
Guinn is equally bullish on the future of home-based medical care.
"We can't keep assuming that hospital-based care is the best choice for all of the patients that we currently hospitalize. That is not to say patients should receive lesser care—they should receive care that is appropriate for their needs. As our population ages, home-based medical care is going to be more important rather than less important," she says.
Guinn says home-based medical care is an attractive care model for frail seniors and other high-risk patients. "What a better way to get care. You stay home. The doctor comes to you. The care team spends an hour or an hour and half with you. We do flu vaccines in the home. We do Pneumovax in the home and other shots. We even have a podiatry nurse who comes in and does foot care for our diabetic patients. Who wouldn't prefer that as a way of getting care?"
Healthcare at Home model
At Presbyterian Healthcare Services, Healthcare at Home programs offer a range of care in the home from primary care, to urgent care, to Hospital at Home. The health system built its home-based medical services unconventionally, Guinn says.
"We did not follow what most people would call a normal progression. Normally, you would set up a house calls practice, then branch out. We became interested in Hospital at Home when it was being created and thought it was a good idea for us. Then we discovered that we needed broader-based services for our patients than Hospital at Home could provide. Hospital at Home really is hospitalization. We have criteria for admission just like a hospital would have criteria. But often patients do not need that level of care, so we had to broaden what we were doing. That is how we ended up backing our way to house calls," she says.
For other health systems that are considering adoption of home-based medical care services, Guinn says organizations should conduct an in-depth needs assessment first. "Whatever progression you take in launching home-based medical care services, you need to understand what the needs are. You also need to understand the stakeholders, whether they are your patients, your board of directors, your insurer source, or your hospital system. You have got to understand their needs, then construct programs that are appropriate."
More than 1,000 patients are receiving medical services through Presbyterian's Healthcare at Home programs, she says. The Hospital at Home program can serve as many as 14 patients daily. About 700 patients are receiving primary care and urgent care services through Healthcare at Home's Complete Care program. And about 300 people are receiving care at a bricks-and-mortar clinic established for Healthcare at Home patients.
"We created a small clinic for people who would prefer to be seen in a clinic setting even though they qualify medically for the home programs. What we have found is that people drift back and forth between the home and clinic settings depending on their need. If they have an urgent issue, we will see them in the home," Guinn says.
Across Healthcare at Home programs, there are 285 employees.
Patients are highly satisfied with Healthcare at Home programs, she says. In patient satisfaction scores for the second quarter of this year, 100% of Hospital at Home patients reported that they would recommend the service for others, and 95% of Complete Care patients reported that they would recommend the service for others.
Hospital at Home
There are three keys to success in operating a Hospital at Home program, Guinn says.
"First of all, it is a really good funding mechanism. Medicare does not pay for this service, which is a shame because it is valuable. So, contracts must be built with other insurers such as Medicare Advantage health plans," she says.
The second crucial Hospital at Home component is recruiting an appropriate clinical care team, Guinn says. "Hospital at Home requires a rapid response team. You have got to have a team that has the proclivity to move quickly when necessary. For example, many of our Hospital at Home nurses used to work in emergency rooms—they have the sense of the urgency of care."
Hospital at Home physicians must be able to work independently, she says. "People naturally assume that a Hospital at Home provider is a former hospitalist, but we are more likely to hire rural primary care physicians. Those clinicians are isolated enough that they are used to coping with whatever comes through the door. Our Hospital at Home clinicians need to be confident enough and have enough breadth to be able to cope with whatever they find in the field."
The third essential element of a successful Hospital at Home program is "prearrangement," Guinn says. "You need to know where you are going to get your medications and where you are going to get your durable medical equipment. You need to arrange infusions in the home and you need to establish partnerships with companies that move rapidly enough to ensure patient safety."
The Hospital at Home program is not appropriate for all patients who are sick enough to require hospitalization, she says. "Basically, it involves the idea of patient safety. There are many conditions that we can treat in the home, but there are some conditions that are advanced enough that we would prefer the patients go into a tertiary facility."
The program treats patients with nine diagnoses, including congestive heart failure exacerbation, COPD exacerbation, community-acquired pneumonia, DVT and simple pulmonary embolism, complicated cellulitis, and complicated UTI. "For all of those diagnoses, there are markers for distress that are beyond what we feel is safe for the home," Guinn says.
Funding home-based medical care services
At-risk contracts such as those set in Medicare Advantage health plans are the best fit for providing home-based medical care services, she says.
"With home-based medical care, you absolutely have to find a funding source that does not focus on payment for services rather than payment for outcomes and results. You need to have at-risk funding. The goal is always to identify how you can fund these services—acknowledging that the funding is based on value and cost savings by offering appropriate care, not on a fee-for-service model."
Healthcare at Home's Complete Care program has generated significant cost savings, Guinn says. "For the four years between January 2015 and December 2019, Complete Care reduced the cost of care by 38% compared to predicted cost for similar patients."
She says the cost savings from Complete Care are generated on several fronts, including medication management, decreased utilization of emergency department and hospitalization services, and fewer specialist visits.
Hospital at Home also drives cost savings, including avoided postacute care services, Guinn says. "If you don't go to the hospital, then you don't go to a skilled nursing facility. Postacute care costs are really significant for this population, and a hospitalization predisposes toward spend in postacute care costs."
A Health Affairsarticle published in 2012 found that Presbyterian's Hospital at Home program generated cost savings in patient care of 19% compared to similar patients who received care in an inpatient setting.
Photo credit: Illustration by Francesco Ciccolella
In its 2020 best performers data report, MGMA rates physician practices on operations, profitability, productivity, and value.
The Medical Group Management Association (MGMA) has released its 2020 best performers data report on physician practices.
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MGMA evaluated nearly 4,000 medical groups on four metrics: operations, profitability, productivity, and value. More than 1,000 of the medical groups rated highly on at least one of the metrics, earning "better performer" status.
Operations: Less than the median for percentage of total accounts receivable over 120 days, less than the median for days adjusted fee-for-service charges in accounts receivable, and greater than the median for adjusted fee-for-service collection percent
Profitability: Less than the median for total operating cost per work relative value unit (RVU), less than the median for total cost per total RVU, less than the median for total operating cost as a percent of total medical revenue, and greater than the median for total medical revenue after operating cost per physician
Productivity: Greater than the median for total medical revenue per physician, greater than the median for total medical revenue per staff, greater than the median for work RVUs per staff, and greater than the median for provider work RVUs for at least 66% of providers
Value: Physician practices report quality metrics and practices qualify for better performer status in at least one other category
The MGMA report, which is based on 2019 data, includes several key data points and benchmarks:
Compared to lower performing practices, better performer practices reported nearly 9% higher medical total operating cost per full-time-equivalent (FTE) physician. Better performer practices also reported 19% higher median total physician compensation and benefits. These findings indicate better performers benefit from investments in staff, facilities, and operations, the report says.
Better performers have higher staff levels and slightly higher expenses. Better performers had 20% more business office staff and 18% more nursing staff than the median for all medical groups. Business office staff help drive accounts receivable collections. Additional nursing staff help clinicians to see more patients, which increases practice productivity. For example, better performers had 20% more patient visits and 10% greater total RVU production.
Based on the percentage difference between better performers and all practices, better performers have higher total compensation, ranging from 8.36% for general surgery to 27.76% for dermatology.
Based on the percentage difference between better performers and all practices, better performers have higher productivity as measured by work RVUs, ranging from 15.56% for family medicine to 29.63% for dermatology.
Better performers collect at least 6% more accounts receivable in the first 30 days.
Better performers earn at least 40% more in total medical revenue after operating cost compared to all reporting practices.
Interpreting the data
The ability to see more patients helps drive higher compensation at better performer physician practices, Andy Swanson, MPA, vice president of industry insights at Englewood, Colorado-based MGMA, told HealthLeaders. "With many medical groups having pay tied to production, more patients seen is going to net out on dollars spent for clinicians seeing patients."
Efficiency is pivotal in maximizing work RVUs, he says.
"The first step is an in-depth, minute-by-minute analysis of what a patient visit looks like, so you can identify waste or time that can be cut. Once you have done that in-depth analysis, then you get into the tools to enable a patient visit, which inevitably comes down to your electronic health record. Whoever is taking notes on a patient—whether it is a scribe, nurse, or doctor—you need to know whether that process for entering information on the patient's chart and for billing is going as smooth as it can go."
To maximize collection of accounts receivable, physician practices need to understand the payer profile of patients, Swanson says.
"You must understand not just what the patient is coming in for, but also what the patient's payment options are going to be. Do they have a government payer? Do they have a commercial payer? Or are they a self-pay patient? Once you understand who the payer is, you need to understand the financial obligations of the patient before they walk through the door, so that things like deductibles and co-pays are collected."
Different payer profiles require different accounts receivable approaches, he says.
"For government pay and commercial pay, you need to know the terms of payments on the patient's part vs. the carrier's part. If you have a self-pay patient, you need to come up with a rigorous payment plan or methodology that the clinic follows every time a self-pay patient comes in. That may look like $25 for a typical visit, then a payment plan for the next 30 days after care to get to full payment."
Financial benchmarks are important and an indicator of success, but medical groups seeking to improve their performance need to look deeper at factors related to operations, profitability, and productivity, Swanson says.
"If medical groups want to take action on financial outcomes, they are going to need to look at a myriad of key performance indicators that drive the financial measures. Spending time on those key performance indicators is where medical groups find success in moving the financial-benchmarks needle."
Research shows that clinicians can make a compassionate connection with patients in less than a minute.
The co-author of a book on compassion in healthcare says that clinicians who feel they do not have the time to make a compassionate connection with patients need a mindset change.
Many studies have shown that compassionate care generates positive outcomes. One study found that shifting from a low- to a high-scoring category of physician empathy decreased the odds of metabolic complications among diabetic patients by 41%. Another study found that homeless patients assigned to standard medical care plus compassionate contact from trained volunteers had 33% fewer emergency department visits and were twice as likely to rate their hospital experience highly.
Despite the widespread evidence on the benefits of clinicians showing compassion to their patients, a study found that 56% of physicians did not feel they had the time to be compassionate.
"That study begs the question—how long does it take to be compassionate?" says Stephen Trzeciak, chairman and chief of the Department of Medicine at Cooper University Health Care in Camden, New Jersey, and chairman of the Department of Medicine at Cooper Medical School of Rowan University in Camden. Trzeciak is co-author of the bookCompassionomics: The Revolutionary Scientific Evidence That Caring Makes a Difference.
It takes very little time for clinicians to be compassionate with patients, he says. "We devote a whole chapter in Compassionomics to the issue of time. We found the scientific evidence that timed being compassionate. There have been several studies in the literature, and what they have all found is that it takes less than a minute to make a meaningful, compassionate connection with a patient."
To illustrate that it takes little time for clinicians to be compassionate, Trzeciak cited a Johns Hopkins study involving survivors of breast cancer. The breast cancer patients were exposed to two different interactions with oncologists. One interaction was purely informational, and the experimental arm of the study had an interaction that was both informational and compassionate.
"What they found was that the experimental arm compared to the standard informational arm had a statistically significant reduction in anxiety among the cancer survivors. In the experimental arm, oncologists provided the same consultation with just a little bit of extra communication before and after the purely informational interaction. There were statements such as, 'We are here together. You are not going to go through this alone. I am here with you,'" he says.
In the Johns Hopkins study, the amount of time devoted to being compassionate was negligible, Trzeciak says. "Just 40 seconds of extra communication with those types of statements generated a statistically significant reduction in the anxiety of these cancer patients using a validated scale to measure anxiety. Even what some people might consider to be small doses of compassion make not only meaningful differences for patients but also measurable differences for patients."
For clinicians, having time to be compassionate is a matter of perception, he says. "It all goes to mindset. When clinicians say, 'I don't have enough time,' the data shows that being compassionate does not take you any longer. Mindset is the most important factor. It is just not true that being compassionate takes more time—we just think that it does. That is what the evidence shows."
Organizational benefits
Employing clinicians who show compassion to their patients has benefits for healthcare organizations, Trzeciak says. "More compassionate care is associated with higher quality care, fewer medical errors, and higher patient satisfaction."
When clinicians show compassion to their patients, it improves patient experience, he says.
"When you look at surveys of patients, they talk about the relational aspects of healthcare. They do not talk about the technical aspects of healthcare. Some clinicians find that surprising; but, in general, most patients believe that their doctors and nurses know what they are doing. They just presume technical proficiency. What they want is the caring part of healthcare."
Compassionate care has a powerful impact on patient experience and the financial gains that a positive patient experience can generate, Trzeciak says.
"There is compelling evidence that, on average, healthcare organizations that do better with patient experience do better in terms of financial performance. Compassion matters for overall patient experience, and patient experience drives bottom line."
Healing the healers
Compassionate care also helps address clinician burnout, he says. "There is evidence that compassion for others can be a powerful therapy for the giver. The evidence in the literature shows that compassion is beneficial for the giver in that compassion for others promotes resilience and resistance to burnout."
Compassionate connections and strengthening relationships with compassion help prevent clinician burnout, Trzeciak says.
"We all know about the burnout crisis in healthcare and the costs of burnout in terms of employee turnover. The preponderance of evidence in the scientific literatures shows that compassionate connections with others and the quality of your relationships—whether it is the quality of relationships with your patients or relationships with colleagues—are the key to resilience and resistance to burnout."
Given the benefits of compassion for patients, healthcare organizations, and clinicians, it should be viewed as an integral part of medicine, he says. "What we found is that compassion matters, not just in sentimental and emotional ways but also in evidence-based ways. We consider compassion to be part of evidence-based medicine."
The United States has reported more coronavirus deaths than any other country.
U.S. coronavirus deaths are likely understated, and the United States has relatively high COVID-19 mortality compared to 18 similar countries, a pair of recent studies published by the Journal of the American Medical Association shows.
The United States has led the world in reported coronavirus deaths. As of Oct. 15, more than 221,000 Americans had died of COVID-19, according to worldometer. The country with the next highest death count was Brazil at more than 150,000.
"Few people will forget the Great Pandemic of 2020, where and how they lived, how it substantially changed their lives, and for many, the profound human toll it has taken," an editorial accompanying the JAMA studies says.
Accounting for coronavirus deaths
One of the JAMA studies focuses on U.S. excess deaths—the difference between observed and expected deaths—from March to July 2020. The study includes several key data points.
From March 1 to Aug. 1, there was a 20% increase over expected deaths, with 1,336,561 deaths reported and 1,111,031 deaths expected.
Of the 225,530 excess deaths, only 67% were attributed to COVID-19.
The Top 10 states for highest per capita excess death rates were New York, New Jersey, Massachusetts, Louisiana, Arizona, Mississippi, Maryland, Delaware, Rhode Island, and Michigan.
There were statistically significant increases in two other causes of death—heart disease and Alzheimer disease/dementia. The increase in heart disease deaths coincided with the spring surge of coronavirus deaths. The increase in Alzheimer disease/dementia deaths coincided with the spring and summer surges of coronavirus deaths.
The number of excess deaths attributed to the coronavirus is likely understated, the study's co-authors wrote. "Although total U.S. death counts are remarkably consistent from year to year, U.S. deaths increased by 20% during March-July 2020. COVID-19 was a documented cause of only 67% of these excess deaths."
Two factors may account for the understated number of excess deaths tied to the coronavirus, they wrote.
"U.S. deaths attributed to some noninfectious causes increased during COVID-19 surges. Excess deaths attributed to causes other than COVID-19 could reflect deaths from unrecognized or undocumented infection with severe acute respiratory syndrome coronavirus 2 or deaths among uninfected patients resulting from disruptions produced by the pandemic."
Comparative data
In terms of COVID-19 deaths, the United States fares poorly in a comparison with 18 other Organisation for Economic Co-operation and Development countries, the other JAMA study found.
The study compares U.S. coronavirus mortality to 18 other OECD countries with a population of at least 5 million and a per capita gross domestic product of at least $25,000. The countries were categorized by COVID-19 per capita mortality as low, moderate, or high.
The research includes several key data points.
On Sept. 19, 2020, the United States reported COVID-19 per capita mortality at 60.3 per 100,000 of population, which was higher than countries with low or moderate coronavirus mortality but comparable to other high-mortality countries.
Australia was categorized as a low-mortality country, with 3.3 COVID-19 deaths per 100,000. If the United States had been able to match Australia's per capita mortality, 94% of American deaths could have been avoided.
Canada was categorized as a moderate-mortality country, with 24.6 COVID-19 deaths per 100,000. If the United States had been able to match Canada's per capita mortality, 59% of American deaths could have been avoided.
The United States had a lower coronavirus mortality rate than high-mortality countries during the early spring, but the U.S. coronavirus mortality rate has been higher than all other high-mortality countries since May 10.
The U.S. per capita coronavirus mortality rate has been relatively high compared to OECD peers, the study's coauthors wrote. "After the first peak in early spring, U.S. death rates from COVID-19 and from all causes remained higher than even countries with high COVID-19 mortality. This may have been a result of several factors, including weak public health infrastructure and a decentralized, inconsistent U.S. response to the pandemic."
Mobile stroke programs provide speedy evaluation and treatment of patients when every minute counts.
A Cincinnati-based health system with a history of innovation in stroke care has launched a mobile stroke unit.
Nearly 800,000 people have strokes annually, according to the American Heart Association. A rapid response to stroke is crucial for positive outcomes. If a stroke is caused by a clot lodging in a blood vessel supplying the brain, most patients need the clot-busting drug tissue plasminogen activator (tPA) within three hours.
UC Health crafted the FAST method for detecting stroke and played a leading role in the development of tPA in the late 1980s. FAST stands for Face drooping, Arm weakness, Speech difficulty, and Time to call 911.
In August, UC Health launched a mobile stroke unit that responds to a patient's home when acute stroke is suspected. "The overall goal of the Mobile Stroke Unit is to bring a lot of what we can do in the emergency department for acute stroke patients to the curbside of patients, so we can diagnose and potentially treat in a very timely manner," says Christopher Richards, MD, MS, medical director of UC Health's Mobile Stroke Unit program.
The Mobile Stroke Unit deploys out of the firehouse at Springfield Township, Ohio, which is centrally located in UC Health's service area. The service is available seven days a week from 7 a.m. to 7 p.m.
The startup costs for the program—including the ambulance, equipment, supplies, and training—were $1 million. The annual operating costs, which consist mainly of personnel and supplies, are about $500,000.
How the Mobile Stroke Unit works
The Mobile Stroke Unit ambulance is manned by a paramedic, nurse, CT scan technician, and EMT/driver. A key element of the personnel is a stroke neurologist who participates in Mobile Stroke Unit calls virtually, Richards says.
"The stroke neurologist who joins the team virtually is a critical part of the operation. The decisions about clot-busting medications, reversing bleeding strokes, and blood pressure management are beyond the scope of a critical care nurse or a paramedic. So, the consultation we have from the UC Health stroke team is a critical part of the Mobile Stroke Unit," he says.
The nurse and paramedic facilitate the stroke neurologist's examination with an iPad, so the physician can not only interact with the patient but also watch as the patient is screened for symptoms such as poor coordination and speech difficulty. "The evaluation is the same as a patient would receive in an emergency room," Richards says.
A patient receives a CT scan in UC Health's Mobile Stroke Unit. Photo Credit: UC Health
Having CT scan capability in the ambulance plays an essential role, he says. "When the patient is brought to the Mobile Stroke Unit, one of the first things the team can do is give a CT scan. That is a huge differentiator in stroke care to determine whether there is a bleeding stroke, which has a vastly different treatment pathway, or a more common ischemic stroke with blockage of an artery."
The Mobile Stroke Unit works in concert with local emergency medical services ambulances, Richards says.
"What typically happens is that a patient, loved one, or bystander will call 911. They communicate with a dispatcher about what is happening. If the dispatcher suspects stroke, they will dispatch a local EMS ambulance and may dispatch the Mobile Stroke Unit at the same time. Oftentimes, a local EMS paramedic will be on the scene first and conduct screening and evaluations, then the Mobile Stroke Unit arrives."
The local EMS crew takes charge of the scene, he says.
"We help in whatever way we can with patients. To foster that relationship before we launched, we did significant outreach to our EMS partners in the areas where we would be responding to make sure they understood what we could do, what we could not do, how we could help, and how we would interact on scene."
For patients suffering ischemic stroke, the Mobile Stroke Unit plays a pivotal role in speeding up administration of tPA to dissolve blood clots, Richards says.
"Without the Mobile Stroke Unit, the best scenario is paramedics get on scene quickly, they do some screening and recognize a stroke is occurring, then there is transport to the hospital, an intake process at the hospital, and a CT scan. By being able to bring a CT scanner, tPA, and a stroke team physician virtually to the curbside, the Mobile Stroke Unit cuts out a lot of time."
Other mobile stroke programs have reported that they can speed up administration of tPA by 30 to 45 minutes. "That time could be the difference in levels of disability and in receiving tPA or not," he says.
The Mobile Stroke Unit is at the curbside for as long as an hour, and most patients are transported to local hospitals.
Keys to success
There are five elements to operating a successful mobile stroke program, Richards says.
1. Accounting for the entire episode of care: The treatment of stroke is a "chain of survival" and the chain is only as strong as its weakest link, he says. "The chain stretches from laypersons at home recognizing that a loved one may be having stroke symptoms, to the 911 dispatcher, to paramedics, then all the way down the line to the hospital. The Mobile Stroke Unit is a way to compress that chain of survival."
2. Laying a foundation: The community must be involved in establishing a mobile stroke program, Richards says. "When we set up our program, one consideration was how the Mobile Stroke Unit was going to be received by the public, who is used to their local EMS ambulance showing up and knowing they are going to be on the scene for a short period of time. It is a change of mindset for the public. Our Mobile Stroke Unit is going to be on the scene for an extended period."
3. Engaging EMS partners: Establishing a working relationship with local EMS crews is crucial, he says. "We operate in a system where we ask to be invited to participate with our local EMS agencies."
4. Creating hospital partnerships: Once patients have been evaluated and treated as needed, the UC Health Mobile Stroke Unit sends patients to the closest and most appropriate hospital, regardless of whether the hospital is part of the health system. The logistics of sharing information is pivotal, Richards says.
"When we do a CT scan in the back of the Mobile Stroke Unit, our radiologists at UC Health read those images, but that read and those images have to be accessible to a receiving hospital if it is not a UC Health facility. So, we have worked through the logistics of the interoperability of systems, which has been a critical component of our program."
The Mobile Stroke Unit program also has established protocols for communication between the virtual stroke neurologist and the treatment teams at local hospitals, he says. "That has allowed us to do a couple of things. First, while we most commonly transport patients to an emergency department, we can go directly to an interventional suite if the patient has the type of clot that neuro-interventionists can take out. We also can go directly to a neurological intensive care unit."
5. Stocking supplies: It is essential for a mobile stroke program to have medical supplies to meet the needs of patients with suspected stroke, Richards says. "We have worked closely with our pharmacy colleagues to think about which medications we should have onboard."
ECMO life support can be used when coronavirus patients with acute respiratory distress syndrome respond poorly to mechanical ventilation.
Seriously ill coronavirus patients placed on extracorporeal membrane oxygenation life support have a similar mortality rate as other patients placed on ECMO with acute respiratory distress syndrome (ARDS), a recent research article says.
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.
The co-authors of the recent research article wrote that the study provides "provisional support" for using ECMO to treat coronavirus patients with acute hypoxemic respiratory failure. "In ECMO-supported patients with COVID-19 and characterized as having ARDS, estimated in-hospital mortality 90 days after ECMO initiation was 38.0%, consistent with previous mortality rates in non-COVID-19 ECMO-supported patients with ARDS and acute respiratory failure."
The recent journal article, which was published by The Lancet, features data collected from more than 1,000 ECMO patients at more than 200 hospitals. The study includes two key data points.
COVID-19 patients with ARDS who received respiratory (venovenous) ECMO had a 38.0% estimated cumulative incidence of in-hospital mortality 90 days after ECMO began.
COVID-19 patients with ARDS who received respiratory ECMO had a mortality rate similar to the mortality rate found in the largest randomized controlled trial of ECMO for ARDS patients without coronavirus—the ECMO to Rescue Lung Injury in Severe ARDS (EOLIA) trial. In the EOLIA trial, 60-day mortality for ECMO patients with ARDS was 35%.
Interpreting the data
The lead author of the study told HealthLeaders that the research is significant because it provides a generalizable estimate of mortality for ECMO-supported patients with COVID-19, and the estimate is similar to the reported mortality in other major studies of ECMO support for ARDS patients.
"If your center is experienced in providing ECMO support to patients with ARDS you might expect similar results when providing ECMO support to patients with COVID-19-related ARDS," said Ryan Barbaro, MD, MS, an assistant professor at University of Michigan in Ann Arbor, Michigan.
Organ injury is a key factor for survival of coronavirus patients with ARDS who receive ECMO, he said.
"We found that patients had a higher risk of dying if they had worse lung disease, required circulatory support, had kidney injury, or experienced a cardiac arrest. Our study did not answer when is the best time to initiate ECMO support for patients with COVID-19. However, it does suggest that patients who initiated ECMO support with less organ injury had less risk of dying."
Barbaro speculated that ECMO can be an effective treatment for coronavirus patients with ARDS because the technology avoids lung damage associated with mechanical ventilation and effectively oxygenates a patient's blood.
"The World Health Organization recommends doctors consider ECMO support in patients who have failed lung protective ventilation. In theory, ECMO benefits patients because it avoids the accumulation of injury caused by high ventilator pressures or caused by the inability to provide enough oxygen to the patient. In these cases, ECMO support can do the work of the lung outside of the body—this is analogous to how dialysis can do the work of the kidney outside of the body."