When community-based organizations are already meeting social needs, healthcare organizations should build partnerships rather than building their own programs.
Health systems and hospitals across the country are forming partnerships to help address social determinants of health (SDOH) in the communities they serve.
Social determinants of health such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. By making direct investments in initiatives designed to address SDOHs and working with community partners, healthcare organizations can improve patient health in profound ways beyond the traditional provision of medical services.
For healthcare organizations, there are specific circumstances when forming partnerships is preferred over making direct investments to meet SDOH needs, says Adam Myers, MD, chief of population health and director of Cleveland Clinic Community Care at Cleveland Clinic in Ohio.
"Partnerships are effective anytime when there is work already being started or when work that hasn't been started would best be done collaboratively," he says.
Health systems and hospitals should resist the temptation to create a "de novo project" aimed at any SDOH, Myers says. "Rather than creating our own program, we often need to be learning, listening, and standing beside existing community organizations to determine what we can do to support them and create synergy."
Trust is the indispensable ingredient for a successful SDOH partnership, he says. "It has to be built on trust, and trust is only possible through true listening, seeking to understand each other's felt needs, and partnering in ways that strengthen community-based organizations and help meet community needs."
Humility is also an essential factor when working with community-based organizations (CBOs), says Annette Fetchko, who was the regional director of the Center for Inclusion Health at Pittsburgh-based Allegheny Health Network until recently and currently serves as CEO of the Bethlehem Haven homeless shelter in Pittsburgh. "Health systems have always felt that we have the answer. However, we are learning that we need to understand what is needed from the community's perspective and the CBO's perspective. That has been essential in forging relationships with CBOs."
Barbara Gray, MBA, senior vice president for social determinants of health at AHN's corporate parent, Pittsburgh-based Highmark Health, offers several pieces of advice to healthcare organizations seeking to forge SDOH partnerships.
"Take the time to invest in the relationship. Understand each other's goals and objectives. Articulate the guiding principles under which you are going to operate as a partnership. Be flexible. Recognize what each other brings to the table. And be open to learn from each other and transform—not only the program but also the way you see your role in serving your population," Gray says.
Food security partnerships
The opening of two Healthy Food Centers on AHN hospital campuses is a prime example of effective SDOH partnerships, Fetchko says.
The first step was identifying the need and recognizing the benefits of establishing partnerships, she says. "When we began to screen at the system level for food insecurity and evaluated the data, we clearly recognized that there was a significant social gap in access to nutritious food. As a health system, we also recognized that we were not the experts in identifying access to nutritious food and distribution of those foods. Organizations in our communities were far better experts."
AHN opened the health system's first Healthy Food Center in April 2018 at the West Penn Hospital campus in Bloomfield, Pennsylvania. The second Healthy Food Center opened in January at Allegheny General Hospital in the North Side neighborhood of Pittsburgh.
Each Healthy Food Center is managed by a registered dietician and stocked with nutritious dried, refrigerated, and frozen foods. AHN clinicians can make patient referrals to the Healthy Food Centers through the health system's electronic medical record, Epic. CBOs can make referrals to the Healthy Food Centers via a scanned document or fax.
Making referrals through Epic helps ensure that referred patients don't fall through the cracks, Fetchko says. "If a referred individual has not engaged with the Healthy Food Center, we have a process where we will do outreach to that individual. We ask whether they plan on making an appointment, whether they understand the concepts of the Healthy Food Center, and whether they need transportation assistance because we set up a partnership with a local nonprofit organization to provide transportation."
As of mid-April, there had been 2,200 referrals to the Healthy Food Centers, providing meals to more than 6,700 people, she says.
The cost of operating one of the Healthy Food Centers, which is funded by AHN, ranges from $175,000 to $200,000 annually inclusive of personnel costs. However, community partnerships play a pivotal role at the facilities, Fetchko says. "As we identified the needs of community residents, we worked with CBOs such as Greater Pittsburgh Community Food Bank and 412 Food Rescue to determine how to source, distribute, and provide access to nutritious food. We leveraged the expertise of each organization."
The food bank helped AHN convene several CBOs to learn about the community's food needs as well as about food distribution and sourcing, Fetchko says. And 412 Food Rescue, which is a nonprofit organization that sources food that would otherwise be thrown away, makes a "very large donation" to the Healthy Food Centers, she says.
Other significant CBO partnerships for the Healthy Food Centers include the Bloomfield Development Corporation, which hosts a farmers' market, and The Food Trust based in Philadelphia.
The Food Trust provides "food bucks" to the Healthy Food Centers that can be redeemed at participating corner stores, supermarkets, farmers' markets, and Green Grocers for fresh produce, says Senior Healthy Food Center Manager Colleen Ereditario, MPH, RD. "Since July 2018, $15,000 worth of coupons have been redeemed from our Healthy Food Center clients alone. The clients report that, as a result, they have increased fruit and vegetable intakes and access that they would not have had otherwise."
Early longitudinal data shows the Healthy Food Centers are having a positive impact on clinical metrics, Fetchko says. "Because the first Healthy Food Center has been open for more than 18 months, we can look to see whether we have had a positive impact on hemoglobin A1c, cholesterol, and high blood pressure. As part of the longitudinal study for A1c, we have seen a 20% reduction in A1c over a six-month period and sustained that over a nine-month period."
Although no single organization can meet the emergency food needs resulting from the COVID-19 pandemic, the Healthy Food Centers have risen to the challenge, Fetchko says. "The Healthy Food Centers have continued to maintain daily access to nutritious food sources by implementing a modified process whereby individuals can receive bags of nutritious food at the centers that are packaged and distributed by center staff. Included in these bags are recipes to support meal preparation as well as nutrition information."
The Healthy Food Centers have also added community-based services during the pandemic, she says. "Our team has implemented a process to distribute emergency food boxes via the centers as well as home delivery for those who are quarantined or self-isolating due to health risks associated with the pandemic. These individuals are not able to access the broader drive-up food distribution, so the Healthy Food Centers' ability to try to serve these individuals is critical."
Nurse practitioners report several impacts on their profession during the pandemic, including the easing of practice restrictions in some states and furloughs.
A new survey shows the coronavirus pandemic has had a profound impact on nurse practitioners.
Nurse practitioners have been providing care to all coronavirus disease 2019 (COVID-19) patients from testing and triage, to emergency medicine, to inpatient medical wards, and ICUs. To address coronavirus patient surges, many states have loosened restrictions to practice for nurse practitioners.
The new survey, which was conducted online from July 28 to August 9 by the American Association of Nurse Practitioners (AANP), features data collected from 4,000 nurse practitioner respondents. This is the second survey AANP has conducted during the coronavirus pandemic.
The new survey includes several key data points.
Treatment capacity: 82% of nurse practitioners said their facility was better prepared to address the novel coronavirus compared to the beginning of the pandemic. About one-third of survey respondents said their facility was prepared for a COVID-19 patient surge, challenges related to delayed or deferred care, and the upcoming flu season.
Testing: Three-quarters of nurse practitioners reported that lack of timely coronavirus testing is the most daunting barrier to providing effective COVID-19 care. Limitations on testing due to eligibility criteria have improved since the first AANP survey in the spring. In the first survey, 69% of nurse practitioners reported limited testing due to eligibility criteria. In the new survey, 46% reported limited testing due to eligibility criteria.
Safety impact: In the first AANP survey, 2% of nurse practitioners reported being infected by the coronavirus, and that figure has nearly tripled to more than 5% in the new survey. In the first survey, a quarter of survey respondents cited insufficient personal protective equipment (PPE) as a major pandemic concern, with 79% reporting they had been forced to reuse PPE. In the new survey, 18% of nurse practitioners said they had insufficient PPE.
Workforce impact: Since the beginning of the pandemic, nearly 17% of nurse practitioners report being furloughed; but most have gotten their jobs back, with 4% remaining furloughed at the end of July. Nurse practitioners have also experienced layoffs or termination, with 3% remaining laid off or unemployed after termination at the end of July. In the new survey, about 40% report income decreases, compared to 36% in the first survey.
Practice restrictions eased: In the new survey, more than half of nurse practitioners reported that temporary suspension of state supervisory or collaborative practice pacts was beneficial.
Telehealth: The two surveys reflect the expansion of telehealth services during the pandemic. In the first survey, more than half of respondents reported their practice was shifting patient care to telemedicine. In the new survey, 63% of nurse practitioners reported their practices were transitioning patients to telehealth services.
Interpreting the data
While coronavirus testing has improved since the beginning of the pandemic, testing issues remain to be resolved, Sophia Thomas, DNP, APRN, president of the AANP told HealthLeaders. "More than half of NPs say there is adequate access to testing in their community. But there are many NPs who report access to testing is limited, especially for patients who need to meet eligibility criteria."
Delayed test results is a major concern, she said. "Three-quarters of NPs are reporting delays in getting test results, which is probably the most significant thing in controlling the spread of coronavirus other than wearing masks. Getting adequate test results back in a timely manner is key in preventing the spread of COVID-19. Especially for asymptomatic carriers, once they get a positive result it reaffirms to them that they need to wear a mask to prevent the spread to others and they need to socially isolate."
In several states, the temporary lifting of practice restrictions on nurse practitioners during the pandemic has been a welcomed change, Thomas said. "Five states—Wisconsin, New York, New Jersey, Kentucky, and Louisiana—have temporarily lifted all practice agreement restrictions on nurse practitioners. The actions taken by these governors are models for the nation, allowing their states to surge the number of frontline providers, treat patients with underlying health conditions, and meet vital primary care needs."
More states should ease practice restrictions on nurse practitioners, she said. "About 89% of nurse practitioners are educated in primary care roles, which is important to providing care and access to care for patients. We are calling on the remaining governors to waive the restrictive barriers that undermine access to care and limit scope of practice. We need to modernize all of these outdated barriers. Twenty-two states and the District of Columbia currently have full practice authority for nurse practitioners."
The new survey's finding that 18% of nurse practitioners lack adequate PPE is troubling, Thomas said. "It is always a concern when any provider is without the recommended PPE."
However, the availability of PPE has improved significantly since the beginning of the pandemic, she said. "The supply of PPE is much improved."
The employment market for nurse practitioners, which took a hit in the early phase of the pandemic, is relatively strong, Thomas said. "While nearly 17% of nurse practitioners have had a furlough, the majority of them have returned to work. As primary care reopens and practices are better prepared for the pandemic, we expect furloughs will end and nurse practitioners will go back to work."
The expansion of telehealth services during the pandemic is likely to continue, and telemedicine has become a crucial element of the nurse practitioner skillset, she said.
"Telehealth is now an essential skill for nearly everybody in healthcare. Nurse practitioners have a strong presence in this space, and the pandemic has exposed more nurse practitioners and patients to this form of care. … In our survey, 63% of nurse practitioners are continuing to transition patients from in-person visits to telehealth visits, and I am encouraged by this tremendous demand. This is an opportunity to improve access to care."
An outdoor coronavirus screening station can be configured and equipped to eliminate direct contact between patients and healthcare workers.
A walk-through novel coronavirus screening station that isolates patients from healthcare workers decreases personal protective equipment utilization and quickens patient processing, a new Annals of Emergency Medicineletter to the editor says.
Personal protective equipment (PPE) has been in limited supply since the coronavirus disease 2019 (COVID-19) pandemic hit the United States early this year. For health systems and hospitals facing surges of COVID-19 patients, emergency departments have been strained in providing triage.
Compared to an outdoor COVID-19 screening station where healthcare workers come into direct contact with suspected coronavirus patients, an outdoor COVID-19 screening station that isolates healthcare workers from patients generates significant benefits, the letter to the editor says.
Average daily consumption of N95 respirator masks decreased 87%
Average daily consumption of isolation gowns decreased 93%
Processing time to screen patients decreased 83%
An outdoor COVID-19 screening station that isolates healthcare workers from patients has several key elements, the letter to the editor says.
Separate passageways for patients and healthcare workers
A quarantine triage area, a patient tele-consulting room, a chest X-ray booth, and consultation cubicles for nasal sampling
All assessments are conducted with healthcare workers behind acrylic windows, so there is no need for the workers to don PPE
Healthcare workers communicate with patients through an audio system
The chest X-ray booth is configured so technicians can position the digital cassette and portable X-ray unit without coming into direct contact with patients, avoiding the donning of PPE
Nasal swabs and blood samples are collected at windows equipped with glove ports
Specimen tubes and vials in collection bags are passed from patients to healthcare workers through a sealed port
Patients are screened sequentially, which lowers congestion of patients and speeds the screening process
Injuries to the head and neck in absence of injury to other parts of the body can be suspicious injury patterns in older adults.
Elder abuse is difficult to identify, but recent research shows injury patterns that are indicative of elder abuse rather than unintentional injury.
Elder abuse from violence is difficult to detect because seniors have thin skin and take medications such as blood thinners that lead to easy bruising, and they can have osteopenia or osteoporosis that increase the risk of broken bones. Elder abuse has serious health consequences, including depression, anxiety, post-traumatic stress disorder, and significant trauma injuries. And it is not well recognized in the clinical setting.
The lead author of the recent research, which was published in Annals of Emergency Medicine, told HealthLeaders that clinicians play a unique and vital role in the detection of elder abuse.
"Elder abuse is dramatically underrecognized and underreported. One of the reasons for that is many older adults do not come into contact with other folks. In fact, contact with a medical professional might be the only time that an older adult leaves their home. As a result, physicians—particularly emergency room clinicians—have an opportunity and responsibility to identify elder abuse, neglect, and exploitation," said Tony Rosen, MD, MPH, and assistant professor of emergency medicine in the Department of Emergency Medicine at Weill Cornell Medicine and New York Presbyterian Hospital in New York.
The research is based on medical, police, and legal records collected from 78 successfully prosecuted elder abuse cases with physical injury from 2001 to 2014. There was a control group of 78 patients who suffered injuries in unintentional falls.
The study features several key data points.
Compared to older adults who experienced unintentional falls, elder abuse victims were more likely to have bruising, 78% vs. 54%
Compared to older adults with unintentional falls, abuse victims were more likely to have injuries on the maxillofacial, dental, and neck area, 67% versus 28%
Compared to older adults with unintentional falls, elder abuse victimes were more likely to have maxillofacial, dental, or neck injuries in the absence of upper and lower extremity injuries, 50% vs. 8%
Compared to older adults with unintentional falls, seniors who were victims of physical abuse were more likely to have injuries to the left cheek or zygoma (22% vs. 3%), neck (15% vs. 0%), or ear (6% vs. 0%)
The head and face are a primary target for elder abuse perpetrators, Rosen said. "When you are angry at someone, you lunge for things that are exposed and things that are symbolic of the person you are angry at. Ultimately, the face is an attractive target to an assailant. According to the literature on younger age groups, the face is a common place to be injured in an assault."
Injuries to the face in the absence of injuries to other parts of the body should raise suspicion of elder abuse, he said. "If someone is prone to bruising, they should be covered with bruises in an accidental fall. So, the presence of bruising in the face combined with the absence of bruising in places where people get bruised more often—like the shins or the knees—is more concerning."
Neck injuries are particularly suspicious, Rosen said. "We found injuries to the neck were most consistent with elder abuse. When you fall, the neck is protected by the face and the shoulders. So, it is hard to injure your neck in a fall, unless you fall against the edge of a table or refrigerator. As a result, we think injuries to the neck are particularly concerning."
The study's data indicate exploration of elder abuse is appropriate for a small but significant percentage of fall patients, he said. "We recognize that no matter how good of a job we do identifying elder abuse, falls and other unintentional injuries are still going to be more common. So, the first thing we can do with these findings is to keep in mind that every single fall is not necessarily a fall. There ought to be characteristics about the injury pattern that ought to make us question whether injuries really occurred from a fall."
Addressing suspicion of elder abuse
In most states, clinicians are mandatory reporters of elder abuse, and most cases are reported to adult protective services.
When elder abuse is suspected, the first step for clinicians is to interview the patient with no home caregivers or family members present, Rosen says. "The second thing is you want to make sure that you conduct interviews in a supportive and nonjudgmental manner while ensuring privacy. You need to build a therapeutic alliance with the patient and the family."
Patients should be treated sensitively because they are potentially trauma survivors, he says. "Providing trauma-informed care is important for these patients and their families. Trauma-informed care includes being sensitive to the profound impact of traumatic and stressful life experiences on a patient's physical and mental health. Previous and even remote traumatic experiences can cause depression, anxiety, or post-traumatic stress disorder."
Effective approaches to emergency preparedness during a pandemic include proactive resource management and involving stakeholders in planning efforts.
The coronavirus disease 2019 (COVID-19) pandemic has exposed emergency preparedness weaknesses in the U.S. healthcare system.
In the early stage of the COVID-19 pandemic, hospitals in New York City struggled mightily to cope with an epic surge of coronavirus patients. Across the country, the pandemic has strained supply chains for critically important materials and equipment such as personal protective equipment (PPE) and ventilators.
There were three primary reasons why health systems and hospitals were ill-prepared for the COVID-19 pandemic, according to Brian Armstrong, RN, MBA, BSN, a healthcare consultant at Philips Healthcare Transformation Services, a business division of Amsterdam, The Netherlands–based Royal Philips Electronics. He has extensive experience in emergency preparedness, including serving as director of emergency services at Prime Healthcare in Atlanta.
1. Dusty emergency management plans
Once emergency management plans are developed and agreed upon, they are frequently stored away and rarely revisited, Armstrong says.
"Instead, these plans should be more frequently practiced and become flexible, living documents that align with evolving operations. Due to the fast pace and busy nature of health systems and hospitals, often plans are reviewed once a year when the healthcare organization runs a drill to meet regulatory requirements. Unfortunately, this lack of ongoing review and reassessment meant that when COVID-19 began to sweep the globe, many health systems did not have adequate plans in place for defining roles or adjusting supply chains."
2. False sense of confidence based on experiences with earlier outbreaks
Before COVID-19, contagion response was not a high priority at health systems and hospitals, he says.
"Prior to COVID-19, there was not much emphasis placed on contagion response. Pandemics are very rare, and we have no recent experience with an overwhelming outbreak of this fashion. While the H1N1, Ebola, and SARS viruses were expected to have a dramatic effect on public health and the healthcare system, the actual effects were less severe than anticipated, which may have lulled organizations into a false sense of security."
3. Regional variation in emergency preparedness
Hospitals and health systems conduct annual vulnerability threat assessments that create a regionally specific priority matrix on what to focus on related to disasters and major threats. These vulnerability threat assessments are not well-suited to national calamities such as the COVID-19 pandemic, Armstrong says.
"This can be quite different depending on location. A hospital in Florida will have hurricanes rate much more highly than a hospital in Ohio, which might see tornados high on the list. A global pandemic was not high on any hospital's threat assessment."
Preparing for future pandemics
Pandemics are not a matter of "if" but "when," he says. "With this reality in mind, it is not too soon for health systems and hospitals to examine what policies and procedures failed them during this COVID-19 event."
There are four main ways health systems and hospitals can be better prepared for future outbreaks, Armstrong says.
1. Proactive resource management
Many health systems and hospitals function with "just-in-time" supply chains. Healthcare organizations should take time to identify and activate supply streams, review stockpile levels, and rotate supplies to avoid expiring items, he says.
2. PPE management
Health systems and hospitals need better command and control for PPE. These organizations spend a lot of time on training about how to use PPE, then must retool when new PPE is substituted, Armstrong says.
Health systems and hospitals should look closely at longer term and renewable PPE such as powered air-purifying respirators and N95 respirator masks as well as methods to extend the life of PPE. One suggestion is to develop a system to forecast PPE usage based on burn rates. This system should be reviewed daily or weekly depending on the usage tempo, he says.
3. Involving stakeholders in planning
It is crucial to involve all departments and decision-makers in emergency preparedness planning and recovery efforts. Involving frontline clinicians in planning improves understanding of their experience during an emergency, helps with engagement and adoption of new processes, and gives medical professionals a vested interest in emergency preparedness rather than just telling them what to do, Armstrong says.
4. Boosting technology infrastructure
Health systems and hospitals should be working now to improve technology infrastructure such as establishing robust telemedicine and remote work capabilities. These investments ensure business and operational continuity during a crisis, he says.
Pandemic lessons learned
From an emergency preparedness perspective, there have been several lessons learned from the COVID-19 pandemic, Armstrong says.
"COVID-19 has taught us that there is no one-size-fits-all emergency management plan—each needs to be customized and adjusted frequently. Rather than having a plan just to check a regulatory box, make emergency management an integrated part of operational strategy and incident command systems a part of everyday work."
The COVID-19 pandemic has demonstrated the importance of vigilance, he says. "Health systems and hospitals need to consider that novel infectious diseases have been relatively common over the past decade, and the ongoing risk of resurgence and the chance of new pathogens requires healthcare leaders to take a new approach to maintaining essential capabilities to respond to an initial outbreak or event."
Vigilance requires ongoing emergency preparedness, Armstrong says. "When previous infections have run their course, the command center has closed, equipment has been put away, and plans have gone back on the shelf. While it may not be necessary to maintain incident command readiness at all times, some aspects of command systems and monitoring need to remain a constant part of daily operations to help ensure infection outbreaks are a staple consideration in daily huddles and reports."
To avoid emergency preparedness pitfalls during future infectious disease outbreaks, health systems and hospitals should avoid a lack of reflection, he says.
"After a crisis, people get complacent, memories fade, and processes slide back into pre-crisis operational structures. It is important that no time is wasted to examine what did not work and put plans in place to mitigate root issues the next time. While an after-action report is important, organizations also need to do mid-action reports and address hard-hit areas to improve response for a potential second wave or future pandemic."
Emergency departments have developed strategies to handle coronavirus patient surges such as addressing limited space in their facilities.
Emergency department management and clinical care practices to cope with coronavirus disease 2019 (COVID-19) patient surges have evolved since the pandemic began, according to a recent journal article.
Particularly for the most seriously ill COVID-19 patients, emergency departments are an essential healthcare setting during the coronavirus pandemic. Given their key role, EDs need to function efficiently and effectively to save lives.
The recent journal article, which was published in Annals of Emergency Medicine, highlights six lessons learned that can help emergency departments rise to the challenges of addressing COVID-19 patient surges.
"The very novelty of COVID-19, in multiple senses—immunologic novelty for a population lacking herd immunity, clinical novelty in its diversity of presentations, and sociocultural novelty in that it has appeared amid nationwide tumult and institutional distrust—makes it a perfect storm. It has caught much of the United States unprepared. Yet despite the many uncertainties about COVID-19, emergency physicians have gained critical practical knowledge," the journal article's author wrote.
1. Hot zones and cold zones
To deal with a rush of COVID-19 patients, emergency departments should be divided into two areas, according to the journal article. A hot zone should be created for the assessment and treatment of patients who are suspected of having COVID-19 or influenza. A cold zone should be created for other patients.
A contributor to the journal article told HealthLeaders that having hot zones and cold zones in an emergency department generates two primary benefits during a COVID-19 patient surge.
"On the patient side, one of the things that people are most afraid about during the COVID-19 pandemic is being infected. Therefore, having different areas where people with COVID-19 or people with suspicion of COVID-19 are handled creates physical separation and less likelihood that even casual contact could happen. It gives not only a measure of safety but also an enhanced appearance of safety for people coming into an ED," says Donald Yealy, MD, Department of Emergency Medicine chair at the University of Pittsburgh School of Medicine in Pittsburgh.
"On the provider side, having different areas where patients are placed either with or without suspicion of COVID-19 allows for more efficiency in staffing, more consistent care, and more protection of the patients and the providers," he says.
2. Rapid COVID-19 testing
The capability to test patients for COVID-19 in a timely manner is helpful in the ED setting, and it could be essential when the influenza season begins in the fall, the journal article says.
For emergency room clinicians, rapid COVID-19 testing is a desirable tool, Yealy says. "If you could get a test that was quick and retain the accuracy of the more standard viral tests, it would help us identify at the beginning of a hospitalization who has symptomatic and asymptomatic COVID-19."
3. Personal protective equipment
In emergency rooms, having adequate supplies of personal protective equipment (PPE) is crucial during a COVID-19 patient surge, the journal article says. "Ensuring adequate PPE and adapting facilities in ways that conserve this resource by reducing repeated donning and doffing will be essential to safeguard staff before waves of new cases again become overwhelming."
Yealy says four factors determine the availability of PPE: the production of PPE, the distribution of PPE, the intensity of cases, and the use of the equipment. For now, he is cautiously optimistic. "There is enough PPE even if the virus numbers increase. I don't anticipate that there will be widespread shortages again, but there could be individual facilities that could be under duress."
4. Alternatives to mechanical ventilation for COVID-19 patients
Both in terms of available resources and patient outcomes, placing COVID-19 patients on mechanical ventilation is problematic, and alternative treatments should be used when possible, the journal article says.
The approach to mechanical ventilation for seriously ill coronavirus patients has evolved significantly since the beginning of the pandemic, Yealy says.
"Early on, we felt that what was most key was to assist respiration by all means necessary, including endotracheal intubation and mechanical ventilation as early as possible because of the fear of profoundly low oxygen levels. We have now learned that haste to begin standard mechanical ventilation with an endotracheal tube may not serve patients well. Alternatives such as high-flow oxygen, prone positioning without intubation, and using other noninvasive ventilatory techniques can be quite helpful for an extended period," he says.
As is the case with any critical care therapy, expertise is important when proning coronavirus patients in the ED, Yealy says. "Proning is not something you can just learn on the fly. There are lots of things that can go wrong. So, you either have to have proning teams or you have to have within your staff subsets of people who understand how to do proning and are practiced at it."
5. ED space constraints
During a COVID-19 patient surge, EDs need to be creative in managing triage space such as erecting tents and other outdoor facilities, the journal article says.
Using tents to address ED space concerns is a good strategy under the proper circumstances, Yealy says.
"Tents are a reasonable alternative for the patients with the lower level of symptoms and acuity because they help provide care to very large numbers of patients if you have a physically restrained bricks-and-mortar environment. Obviously, outdoor triage and treatment facilities can be shackled by their location and the weather. In the far Northeast, those kinds of facilities would be a very difficult way to provide care in February. In the Southwest, those kinds of facilities could be the perfect way to provide care year-round."
For EDs in many areas of the country, repurposing existing bricks-and-mortar areas for clinical care such as conference rooms is an attractive option for managing limited space, he says.
6. Telemedicine
Utilizing telehealth capabilities can reduce the strain on EDs during a COVID-19 patient surge, the journal article says.
"It can help people with lower-level symptoms get the care and advice they need without having to come to the emergency department," Yealy says.
Combining the World Health Organization's operating room checklist with a preoperative and postoperative checklist benefits patients, research indicates.
Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark reportTo Err Is Human: Building a Safer Health System. Despite two decades of attention, estimates of annual patient deaths due to medical errors have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.
The recent research, which was published in JAMA Surgery, examines information collected from more than 9,000 surgical procedures. The research features three key data points:
Joint use of the World Health Organization Surgical Safety Checklist (WHO SCC) and the SURPASS checklist was associated with fewer complications, odds ratio 0.70
Joint use of the checklists was associated with fewer reoperations, odds ratio 0.42
Joint use of the checklists was associated with fewer hospital readmissions, odds ratio 0.32
"Findings from this study demonstrate that adding the preoperative and postoperative SURPASS checklists to the intraoperative WHO SSC may be clinically advantageous. We found that the joint application of the two surgical checklist systems was associated with reduced in-hospital complications, emergency reoperations, and hospital readmissions," the researchers wrote.
The reduction in readmissions was likely due to the SURPASS checklist promoting best practices when patients leave a hospital such as medication management and setting recovery expectations, the researchers wrote.
WHO SCC and SURPASS checkpoints
The SURPASS preoperative and postoperative checklist includes the following steps:
Admission to ward: Ward doctor checks whether imaging is present and lab work has been done; surgeon checks whether informed consent has been registered and the operation side has been marked; anesthesiologist assesses patient's condition and orders blood products; nurse makes sure premedication is administered
Recovery room or ICU: Surgeon provides instructions about drains, diet, and medication; anesthesiologist provides instructions about ventilation and medication
Ward boarding: Surgeon and anesthesiologist specify changes in postoperative instructions
Discharge: Ward doctor conducts follow-up, checks medications, and writes discharge letter
The WHO SCC includes the following steps:
Before induction of anesthesia: Patient should confirm his or her identity, surgical site, and procedure; the surgical site should be marked; the surgical team should know whether the patient has any allergies
Before skin incision: All team members introduce themselves by name and role; essential imaging should be displayed; confirmation of antibiotic prophylaxis within the prior 60 minutes
Before patient leaves the operating room: The OR nurse should verbally confirm the name of the procedure, and the surgeon, anesthesiologist, and OR nurse should identify concerns for the recovery and management of the patient
Combining the SURPASS checklist with the WHO SCC
The lead author of the recent research told HealthLeaders that training medical staff on how to use the SURPASS checklist is a key element of the study.
"The primary elements of the training consisted of written and oral information provided to staff groups from the research/implementation group, with daily follow-ups being made in each department by their own staff. During this effort, exemplifying things having been intercepted by checklist use motivated the staff to use the lists daily," said Anette Storesund, RN, PhD, a consultant in the Department of Research and Development at Haukeland University Hospital in Bergen, Norway.
Combining the surgery checklists has a more significant impact on patient safety and clinical outcomes than adhering to a single checklist, she said. "To get the full benefit from the SURPASS checklist's use, all of the different checklists need to be utilized. We also found stronger effects when all the checklists for all the key healthcare personnel were used, compared to when some of the checklists had been left out."
Financial struggles of physician practices present opportunity to health systems.
The coronavirus disease 2019 (COVID-19) pandemic is impacting the market for health systems and hospitals acquiring physician practices, a recent report says.
The COVID-19 pandemic has had a profound impact on independent physician practices. In the early stage of the pandemic, patient volume at physician practices plummeted, financial losses mounted, and practices boosted telemedicine capabilities to offer services in a safe manner.
The recent report, which was published by New York-based McKinsey & Company, is based on a national survey of general and specialty physicians conducted in 2019 and repeated six weeks into the pandemic.
"New financial pressures resulting from the COVID-19 pandemic may increase physician practice acquisition and consolidation. However, results from McKinsey physician surveys both before and during the COVID-19 pandemic suggest that these partnerships may benefit from an updated approach. … While autonomy has remained a priority for physicians, respondents indicated that they will consider partnerships or joining a health system as a result of financial uncertainty resulting from the COVID-19 pandemic," the report says.
The report includes five key data points about health system and hospital acquisitions of physician practices:
Compared to small independent physician practice clinicians, employed physicians were more likely to cite financial stability as a top factor in their current practice model decision (53% of employed physicians vs. 38% of small independent physician practice clinicians)
About 40% of employed physicians cited personal and practice finances as factors in their decision to become employed
Six weeks into the COVID-19 pandemic, 53% of independent physicians said they were worried that their practice would not survive the pandemic
At large independent physician practices, 58% of survey respondents said they would prefer to remain independent
At small independent physician practices, 71% of survey respondents said they would prefer to remain independent
"In light of these survey findings, health systems and other stakeholders may consider strategies to optimize the mutual benefits of physician practice acquisition," the report says.
Gauging the physician practice acquisition market
The survey data collected during the COVID-19 pandemic indicates a bullish market for physician practice acquisitions by health systems and hospitals, Rupal Malani, MD, MS, MA, a partner at McKinsey & Company, told HealthLeaders.
"In our survey, conducted six weeks into COVID-19, 53% of all independent physician respondents shared that they were worried about their practices surviving, and that roughly 20% to 40% were considering partnering with a larger entity, selling their practice, or becoming employed. This means we have a sizeable number of physicians potentially seeking out new opportunities, and health systems in turn are scrambling to determine how (and if) to acquire this new surge of talent," she said.
However, the appetite for physician practice acquisition is finite, Malani said. "What we also heard in last year's survey is that 26% of physicians who joined a health system or larger entity reported buyer's remorse, indicating that physicians aren't always satisfied with employment. And, anecdotally, we have observed that health systems are also not always achieving their desired outcomes from the employed physician base, whether it is regarding cooperation to reduce supply expense or care coordination to reduce total cost of care."
Based on the survey data, there are significant implications for how health systems and physicians should approach physician practice acquisitions, she said.
"There may be an opportunity for health systems to define and effectively communicate the value proposition to physicians, as well as the expectations of physician employment. Similarly, physicians could benefit from being thoughtful and candid about their expectations of employment and understand what flexibility might exist to meet their needs."
Long-term impact of pandemic on physician practice acquisitions
As health systems and hospitals ponder rebuilding their enterprises after the COVID-19 pandemic crisis passes, now is a good time for them to consider what they really want out of the physician practices they are acquiring, Malani said.
"It's a true moment of reflection for health systems to consider their own value proposition, but they shouldn't reflect too long. There are other entities out there looking to acquire these practices, and health systems have to be prepared to act with alacrity."
In this decision-making process, local market concerns are crucial for health systems, hospitals, and physician practices, she said.
"Our survey is a great way to get an aggregate voice of physicians, but the ultimate decision for the acquisition of a practice will depend on myriad local market factors and the health system's approach to individual physician needs. That is where communication is paramount, and the more upfront each side can be about their own goals and expectations, the better chance all parties have for success."
A respiratory therapist who traveled to New York City during The Big Apple's coronavirus patient surge shares her story.
With respiratory distress common among seriously ill coronavirus patients, respiratory therapists are at the tip of the spear on the pandemic frontline.
Respiratory therapists have been in short supply during the coronavirus disease 2019 (COVID-19) pandemic. A study published in 2015 identified the supply of ventilators and the staff to manage them as a weak point in the U.S. healthcare sector's capability to function effectively during a public health crisis.
Julie Sullivan, who has worked as a respiratory therapist for the past 16 years, answered the call when hospitals were overrun by COVID-19 patients in New York City. She took a leave of absence from her Texas hospital and traveled to Brooklyn, New York, to work at NYU Langone Hospital during the height of New York City's COVID-19 patient surge in the spring. She is currently working at Prince William Medical Center in Manassas, Virginia. She also is a spokesperson for the Allergy and Asthma Network.
"When I was in New York at NYU Langone in Brooklyn, all I had was ventilated patients. It was pretty much an all-COVID hospital when I was there," Sullivan says.
During a COVID-19 patient surge, respiratory therapists are assigned to work with patients in respiratory distress, she says. "They are usually desaturating, so their oxygen level is low. You want the oxygen level for a normal, healthy person to be as close to 100% as possible. If a patient has an underlying disease such as chronic obstructive pulmonary disease or asthma, it might be OK for the oxygen level to be in the low 90s. I often get a call for a COVID-19 patient with an oxygen level in the 70s."
There are three primary kinds of care that respiratory therapists provide to seriously ill COVID-19 patients, Sullivan says.
1. Heated high-flow nasal cannula therapy allows respiratory therapists to provide patients with 100% oxygen at a rate of at least 40 liters per minute. In contrast, a regular nasal cannula provides patients with about six liters of 100% oxygen per minute.
2. A CPAP orBiPap machine is used for COVID-19 patients who do not respond well to heated high-flow nasal cannula therapy. The machine uses pressure to push oxygen into the lungs.
3. Intubation and mechanical ventilation is the last resort for respiratory therapists to oxygenate COVID-19 patients when other methods fail. "For ventilated patients, we maintain their airway, we draw arterial blood gases because that gives you a better picture of what their arterial blood gas levels are, and we try to maximize the ventilator settings to improve oxygenation. We also have done things like continuous nebulizers and vasodilators."
At NYU Langone, ventilators were often unsuccessful in saving patients, she says. "I know of only two patients who got intubated and got off the ventilator. A lot of times, I felt that no matter what we did, nothing helped the patients. When they got so sick, even intubating them just prolonged the inevitable."
Dealing with respiratory therapist shortages during a patient surge
Under ideal circumstances, respiratory therapists work with a handful of ventilated patients during a shift. At NYU Langone, Sullivan worked with as many as 18 ventilated patients at a time.
Pairing respiratory therapists with critical care nurses was the primary strategy to maximize the efforts of respiratory therapists at NYU Langone, she says. "We typically worked side-by-side with the nurses because we went into the patient rooms and tried to tag-team the patients together."
The nurses performed routine tasks that the respiratory therapists would normally have done themselves, Sullivan says. "We trained the nurses to be a little more self-sufficient and not call respiratory therapists for simple tasks such as switching a nasal cannula or doing a couple of puffs with an inhaler for a COVID-19 patient with COPD. These are not critical emergent issues that could take a respiratory therapist away from the beside where we need to be. You can use nurses to do some of the basic things that busy respiratory therapists may not be able to get to."
NYU Langone also used hygienists to clean respiratory therapy equipment because the respiratory therapists did not have the time to process equipment, she says.
Working in a 'warzone'
At NYU Langone, the hardest part of working during the COVID-19 patient surge was the sheer volume of seriously ill patients, Sullivan says.
"We called one of the COVID-19 units the seventh circle of hell because it was not negative pressure. So, you would have two COVID-19 patients in a room, and it literally looked like a warzone. I still have flashbacks about how many sick people were in the same rooms and how overwhelming that was. I can't tell you how many times we went into a room and a patient would be expired and still be on the ventilator with IVs going."
Under these kinds of circumstances, medical staff need to brace for the worst, she says. "You need to know that the situation is intense and unlike anything you have ever seen before. In a typical week, you might have one or two code blues when a patient goes into cardiac arrest, and you might think that is a lot. At NYU Langone, there was a time when we counted 26 code blues in an eight-hour period. That is an insane number of codes in a short amount of time."
To cope emotionally and physically with a COVID-19 patient surge, healthcare workers must draw on every strength in their being, Sullivan says.
"It's will power, and you dig deep. My grandmother was an Army nurse, and my grandfather was a surgeon during World War II, and I just thought this was my chance to help out my fellow man. I committed myself to doing the best that I could do. I committed myself to working hard from the moment I walked through the hospital door to the moment when I would leave."
Facing death on an epic scale was a daunting challenge, she says. "The most heartbreaking thing for me—and it still gets to me—was all of the people who were dying horrible deaths. And they were dying alone with strangers. There were not enough iPads to call family members. We did not have the passwords on patients' smartphones. But we did Facetime with family members when we had time."
For Sullivan, small acts of kindness helped her deal with the darkest times. "I would do little things to make myself feel better, like cleaning a patient's face. If they had tears, I would wipe them off. I would sing to my patients when I went into their rooms. I hoped that it helped them—I hope that it showed that people cared about them."
The pandemic has highlighted problems that have plagued U.S. healthcare for decades.
The coronavirus disease 2019 (COVID-19) pandemic has four monumental implications for U.S. healthcare, a recent journal article says.
The COVID-19 pandemic poses the greatest public health threat in the United States since the Spanish flu outbreak a century ago. As of Aug. 4, more than 4.8 million Americans had been infected with the novel coronavirus and 159,000 had died, according to worldometer.
The recent journal article, which was published by the New England Journal of Medicine, says the COVID-19 pandemic has laid bare fundamental weaknesses in U.S. healthcare.
"The novel coronavirus pandemic has spawned four intertwined healthcare crises that reveal and compound deep underlying problems in the healthcare system of the United States. In so doing, however, the pandemic points the way toward reforms that could improve our ability not only to cope with likely future epidemics but also to serve the basic healthcare needs of Americans," the journal article co-authors wrote.
1. Health insurance crisis
The economic calamity associated with the COVID-19 pandemic has dealt a devasting blow to employer-sponsored insurance.
More than 20 million Americans have lost their jobs since the COVID-19 pandemic upended society in March. The spike in unemployment is likely to prompt millions of Americans to lose their employer-sponsored insurance. A recent Commonwealth Fund survey found that 40% of respondents or their partner who were laid off or furloughed had employer-sponsored insurance.
The pandemic-induced healthcare coverage mess is an opportunity to build on the coverage gains achieved through the 2010 Patient Protection and Affordable Care Act, the journal article co-authors wrote. "Proponents of expanded coverage have multiple policy options to choose from, ranging from a government-financed single-payer system such as Medicare for All to reforms that build on current law."
2. Healthcare provider financial crisis
The COVID-19 pandemic has wreaked calamitous financial losses at hospitals and physician practices. "Office-based practices had reductions of 60% in visit volumes in the first months of the crisis, and, by their own estimates, hospitals will lose an estimated $323.1 billion in 2020," the journal article co-authors wrote.
There are two primary solutions for the healthcare provider financial crisis, they wrote.
Shifting away from the fee-for-service model of healthcare payment to a capitation model. "One advantage of full or partial capitation and prospective budgeting is that they offer hospitals and health professionals a predictable stream of revenue that is unlinked from the volume of services provided. Capitation would have protected many providers against the sharp short-term losses they are sustaining as a result of COVID-19," the journal article co-authors wrote.
Boosting resources for services that have not been well-financed under the fee-for-service model such as primary care, behavioral health, and rural healthcare.
3. Healthcare disparity crisis
The coronavirus pandemic has exposed racial and ethnic disparities in U.S. healthcare, the journal article co-authors wrote. "Black persons constitute 13% of the U.S. population but account for 20% of COVID-19 cases and more than 22% of COVID-19 deaths, as of July 22, 2020. Hispanic persons, at 18% of the population, account for almost 33% of new cases nationwide."
There are five primary ways healthcare disparities can be address, they wrote.
Broad societal action could be taken to improve the social determinants of health problems that beset communities of color such as substandard education and food insecurity.
Establishing universal healthcare coverage would improve access to care for racial and ethnic groups, which would help reduce the incidence of chronic conditions in these populations.
Boosting resources for safety-net hospitals and small community healthcare facilities also would improve access to healthcare services.
Anti-bias training could be mandatory in the education and licensing of healthcare workers.
Medicare and Medicaid payments could be tied to quality of care metrics for healthcare services provided to communities of color.
4. Public health crisis
Compared to other countries, the United States has been the hardest hit during the COVID-19 pandemic, uncovering weaknesses in the American public health system.
"Put simply, that system failed to quickly identify and control the spread of the novel coronavirus. The United States did not make testing widely available early in the pandemic, was late to impose physical-distancing guidelines, and has still not implemented either as widely as needed. National guidance on managing the pandemic has been inconsistent and delayed. Many states have now abandoned stringent physical-distancing guidelines without careful attention to public health measures needed to prevent resurgence," the journal article co-authors wrote.
There are five primary actions to improve the public health system, they wrote.
The country needs to strengthen its ability to implement collective public health measures such as bolstering state and local public health authorities.
During a public health emergency, federal authorities should have the ability to spend taxpayer dollars without congressional approval.
During a pandemic, the federal government should be able to mandate state efforts to control the spread of infection.
During a pandemic, the federal government should be able to manage the distribution of vaccines and antimicrobial agents.
During a public health emergency, the federal government should be able to compel states to allow clinicians to provide interstate telehealth services.
