Methods for promoting a strong physician-patient relationship during telehealth visits include orienting and engaging the patient.
The dramatic growth of telemedicine during the coronavirus disease 2019 (COVID-19) pandemic is having a significant impact on the physician-patient relationship.
In March, when the pandemic took hold in the United States, telehealth visits increased 50%, according to Frost and Sullivan. With in-person medical visits associated with the risk of coronavirus infection, virtual visits emerged as a safe and effective way for patients to meet with their doctors in many circumstances.
"Whether telemedicine is a good or bad thing for the physician-patient relationship is largely dependent on the individual level of comfort of the patient and their physician," says Joy L. Lee, PhD, a research scientist at Regenstrief Institute and an assistant professor at Indiana University School of Medicine in Indianapolis.
During the pandemic, Lee says there are four primary ways to foster a positive impact on the physician-patient relationship while conducting a virtual visit.
1. Preparing the patient: Physicians should set expectations when starting a virtual visit with a patient, she says. When holding a patient's first virtual visit, the physician should say, "This is going to look different than our usual visits." Physicians also need to help patients realize that they are still getting healthcare during a virtual visit—they are still getting what they came for.
2. Engaging the patient: "It is important to prime patients with questions such as, 'What are some of the things you want to talk about today? What are your primary healthcare concerns?' Patients need to know that even though they are not in a clinic, their questions will still get answered," Lee says.
3. Organizational guidelines: "Institutions can help clinicians establish good relationships with patients as well. Physicians are feeling overwhelmed with a lot of things as they adjust their practices to the pandemic. So, it helps for hospitals and clinics to set best practices and guidelines for telehealth visits. For example, if you do not have a medical assistant who is doing the virtual rooming, institutions can provide guidance for physicians about questions they can ask to orient the patient," she says.
4. Acknowledge the pandemic's impact: "Physicians should make room to address COVID-19 even if a virtual visit is routine and has nothing to do with the coronavirus. Providers should ask a question or two such as, 'How are you doing now? How are you dealing with COVID-19? What does this pandemic mean for you?' It is helpful to acknowledge the pandemic because we are doing virtual visits in part due to the coronavirus. Providers should not skirt the issue," Lee says.
A more general best practice for physicians conducting virtual visits is to deliver the visit in a quiet and secure space, she says.
"Physicians should be in a quiet place because they are talking about personal health information. Physicians should make sure the patient is not hearing a lot of noise in the background, so they know the physician is in a safe environment. Physicians should not be interrupted during virtual visits—the patient should feel they have the physician's attention."
Another general guideline is to anticipate technical difficulties, Lee says. "Physicians should make sure they have the bandwidth for a video visit. They should have backups in place in case something goes wrong such as having a phone number for the patient to call if the video visit crashes."
Maintaining and building relationships through telemedicine
If a patient already had a great relationship with a provider before the pandemic, then the switch to video or phone calls will be relatively easy because there is already a maintained relationship, Lee says.
Establishing a good relationship through telemedicine is more difficult with new patients and patients who have had infrequent visits with a physician. For those patients, it takes time and effort to foster a strong relationship with patients through telehealth visits, she says.
"The practice needs to be proactive in communicating with patients. They can provide numbers to call, or let patients know that secure messaging is always available. Even for patients who have not seen their doctor in three years, they can be told proactively that they can schedule a visit if something comes up. Practices can let patients know how to schedule a virtual visit and let them know what a virtual visit will look like, so they know how to prepare for it."
Phone calls are an effective way to conduct this outreach, Lee says.
Business impact
Reimbursement is the main area where the shift to virtual visits is having a business impact on physicians, she says.
"The amount of reimbursement and the types of services that can be reimbursed have changed during the COVID-19 crisis. Due to great lobbying by physician societies and other organizations, the Centers for Medicare & Medicaid Services has been flexible and reacted quickly to the pandemic. Now, phone visits can be reimbursed at the same rate as an in-person visit, and video visits can be reimbursed as well."
Reimbursement has changed in the short-term during the pandemic, and there will likely be lasting changes, Lee says. "Many of these changes are probably here to stay. We are seeing that the demand for telehealth is strong."
Recognizing telemedicine limits
With telehealth, it is important to remember the patients for whom virtual visits do not work, particularly video visits, she says.
"There are a lot of people in rural or low-income communities without stable Internet access. So, it is important for healthcare organizations to figure out how to reach those patients. It can be creating safe environments for face-to-face visits, or telephone calls, or giving patients resources so video visits are available for them."
The coronavirus is taking a heavy toll on patients and their caregivers.
This week, VITAS Healthcare is offering free grief counseling for healthcare workers and others who have experienced tragedy during the coronavirus pandemic.
The coronavirus disease 2019 (COVID-19) pandemic has unleashed a wave of human suffering around the world, with the United States posting the highest number of infections and deaths. As of May 26, 5.5 million cases had been confirmed worldwide, with more than 346,000 deaths, according to Johns Hopkins University & Medicine. In the United States, there were more than 1.6 million confirmed cases, with more than 98,000 deaths.
Starting today through May 29, the VITAS Grief Helpline (866-800-4707) will be available from 4 to 10 p.m. Eastern time. Frontline healthcare workers should self-identify for specialized support services.
Three factors have heightened the level of grief healthcare workers experience at acute care hospitals during the COVID-19 pandemic, says Joseph Shega, MD, senior vice president and chief medical officer at VITAS.
1. Relentless stream of sickness and death: "Healthcare workers have been thrust very suddenly into the experiences of caring for patients who are dying from an atypical cause. In many cases, COVID-19 patients are not elderly and certainly were not terminally ill or seriously injured. Additionally, these frontline workers are now often put in a position of helping patients die without the presence of family or friends. They have also seen a significant number of deaths in their own ranks," Shega says.
2. Dearth of training: "While many acute caregivers have received the necessary training to provide end-of-life care, COVID-19 has created a very different situation for most healthcare workers. Even bereavement training could not properly prepare many healthcare professionals for this pandemic. It is also possible that they are feeling overwhelmed—perhaps even guilty or ashamed—at their inability to treat this disease and save their patients," he says.
3. Unexpected challenges: "The extreme number of deaths they have had to witness—plus the uncertainty of their own safety and well-being—make this situation vastly different than their day-to-day experiences before the pandemic," Shega says.
Tailored grief counseling
VITAS, which provides end-of-life care to over 19,000 terminally ill patients daily, is providing several specialized grief counseling services to frontline healthcare workers, he says.
A safe resource staffed by professionals who can listen, assess, and help healthcare workers share their experiences among like-minded mourners.
Guidance from grief specialists who can help healthcare workers identify and explore self-help strategies and coping techniques to support their grieving and healing process.
Information that helps healthcare workers recognize emotional and physical symptoms related to grief, identify their own grief triggers, and pursue self-help techniques to cope with grief and loss.
Reassurance that the care workers provide is important, compassionate, and essential, even if not all of their patients survive and even if they feel lost in a healthcare environment that is changing around them.
Continuing support
Depending on the scale of grief counseling demand this week, VITAS may continue to operate the organization's grief helpline, Shega says.
Vitas also offers a wide range of bereavement services for those who are grieving a loss of a loved one, including specialty support groups and memorial events for those with unique grieving needs such as spousal loss. "Based on the need for healthcare-specific support groups, we will consider adding an ongoing group to our class schedule," he says.
Diseases that are high priority for diagnostic improvement include relatively rare conditions that have high misdiagnosis rates such as spinal abscess.
New research estimates diagnostic error and misdiagnosis-related harm rates for 15 of the top diseases in the United States.
In a landmark 2015 report, "Improving Diagnosis in Healthcare," the National Academy of Medicine found that most Americans are likely to experience at least one diagnostic error, with some errors having "devastating consequences." The co-authors of the new research focus on the "Big Three" U.S. diseases: vascular events, infection, and cancer. They previously identified that the five most frequent diseases in each "Big Three" category account for nearly half of all serious harms from diagnostic errors.
"Diagnostic improvement initiatives should focus on dangerous conditions with higher diagnostic error and misdiagnosis-related harm rates," the researchers wrote in their new study. The research features data from more than 91,000 patients published in 28 studies.
The Top 5 vascular events are stroke, myocardial infarction, venous thromboembolism, aortic aneurysm and dissection, and arterial thromboembolism. The Top 5 infections are sepsis, meningitis and encephalitis, spinal abscess, pneumonia, and endocarditis. The Top 5 cancers are lung cancer, breast cancer, colorectal cancer, prostate cancer, and melanoma.
The new research, which was published this month in the journal Diagnosis, generated several key data points:
False negative diagnosis rates for the 15 diseases ranged from 2.2% for myocardial infarction to 62.1% for spinal abscess. The median false negative diagnosis rate was 13.6%.
Serious misdiagnosis-related harm rates per incident disease case ranged from 1.2% for myocardial infarction to 35.6% for spinal abscess. The median rate was 5.5%.
One of 85 myocardial infarction patients experience death or permanent disability as a result of misdiagnosis.
About one of 20 patients with any Top 5 "Big Three" disease experience death or permanent disability as a result of misdiagnosis.
About one-third of spinal abscess patients experience death or permanent disability as a result of misdiagnosis.
Diseases that have historically gotten the most attention to diagnosis such as research funding and clinical quality improvement have the lowest harm rates, the Diagnosis researchers wrote.
"Myocardial infarction is the prototype and the only acute illness approaching the target 'standard' of <1% harmed often cited in the emergency department. This is, of course, after a half century of focused efforts to automate electrocardiogram interpretation, develop and refine biomarkers (e.g. troponin), and create routine diagnostic protocols for chest pain or suspected acute coronary syndromes."
Putting misdiagnosis in perspective
There are several reasons why some diseases have relatively higher diagnostic error rates and misdiagnosis-related harm rates, the lead author of the new research told HealthLeaders.
"In some cases, it is because the disease is rarer, so providers have less training and less experience to draw from. In other cases, the disease is simply harder to diagnose because our tests for it are less sensitive, or we don't have access to the tests or consultants we need. But, at a system level, the real problem is that we haven't invested in fixing these problems in a sustained and robust way. When we have—for example heart attack—we've done pretty well," said David Newman-Toker, MD, PhD, director of the Armstrong Institute Center for Diagnostic Excellence at Johns Hopkins and board president of the Society to Improve Diagnosis in Medicine.
The new research indicates which diseases should be targeted for diagnostic improvement initiatives, he said.
"We should focus on diseases where we have (1) the most room to improve, (2) the clearest path to improvement, and (3) the most people who could be helped. That probably includes some of the rarer diseases with really high rates of error such as spinal abscess and aortic dissection, but also some of the more common, dangerous diseases with intermediate rates of error such as stroke, sepsis, and lung cancer."
Like other efforts to create behavior change that has a positive impact on patient care, Newman-Toker said diagnostic improvement initiatives need to rise to two challenges:
Technical barriers that make diseases difficult to diagnose
Adaptive barriers rooted in people resisting change
To overcome technical barriers blocking improved diagnosis, he said the healthcare community needs to have disease- and problem-specific multifaceted solutions based on the "4T" principles. Teamwork that improves engagement of patients, nurses, and allied health professionals. Training to improve diagnostic ingenuity. Technology such as tests and telemedicine to improve diagnosis at the point of care. Tuning that promotes feedback for performance improvement.
To overcome the adaptive barrier, Newman-Toker said there should be adoption of change management principles such as John Kotter's eight-step model: creating urgency, forming a powerful coalition, developing a vision for change, communicating the vision, removing obstacles, generating short-term wins, building on change, and anchoring change in culture.
Louis Brusco's first challenge in his new CMO role was the most daunting of his career.
The new chief medical officer of two New Jersey hospitals says the coronavirus pandemic has left an indelible mark on the practice of medicine.
Louis E. Brusco Jr., MD, was appointed as CMO of Hackensack Meridian Health Raritan Bay Medical Center Old Bridge and Perth Amboy early this year. Previously, he had served as CMO at Atlantic Health System's Morristown Medical Center in Morristown, New Jersey.
Prior to working at Morristown Medical Center, Brusco served in several physician leadership positions at Mount Sinai St. Luke's and Mount Sinai Roosevelt hospitals in New York. He earned his medical degree from Columbia University, and completed his residency in anesthesiology and fellowship in critical care medicine at Columbia Presbyterian Medical Center.
Brusco shared the lessons he has learned from the coronavirus pandemic with HealthLeaders as a new CMO. The following is a lightly edited transcript of that conversation.
HealthLeaders: What is the essential element of clinical care leadership during an epic challenge such as this pandemic?
Brusco: As the chief medical officer, I was tasked with leading the clinical response and the clinical care for a disease that no one had heard of six months before. This disease acted differently than anything else we had seen, and it required people to be nimble and up to date.
The biggest challenge I found was trying to keep up to date with what was being published. Much of the information came in a nontraditional fashion. A lot of the good information to be shared came from podcasts. I put many podcasts on my phone so that I could listen to them driving back and forth to work. That's where we learned not to put patients on ventilators as quickly as we would in the past. That was a big change.
The people on the frontlines were too busy to gather information, so I felt that was my responsibility—to be the clinical leader because the physicians on the frontlines did not have the time to read. Then, I had to present information to the physicians in a way that was not traditional because usually you make a scientific argument. But a lot of the information was not scientific—someone would report that they tried a therapy on 20 patients, and it worked. We didn't have randomized, double-blind trials.
HL: What are the primary lessons learned from Meridian Health's response to the pandemic?
Brusco: Flexibility and breaking down barriers were key. We had to stop thinking of people in a rigid way. So, an anesthesiologist could work as an intensivist.
The emergency rooms were relatively quiet except for the COVID patients coming in. We took emergency medicine nurses, physician assistants, and nurse practitioners and had them take care of patients on the inpatient floors. It took us a while to break down the barriers—the emergency medicine staff did not have access to the computers on the floors. It took a day or two to figure out how to train them to do things that they normally did not have to do.
We learned that flexibility was crucial. People can learn fast when they have the base knowledge. We had people doing things that they had never done before. We used tiered models—you might have four nurses working under an ICU nurse and they had never worked in an ICU before. Then you had an ICU nurse who could take care of eight patients instead of two.
HL: How did you engage staff members to work in new roles?
Brusco: Thankfully, we quickly hit upon the realization that you can't assign people to work in new roles—you have to get volunteers. We knew we were going to have people reassigned; and the question was, where will each individual feel comfortable being reassigned?
For example, I have a physician assistant who works with the orthopedic surgeons. Since she had got out of training, she had never done anything other than work with orthopedic patients. I called her up and said, "Let's figure out what you can do to help us."
It was very clear that she could not be reassigned as a physician assistant working with COVID patients on the floor in the way that an emergency room physician assistant would be reassigned. Then I asked her, "You have worked in the operating room during spine surgery. How comfortable are you with flipping patients onto their stomachs?" She said she did it all the time. So, we had developed proning teams and she joined one of them. We used her skill set in a way that she was comfortable.
Another example is family practice physicians. Our network wanted us to use them—their offices were closed, and we needed to use them in some way taking care of patients at the hospital. I spent about a week talking with them and with the clinical people. In the end, we decided they would be perfect for screening patients at drive-thru testing sites. We found a niche. We found something they were very good at and they could handle.
HL: Did you encounter clinical care pitfalls that should be avoided in future pandemics?
Brusco: The pitfalls we encountered were not specific to the pandemic as opposed to this particular virus.
When our first patients came in, we treated them just like we would have treated any other patient pre-COVID. Obviously, we realized later on that this was not the way to treat these patients. What we learned is to not always categorize a disease into what you think it is. COVID has changed medicine forever. It looked like a disease we had been treating for years—acute respiratory distress syndrome—and it wasn't.
The treatments that we had developed for ARDS did not work for COVID pneumonia. It was a different disease. It reacted differently. Anything new that comes up in the future, we are going to question it the same way we have COVID.
HL: Give an example of a new therapy that was developed to treat COVID-19.
Brusco: We developed a whole new approach to ventilation.
Before this pandemic, we would have never taken a patient who had low oxygen and not put them on a ventilator but have them lay on their stomach. The concept of awake proning was brand new. Nobody would have thought of that before.
What clinicians found is that when you put COVID patients on their stomach, their oxygen got better, and they didn't have trouble breathing. When we started awake proning, it helped keep patients off ventilators, which in certain cases damages the lungs. By keeping these patients off ventilators, you are doing them a favor. So, we came up with proning protocols and proning teams, and it worked very well.
For cancer patients, telemedicine is appropriate for many consultations and follow-up visits.
The coronavirus pandemic has revealed multiple opportunities to use telehealth in cancer care, a breast cancer specialist says.
Telemedicine provides physician practices with a safe method to interact with patients remotely during the coronavirus disease 2019 (COVID-19) pandemic. Telemedicine also enables physician practices to expand services for patient care such as virtual patient check-in capabilities and remote patient monitoring that collects biometric data.
"We feel it is not safe for patients to come directly to our office, or even to a hospital. In our clinic, we have set up multiple times during the day when we are doing telehealth consultations or follow-up visits. There are a select number of patients who fall very nicely into the category of being able to have their consultation done virtually," says Eric Brown, MD, breast program director at Michigan Healthcare Professionals in Farmington Hills, Michigan.
The telehealth visits are appropriate for cancer patients who have nonpalpable findings such as an abnormal mammogram, he says. "So, if you did not feel a lump and just had a screening mammogram and ended up getting diagnosed with breast cancer, those patients are appropriate to have their initial consultation done virtually."
Follow-up visits for cancer patients are well-suited to telehealth, Brown says. "Most of our telehealth visits have been follow-up visits: a check-in to see how things are going or a post-operative visit if the patient has no wound-specific issues. Some of our high-risk patient follow-ups have been done via telehealth."
All patients who have had virtual consultations also have had office visits, he says. "We did make arrangements for an in-person visit as well because that is an important component of what we do. Given the scenario, we were not able to do a physical exam on patients unless we had them come to the office."
Virtual visit best practices
Brown, who has been practicing for 27 years, says conducting consultations over the phone or via a video chat can be challenging. For example, if there is a loved one with the patient off camera, it can be difficult to "read the room," he says.
Engaging patients also can be problematic. "A lot of patients don't know where to look when they are on a video chat, so you are often not looking straight on to them," Brown says.
The key to telehealth visit success is adapting in-person skills to the virtual environment, he says.
"When it is a cancer consultation, you have to continue to provide the breadth of information that you would have if the patient was seen in the office. It was difficult at first to find my mojo; because when you do consultations in the office, you develop a pattern. You can see whether patients are understanding and engage them in the conversation. … By and large, you stick to the pattern, review the things you want to review, and engage patients in that way."
Virtual tumor board meetings
Brown says telehealth has been particularly useful in conducting tumor boards—multidisciplinary meetings his practice holds weekly to review cancer cases.
"As a group, we realized that meeting in person was risky for us because people were at risk for possible exposure in their offices and the community, or they had been moved to different positions in the hospital where they were subject to getting coronavirus," Brown says.
His practice adopted the OncoLens platform for tumor boards. "It has been a huge improvement in attendance. Most importantly, it has allowed us to continue the multidisciplinary approach to breast cancer care that patients deserve," he says.
With travel time cut out of tumor board meetings, attendance has doubled, Brown says. "Pre-pandemic, we would typically have eight to 12 people participate in the weekly tumor board. With the virtual platform, we have had no fewer than 20 and as many as 26 people participate."
The virtual platform has drawn plastic surgeons to the tumor board meetings, he says.
"Before, we would never have a plastic surgeon—even though they were invited—because they were operating and would not have time to participate. Now, we have had no fewer than four plastic surgeons on every tumor board. The more physicians that can participate, the better it is for the patients. You get more opinions, and everybody brings something to the table."
New research shows that primary care accounted for 5.4% of total healthcare expenditures in 2016.
From 2002 to 2016, spending on primary care lagged far behind other healthcare expenditures, a new research article says.
Relatively low spending on primary care is a contributing factor in U.S. healthcare underperforming compared to health systems in other advanced industrial countries. Nations with better access to primary care and superior primary care services generate better health outcomes at lower costs.
From 2002 to 2016, total healthcare spending increased from $810 billion to $1.6 trillion
Inpatient services were the highest spending category in 2016 at $415 billion, accounting for 25.7% of total expenditures
Prescriptions accounted for the highest increase in spending from 2002 to 2016, accounting for 28.6% of increased healthcare expenditures
Emergency medicine was the lowest spending category in 2016 at $62.5 billion, accounting for 3.9% of total expenditures
Primary care was one of the lowest office-based and outpatient spending categories in 2016 at $87.1 billion, accounting for 5.4% of total expenditures
Subspecialty care was the highest office-based and outpatient spending category in 2016 at $266.4 billion, accounting for 16.5% of total expenditures
"We found that spending on inpatient services, specialty care, and prescriptions combined accounted for about two-thirds of the increase in total U.S. healthcare expenditures from 2002 to 2016. In contrast, primary care accounted for 4.2% of the total increase in healthcare expenditures, while declining as a proportion of all expenditures," the research article's co-authors wrote.
The data illustrates the need to invest more resources in primary care, they wrote. "There are many reasons to increase investment in primary care, including its beneficial effects on quality of care, access to care, and mortality. Our results bring attention once again to the many opportunities in the U.S. to increase spending on primary care."
Ventilator information is transmitted to respiratory therapy supervisors, who can direct respiratory therapists to care for ventilated patients.
Yale New Haven Health has launched an initiative to monitor ventilators remotely.
Ventilators are essential equipment for the care of coronavirus disease 2019 (COVID-19) patients who experience respiratory failure. During the COVID-2019 pandemic, ventilators have been not only in short supply but also a staffing pain point, stretching the ranks of respiratory therapists and pulmonologists.
Remote monitoring of ventilators helps support frontline staff, says Chris Gutmann, MS, health system director of clinical engineering at Yale New Haven Health.
"The ventilator surveillance helps relieve the stress of the frontline caregivers. They have backup to help support them. Now, we can get ventilated-patient information to a respiratory therapy manager or shift leader who can have conversations with the respiratory therapists on the floor, who are feeling stressed and pulled in many directions. The supervisors can help manage the patients and the equipment in various situations," he says.
The New Haven, Connecticut-based health system features five acute care hospitals in Connecticut and Rhode Island, including Yale New Haven Hospital.
How ventilator surveillance works
The key element of the new ventilator surveillance system is connecting ventilators, which previously have been standalone devices, to Yale New Haven Health's information technology network, Gutmann says.
The remote monitoring initiative features Capsule Technologies' Capsule Neuron connectivity device, which is mounted to a ventilator and has a Wi-Fi connection to the health system's IT network. The device transmits data from a patient's ventilator and physiological monitors.
"We can then take that information and bring it to the respiratory therapy management to help them support their team. Information is displayed in an overview console that spreads across four monitors. It allows respiratory therapy management to get information in real time that they can compare to the Epic information, other patient demographics, physiological information, and lab results to support the respiratory therapists and nurses on the floor," he says.
The ventilator surveillance station is in the respiratory therapy department, which is completely removed from the clinical floors, says Samantha Herold, MS, a clinical systems engineer at Yale New Haven Health.
"When there is an event that is triggered on the central surveillance station, which is monitored from 8 a.m. to 5 p.m. by a respiratory therapy supervisor, they have the opportunity to escalate those alerts and notifications to respiratory therapists on the floor through our mobile communication system. The supervisors can make sure the staff on the floor have the information to perform an action to either correct the patient condition or modify patient alarm parameters," she says.
The ventilator surveillance system is only being monitored during regular business hours because the technology is on the cutting edge of innovation, Gutmann says. "We just can't staff it 24/7 because this is new technology, so respiratory therapy has not yet changed their entire staffing model. This is going to be a paradigm shift in the same way tele-ICU has changed how critical care doctors can support outlying hospitals."
Yale New Haven Health has IT infrastructure to support the surveillance of 450 ventilators. The initial pilot was limited to 60 ventilators, and the health system plans to have the surveillance system in place for 270 ventilators by the end of the year.
Future applications
The new ventilator surveillance system is an example of Yale New Haven Health's commitment to utilizing innovative technology in patient care, Gutmann says.
"We always look to be at the forefront of technology and new care models. This definitely helps put us in that position. It dovetails into our telehealth programs in general. We provide tele-ICU services to hospitals outside of our own healthcare network. We have a relationship with Epic, where we are helping to develop their tele-ICU tools called Epic Monitor," he says.
In the future, ventilator surveillance will almost certainly have applications beyond COVID-19 care, Gutmann says. "For example, we have a comprehensive heart program at Yale that uses a lot of ventilators for patients who come out of heart surgery."
In addition to ventilators, care has been rationed during the coronavirus pandemic in areas such as testing and emergency medicine.
In addition to ventilators, there are four primary care rationing scenarios during the coronavirus pandemic, a bioethicist says.
There have been several reports of ventilator rationing for coronavirus disease 2019 (COVID-19) patients in Italy and China. Last month, Manhattan, New York–based Northwell Health issued a memo that provided a guideline for clinicians to ration ventilators to COVID-19 patients who were most likely to benefit from the intervention.
"It is not just about ventilators. This pandemic, particularly in places such as New York, Detroit, and New Orleans, is forcing triage and rationing at almost every level," says Christine Cassel, MD, a bioethicist and adjunct professor at UCSF Medical School in San Francisco, and a former president and CEO of the National Quality Forum.
There are four main areas of care rationing during the COVID-19 pandemic, she says.
1. Coronavirus testing
Diagnostic testing has been rationed since the first U.S. COVID-19 patient was identified in January, Cassel says. "Everywhere across the country, you can't just walk in and get a test. There are certain criteria—in the beginning, you had to have a history of foreign travel and you had to be symptomatic. So, many people who want to get a test cannot get one because there is a shortage."
With coronavirus tests in short supply, there should be prioritization for who gets tested, she says.
"We need to test high-risk populations. Every nursing home should test every one of their patients. Healthcare workers who are exposed to the virus should be very high priority for testing. People who provide essential services such as pharmacists, grocery store workers, and anyone else whose work exposes them to the public also should be high on the priority list."
Healthcare workers and essential service workers should also be high priority for testing because they are at risk of infecting other people, Cassel says.
The next level of priority for testing is people who are symptomatic or have been in contact with infected people, she says. "If a family member gets ill, you want to test everybody in that family, not just the infected family member. It is the cluster principle—you want to test everyone who has contacted an infected person."
2. Healthcare worker shortage
The scarcest resource in the pandemic is often healthcare staff, Cassel says.
"We just do not have enough trained doctors and nurses who have the skills and the training to deal with respiratory failure. Before the pandemic, there would be one or two nurses per patient on a respirator because these patients need constant attention. Now, there could be one nurse per 10 patients. That nurse is trying his or her very best to provide the care that all patients need, but there is only so much attention that you can give to any one patient at any one time."
Healthcare workers should have a framework that helps them ration their care time, she says. For example, ICU nurses should have guidelines for prioritizing care of ventilated patients.
"The framework should have clinical characteristics to prioritize patients for attention. It is very important that these characteristics be clinical and not social, or racial, or age-based, or disability-based, " Cassel says.
3. Emergency medicine
During COVID-19 patient surges, emergency rooms can become overwhelmed and staff can face difficult decisions on whom to treat first, Cassel says.
"The emergency room physicians have metrics that they use similar to the clinical scores that critical care doctors and nurses use. Using those metrics, they can often figure out the risk patients face. Ideally, they have the time to think things through and make tough decisions. When there is little time for decision-making, a gut feeling or clinical experience can determine whether a patient needs help immediately or they can afford to wait for care."
4. Therapies and vaccines
Remdesivir has been shown to have a modest clinical impact on COVID-19, but the hope is that more effective medications and vaccines will be available in the future. In the short term, there will likely be rationing decisions in this area, Cassel says.
"Once we have an effective treatment or a vaccine, those medications are not going to be instantly available to everyone. So, we must anticipate that there may be decisions to be made from a public health perspective."
Rationing decision-making
There are several guiding principles for making rationing decisions during the COVID-19 pandemic, Cassel says.
"The best way to do it is to be very transparent, rather than having each clinician on the frontlines feeling like they have to make these decisions. There need to be clear guidelines at the state or municipal level that are endorsed by the government because clinicians will often feel legally vulnerable. In our system, where people are very litigious, doctors and nurses can feel vulnerable, and that just adds to the anxiety and the moral distress they are already experiencing."
Rationing guidelines should be developed as quickly as possible through an inclusive process, she says. "Ideally, the guidelines will have broad public input from all the stakeholders involved. That way, if the guidelines need to be put into effect, they come from the community."
Attending physicians should not be thrust into making rationing decisions for their patients, Cassel says. "The decision should be made by an independent committee that is not directly involved in the patient's care. That is ideal because the individual doctor does not have to feel conflicted in that decision."
Fairness and justice are key concepts in rationing decision-making, she says. Fairness can simply mean first-come, first-served or a lottery to be blind to the characteristics of patients. However, rationing decisions based on fairness alone are usually considered unjust because care may not benefit the people who need it the most.
"In a situation of dire shortage, you may have to provide care to the patient who has the better chance of survival," she says.
Rationing precedents
Care has been purposely rationed in the United States for decades, Cassel says. The most conspicuous rationing of care has been on the ability to pay.
"Because we have a market-based system and because we do not have universal health insurance, people who are poor are much less likely to be able to afford high-quality health insurance. They either have no insurance, or they have Medicaid, which pays very little in many states and is not accepted by many physicians or hospitals, or they have very high-deductible insurance plans, which you have to pay thousands of dollars out of pocket before any coverage kicks in. So, very often, poor people make the decision not to seek care."
Organ transplants have been rationed by law since the passage of the National Organ Transplant Act in 1984. "There are thousands of people on waiting lists all over the country for organ transplants—some of them more desperately ill than others," she says.
The 1984 law established a national organization—the United Network for Organ Sharing. "They set up broad guidelines for allocation. People get on the lists under certain criteria. Sometimes, those criteria are controversial, sometimes the criteria vary from state to state. There are committees—there are people who make this their work of deciding who should get an organ when one becomes available," Cassel says.
The coronavirus is taking a heavy toll on nursing home residents and workers.
During the coronavirus disease 2019 (COVID-19) pandemic, patient transfers between nursing homes and hospitals require heightened consideration, a recent journal article says.
People who are at least 65 and people living in nursing homes are at high risk of serious illness during the COVID-19 pandemic, according the Centers for Disease Control and Prevention (CDC). Nursing home residents face high risk because the facilities have a "congregate nature" and serve older adults with chronic medical conditions, the CDC says.
One-third of COVID-19 deaths in the United States have been residents and workers at long-term healthcare facilities, the New York Timesreported this week.
"Many older Americans who require assistance with Activities of Daily Living (ADLs) live in some type of congregate setting. These patients are particularly vulnerable to outbreaks of infectious disease, given close proximity of living quarters, frailty, functional dependence, and co-morbidities," the recent journal article says.
The co-authors of the journal article provide five recommendations for nursing home residents being considered for transfer to a hospital:
1. Medically stable patients who can be properly isolated from other nursing home residents and staff should not be transferred to an emergency department. For these patients, effective communication between nursing home clinicians and the ED can ensure adequate care in the nursing home setting.
2. During the COVID-19 pandemic, nursing homes should encourage residents and their families to complete advance care planning documents.
3. For nursing home residents with a fever and respiratory symptoms, staff should weigh the risks and benefits of transferring the individual to an ED. "This includes an evaluation of the patient's current state of health, patient-centered goals, and an assessment of prognosis in the context of the COVID-19 illness," the journal article says.
4. Nursing home staff should conduct "forward triage" when residents are considered for transfer to an ED. Key elements of forward triage include determining the resident's acuity and the best setting for meeting the resident's needs. An ED physician should be consulted.
5. Warm hand-offs are essential, such as effective communication between nursing home and ED staff before a transfer, and discussions about medical decisions such as the capacity of the nursing home to accept a patient back from the ED. Procedures should be in place that promote communication between EDs and nursing homes.
Care considerations
Nursing homes are equipped to provide care to ill residents, including treatment of pneumonia, urinary tract infections, skin infections, and fevers, a co-author of the journal article told HealthLeaders last week. "We take care of sick residents all the time in nursing homes," said Kathleen Unroe, MD, MHA, an associate professor of medicine at Indiana University School of Medicine and a research scientist at Regenstrief Institute in Indianapolis.
Nursing home residents should only be transferred to another care setting when treatment cannot be provided at the skilled nursing facility, she said.
"This is most often because they are or have gotten sicker—such as needing more oxygen and showing signs of severe infection such as a low blood pressure. It is important to know the resident's goals for care. Many residents, for example those with advanced dementia, have goals of care focused on comfort. When we can treat the symptoms of their illness, then we can care for them in the facility and avoid hospital transfer, including at the end of life."
In many cases of severe illness, transfer of nursing home residents to hospitals is appropriate, Unroe said. "When their clinical condition and goals of care are consistent with needing hospital-level care, we transfer them. Clear communication with the emergency medical service providers and the clinical providers in the emergency department is essential, especially if COVID-19 is suspected."
Forward triage screens nursing home residents prior to transfer to help direct them to the most appropriate resources, she said. "This requires direct, proactive communication between the ED and nursing home providers prior to transfer. For example, a patient who needs a blood transfusion due to worsened anemia found on labs could go directly to a transfusion center, bypassing the ED."
Communication between nursing homes and EDs is pivotal to achieve warm hand-offs of patients, Unroe said.
"Some health systems have secure communication systems, but you can always pick up the phone, call the emergency department, and ask to speak to the physician. In my experience as a nursing home physician, the ED docs are grateful for the call—especially now. We let too much information get dropped during transfers, which has consequences for our frail patients, and this is even more unacceptable now. These warm handoffs can be promoted by simply doing them, over and over, until it becomes our standard practice."
Photo: Kathleen Unroe, MD, MHA, meets with a nursing home resident. Photo credit: Regenstrief Institute
Social determinants of health (SDOH) such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. In 2018, an estimated 11.1% of U.S. households were food insecure at some point during the year, with food insecurity defined as household members having their eating patterns disrupted because financial and other resources were inadequate to obtain nutritious food.
To address patient food insecurity, healthcare organizations should focus on three steps, the recent report says.
1. Screening and assessment
The first step is determining which patients and populations in your service area are food insecure.
"To identify who may need targeted support, healthcare organizations can integrate screening strategies into standard care. Screening for food insecurity as part of broader efforts to integrate SDOH into healthcare conversations will enable healthcare organizations to better meet their patients' needs and improve population health," the report says.
Success strategies to support screening include:
Incorporating consistent screening as part of routine care, which decreases prejudice, accounts for chronic and episodic food insecurity, and helps track positive changes in nutrition
Utilize a screening tool that identifies food insecurity in both individuals and families
Enlist a multidisciplinary team to design screening methods that decrease strain on healthcare workers
Success strategies for screening individuals include:
Work with community-based organizations (CBOs) to identify food insecure individuals who are in your service area but are not receiving services from your organization—these individuals could be at risk for negative health outcomes
Pair food insecurity screening with other SDOH screening to develop a comprehensive view of an individual's social needs
Train healthcare workers about food resources in your service area to promote screening—some healthcare workers may be reluctant to screen individuals unless they are familiar with community resources
2. Clinical action
Once screening and assessment methods have identified individuals or families as food insecure, the next step is matching these people with the best resources. "The level of effort, investment, and impact of the various food insecurity interventions can vary across organizations and communities," the report says.
The primary focal points for clinical actions are public programs, food access, and access to supporting resources.
Public programs: Federal, state, and local public programs help food insecure people access food but often do not provide food directly. "Assisting individuals to participate in these programs can be a first step toward moving them into food security. Public program strategies should be paired with strategies that supply food to individuals and families in need," the report says.
Food access: An inability to access nutritious food is a key factor in food insecurity. Healthcare organization interventions to promote food access include the "Food is Medicine" strategy, which matches food to a patient's specific health condition, and establishing partnerships with CBOs to provide direct food delivery or financial assistance to overcome food access barriers such as limited mobility.
Access to supporting resources: People who are food insecure often face related SDOH challenges such as housing instability and unemployment. "Providing access to food alone will not help those who are food insecure overcome the circumstances that led to their food insecurity. Giving individuals access to resources they need will help them overcome barriers and challenges to sustainable food security," the report says.
3. Tracking and evaluation
Monitoring metrics demonstrates which food insecurity interventions are effective or generate negative unintended consequences. "Organizations can use data to show return on investment through improved health outcomes, lowered costs, reduced care utilization, and positive changes in other metrics of interest, such as patient satisfaction and number of healthy days reported," the report says.
Technology is an essential element of tracking and evaluating interventions. "When considering which strategies to implement, healthcare organizations should conduct an analysis of both their own technological infrastructure and the patient's ability to access various types of technology and the Internet," the report says.
Success strategies to support tracking include:
Adding food insecurity workflows to electronic health records (EHRs) to ease data management and increase productivity
Understanding the capabilities and needs of CBOs to support their data collection and evaluation efforts
Learning what is most important to patients, and creating methods to track and report data in ways that do not alienate, prejudice, or encumber food insecure patients
Success strategies to track food insecurity and evaluate the results of interventions include:
Setting follow-up appointments during the screening process
Using your EHR to identify food insecure patients and monitor health outcomes linked to food insecurity
Obtaining consent for data sharing, which can boost continuity of care between healthcare practitioners and settings
Targeting interventions
Food access interventions need to be tailored to community circumstances and the specific needs of patients, Kathleen Giblin, RN, senior vice president of quality innovation at the National Quality Forum, told HealthLeaders.
"Patients living in communities with few grocery stores, food pantries, or food banks, or those with mobility challenges, lacking reliable and affordable transportation, or facing financial barriers may need to be referred to in-house interventions to provide direct access to food to have their needs met. In areas with strong community resources and programs, it may be more effective for healthcare providers to connect patients to CBOs that can provide access to nutritious food," she said.
Social determinants of health factors do not exist in a vacuum, Shantanu Agrawal, MD, MPhil, president and CEO of the National Quality Forum, told HealthLeaders.
"Our Food Insecurity and Health Implementation Guide, developed in collaboration with Humana, is a critical step in addressing an essential social determinant. Other SDOH such as transportation, housing, and social isolation are issues that healthcare providers are beginning to tackle through both direct investments and community partnerships," he said.
Regardless of whether healthcare organizations pursue direct investments or community partnerships, SDOH initiatives require teamwork, Agrawal said.
"Bringing together patients, communities, healthcare providers and organizations, and community-based workers to discuss goals, resources, and values can help to build trust, prevent duplication of efforts, and establish shared ownership of actions to address food insecurity and other social determinants of health," he said.