Compared to ventilator care, nasal high flow therapy for seriously ill coronavirus patients has several benefits, including the ability to mobilize patients.
Nasal high flow (NHF) therapy is a less invasive alternative to ventilator care for many seriously ill coronavirus patients, UnityPoint Health experts say.
During the coronavirus disease 2019 (COVID-19) pandemic, ventilator care has been used commonly for coronavirus patients experiencing acute respiratory distress. However, ventilator care has posed several challenges, including shortages ventilators and the staff needed to manage patients on mechanical ventilation.
NHF therapy is delivered to a patient through a high flow nasal cannula. According to the American Association for Respiratory Care (AARC), an NHF therapy system usually features four elements:
Gas blender
Flow meter display
Nasal interface and heated circuit
Humidification system
"One of the hallmarks of an efficient NHF system is to be able to deliver optimally humidified gas at body temperature pressure and humidification," an AARC document says.
At three UnityPoint Health hospitals in Iowa, using NHF therapy has allowed clinicians to keep 73% of seriously ill COVID-19 patients off ventilators. In addition, the duration of NHF therapy for these patients has averaged about three days compared to about eight days for patients placed on mechanical ventilation.
For seriously ill COVID-19 patients, several criteria indicate or contraindicate use of NHF therapy, says Matthew Trump, DO, medical director of UnityPoint Health pulmonary rehabilitation, and co-medical director of the Palliative Care Department at The Iowa Clinic, which is based in West Des Moines, Iowa.
Seriously ill COVID-19 patients are good candidates for NHF therapy if they are awake, breathing spontaneously, and hemodynamically stable, he says. Seriously ill COVID-19 patients are poor candidates for NHF therapy if they cannot maintain their airway and/or have severe respiratory acidosis with a pH of less than 7.2, he says.
Advantages of NHF therapy
In the treatment of severe COVID-19, there are several benefits to using NHF therapy rather than mechanical ventilation, according to Trump and Julie Jackson, respiratory care services manager at UnityPoint Health.
With NHF therapy, the patient is able to be awake, able to mobilize, able to communicate, and able to eat and drink. The ability to mobilize patients avoids some of the weakness and debilitation patients experience when they are on mechanical ventilation.
A physiologic benefit is that the patient's lungs are not subjected to potentially injurious pressure from a ventilator.
Patients receiving NHF therapy can be managed in an inpatient ward as opposed to the ICU setting, which generates multiple benefits including lower demand for ICU beds and avoidance of ICU-related complications such as infections.
Unlike patients placed on mechanical ventilation, patients receiving NHF therapy can be active participants in their care such as involvement in medical decision-making and self-proning. "They can move themselves into a prone position, so their oxygenation is improved. Whereas, if the patient is on a ventilator, it takes a lot of resources and a lot of staff to prone the patient," Jackson says.
NHF therapy can be used when a patient is extubated, which has lowered the rate of re-intubation at the UnityPoint Health hospitals.
When small community hospitals need to transfer a seriously ill COVID-19 patient to a larger hospital for advanced care, many of the patients can receive NHF therapy during transport rather than being intubated.
Dartmouth-Hitchcock Health's Clinical Recovery Command Team leads the effort to restart medical services that were put on hold for the coronavirus pandemic.
At Dartmouth-Hitchcock Health, ensuring safety and adequate medical supplies such as personal protective equipment (PPE) are top goals in reopening services paused for the coronavirus pandemic.
As the coronavirus disease 2019 (COVID-19) pandemic spread across the country in March, many health systems and hospitals suspended some outpatient services and most elective surgeries. Now, most of these organizations are seeking to reactivate paused services without endangering patients and staff. Dartmouth-Hitchcock's strategy could serve as a blueprint for other health systems that were not innundated with COVID-19 patients.
"Our No. 1 priority has been the health and safety of our patients, our visitors, and our staff. The current situation seems manageable. We have never been overwhelmed," says Edward Merrens, MD, chief clinical officer at the Lebanon, New Hampshire-based health system.
Dartmouth-Hitchcock features a 400-bed academic medical center as well as four affiliated critical access and community hospitals in New Hampshire and Vermont.
Safety measures
Dartmouth-Hitchcock has initiated several safety measures, and a key metric shows the efforts have been effective, Merrens says. "We have not had any staff contract coronavirus from a work-related incident."
The safety measures have included:
Universal masking: Masks are provided to everyone—employees and patients—who comes into a hospital across the health system.
Patient encounters: When interacting with patients, staff must wear not only a mask but also a visor. For more sensitive environments—whether it is an operative setting or in a COVID-19 unit—there is the highest level of PPE including gowns and gloves.
Waiting rooms: Some chairs have been removed from waiting rooms to establish social distancing.
Appointments: Patient visits to hospital departments and outpatient clinics have been spread out with extended workdays and weekend visits.
Reduced patient visits: "We have clearly reduced the number of people in the hospital. We have found different ways of getting to people with visiting nurse services to reduce the number of times patients have to come to the hospital. Physical therapy for joint surgery can be done online with videos," Merrens says.
Telemedicine: "We were able to pivot many of our visits to telehealth, which has been a big part of our recovery efforts. We already had a very robust telehealth capacity with our Connected Care, which was doing everything from critical care to specialty care before the pandemic," he says.
Managing the reopening
In early April, Dartmouth-Hitchcock launched the organization's Clinical Recovery Command Team to manage the reopening of paused services.
"We have tried to look at each area and determine what is needed for patients, what are the barriers, what are the things we are trying to achieve, and how we can implement change across our health system," Merrens says.
The command team has nine work groups:
Surgical group focusing on the academic medical center's main operating rooms and the health system's outpatient surgical center
Interventional procedures that are not necessarily operative such as cardiac catheterization, interventional radiology, and electrophysiology
Endoscopy and minor procedures
Primary care and pediatrics
Ambulatory surgical and specialty care
Radiology
Lab work
Community group practice
Affiliated hospitals
The command team reports directly to the health system's president and CEO, Joanne Conroy, MD, and includes many of the organization's senior executives, Merrens says.
The multidisciplinary committee is led by a clinical-administrative dyad: Merrens and Chief Operating Officer Patrick F. Jordan III, MBA. Jeffrey O'Brien, MHA, MS, senior vice president for clinical operations, leads two vice presidents who directly oversee the nine work groups. "The individual work groups have other vice presidents, directors, and line managers who are dedicated to their areas, and they work with clinicians," he says.
Orthopedics is a good example of how the command team is approaching the reopening of paused clinical services, he says. "We have people thinking about restarting orthopedics, and they are working with our perioperative vice president, the orthopedics director, the department chair, and section chiefs. They are not only working on trauma—which has not changed during the pandemic—but also how we think about elective cases."
The command team is operating under several guiding principles, Merrens says.
"The first guiding principle has been assessing our situation. If you look across the country, Seattle, San Francisco, New York City, Boston, Chicago, and New Orleans have all had different experiences in the pandemic," he says. "We have flattened the curve in our region, so we can plan and think about what comes next. If you are in a situation like New York City, where the ICUs were filled, it can be overwhelming."
The command team is committed to simultaneously providing COVID-19 care along with a wide range of other medical services. "What we have been able to do is to think about the pandemic as a long-term process in our region. We have had low levels of infection rates—probably less than 10% of the population. This does not lend itself to herd immunity, but it does lend itself to doing COVID care and regular care at the same time," Merrens says.
Ensuring there is an adequate supply of PPE is essential. "We have had tremendous donations from the community. We have been able to source PPE with colleagues across northern New England. We have implemented a process of recycling our N95 masks—we have a hydrogen peroxide vapor system that allows us to reuse masks. Everyone on the staff has their own mask. Once they use the mask, it can be sterilized," he says.
Academic activities are a significant element of the recovery process. Dartmouth-Hitchcock has assembled a team of experts in microbiology, epidemiology, and lab services to conduct innovative research such as nearly 30 clinical trials related to the coronavirus pandemic.
Meeting community needs is a priority, Merrens says. "That could be COVID care. That could be routine screening. That could be childhood immunizations. That could be hip replacements."
Pandemic's silver lining
The COVID-19 crisis has been a driver of innovation at Dartmouth-Hitchcock, Merrens says. "The pandemic has allowed us to rapidly adopt different ways of doing things—whether it is telehealth or expanding our workday. It has allowed us to make changes that we might not have made as rapidly before the pandemic. We have been able to use the pandemic as an opportunity for positive change."
The height of the pandemic and the reopening process will have a lasting impact on the health system, he says. "This will fundamentally change who we are and how we provide care. So, this is not getting back to how we were doing things before—we will always do things differently in the future."
Reassigning medical staff to serve in new roles such as the ICU setting has been a crucial care strategy during the coronavirus pandemic.
Particularly in hotspots such as New York and New Jersey, medical staff shortages have been a hallmark of the coronavirus pandemic, requiring reassignment of staff to new roles.
To avoid being overwhelmed by coronavirus disease 2019 (COVID-19) patient surges, health systems and hospitals have redeployed medical staff to fill gaps and bolster the ranks of frontline healthcare workers. For example, anesthesiologists have been reassigned from performing elective surgery to providing respiratory care in the ICU setting.
Brian Lima, MD, surgical director of heart transplantation at Northwell Health's North Shore University Hospital in Manhasset, New York, was reassigned to care for seriously ill COVID-19 patients in a converted hospital ICU. He also is an associate professor of cardiothoracic surgery at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York, and author of a recently published book, Heart to Beat.
Lima recently shared his insights into the successful reassignment of healthcare workers with HealthLeaders. The following is a lightly edited transcript of that conversation:
HealthLeaders: For healthcare workers, what is an effective mindset for reassignment?
Lima: In a pandemic, it's all hands on deck. Everybody has to contribute. For me, I ceased being a cardiac surgeon and became a COVID doctor. At the same time, this is what we trained for. We trained to help people and to save lives. This is what the Hippocratic Oath is all about.
You have to take it one day at a time. Do the best that you can and give it your all.
It has to be a growth mindset. You see the growth mindset in a lot of the entrepreneurial literature. When there is an unexpected development or negative outcome, instead on getting down on yourself or slipping into pessimism, you flip it into a positive. If it is a single event, that is not going to define you as a person or a professional.
In this instance, no one saw the pandemic coming and it is a devastating crisis, so you have to try to flip it to a positive lens. This is an opportunity to grow. This is an opportunity to help others. It is not about you—it is about doing good for as many people as possible.
HL: How did you turn responding to the pandemic to a growth mindset?
Lima: I felt that I took care of critically ill patients all the time. As we converted our cardiac ICU into a COVID ICU, I realized these were also critically ill patients with lungs being devastated by the virus. So, it was a matter of pivoting in the way that I take care of critically ill people and going more in depth into one organ system and managing ventilators.
HL: What are the key elements of training and preparing healthcare workers for reassignment?
Lima: What worked well for us is that there were some physicians who were well prepared for reassignment—they spend a lot of their professional time managing complicated patients on a ventilator. We had refresher training with these specialists through Zoom and refresher documents, so we were all on the same page.
We established an approach for critically ill COVID patients and developed a check list for how we were going to progress through our ventilator management. So, it was nice to have concentrated expertise and to disseminate that expertise to physicians who were getting back into the fray in the area of acute respiratory distress syndrome.
It also is important to have backup, so you are not being put on an island all alone. You could always call upon others—we were all in this together. There was a lot of support from physicians who specialized in respiratory failure. It helped reassigned physicians feel comfortable in working with COVID patients.
HL: Based on your experience of reassignment to the respiratory failure ICU setting, what are the keys to success in functioning well in a reassigned role?
Lima: At the individual level, you have to check your ego at the door. Although you may be expert at a specialty, in this environment, where knowledge about the coronavirus is changing daily, you have to be humble. You have to be willing to ask for help, and the help has to be readily available.
It takes courage. Healthcare workers are in a situation where we have an imminent risk to ourselves and to our families at home. You need the courage to face that fear every day and to continue to do the right thing for the patients.
You need to have compassion. Many of these patients don't do well. This is a horrible disease—a very aggressive infection. Despite our best efforts, sometimes the patients don't pull through. Sometimes, all you can do is be compassionate for the patient in their waning moments. There is no family there for the patients because of the strict visiting rules, so being a surrogate loved one for the patients and being merciful and compassionate is huge.
HL: Are there pitfalls to avoid when assigning healthcare workers to new roles?
Lima: You want to give people the opportunity to contribute and help. You should not make reassignment like a demand. Getting buy in is key—you can't come across as being authoritative. Most—if not all—healthcare workers will step forward. For example, in our department, we volunteered to be reassigned.
Having enough personal protective equipment goes a long way because that's one thing you don't have to worry about. Not having enough PPE is a huge pitfall.
HL: How do you foster willingness for reassignment?
Lima: It comes from the top down. You lead by example. If your leadership is volunteering in the trenches, others will follow that example. In my department, our chair, Dr. Alan Hartman, told us he was volunteering to help cover COVID patients, and we all agreed to do the same. We were not told to accept reassignment, we went along with him.
The president of The Physicians Foundation calls on regulators to include doctors in rule decision-making.
The coronavirus disease 2019 (COVID-19) pandemic is highlighting the need to reduce regulatory burdens in healthcare, the president of a physician organization says.
Healthcare is one of the most highly regulated sectors in the U.S. economy. Regulatory compliance costs hospitals $1,200 for every patient admitted, according to the American Hospital Association.
"The COVID-19 pandemic has exacerbated the need to include physicians' input in healthcare policy and regulations. Physicians are the foundation of our healthcare system, yet we have long endured interruptions to the physician-patient relationship and to the workflow of our practices from regulatory decisions," says Gary Price, MD, president of The Physicians Foundation.
The pandemic has compounded the stress and burnout physicians were already experiencing from regulatory burdens, he says. "Prior to the pandemic, onerous regulations made it difficult to enjoy practicing medicine and hindered the physician-patient relationship, which 78.7% of physicians regard as the most satisfying part of their job, according to our 2018 Survey of America's Physicians."
Government officials should include physicians in the design of regulations, Price says.
"To create a patient-focused industry that fosters improved health outcomes, physicians should have influence in reform that addresses inefficient electronic health records and ever-changing practice and payment models, as physicians are patients' biggest advocates. Especially during the COVID-19 pandemic, policies that are physician-informed will increase efficiency in practices and emphasize patient safety and outcomes."
Telehealth: Regulatory move in the right direction
An example of a burdensome regulation that has been eased in response to the COVID-19 pandemic is the Health Insurance Portability and Accountability Act (HIPAA) requirements for telehealth, Price says.
"The U.S. Department of Health and Human Services announced it would loosen the HIPPA restrictions around telehealth to expand access. Now patients can access telehealth appointments through consumer platforms that allow for private video chats, such as Skype or Facetime. Previous regulation required that practices use HIPPA-compliant platforms, but transitions to such platforms are time-consuming and physicians are working frantically to get their patients access to care immediately."
A recent survey conducted by The Physicians Foundation and Merritt Hawkins shows a spike in the number of physicians using telehealth to provide patient services. The survey, which was published last month, found 48% of physicians are treating patients with telemedicine. The 2018 Survey of America's Physicians found that 18% of doctors were practicing with telemedicine.
EHR: Need for improvement
The COVID-19 pandemic has exposed the need to improve interoperability regulations for electronic health records (EHRs), Price says.
"As knowledge about the virus changes every day, physicians need to be able to access and share patient data immediately, which difficult to do with EHRs. Redesigning EHRs with physician input could increase efficiency and lead to better patient outcomes, as well as relieve stress and burnout in physicians."
Data in the Viral Infection and Respiratory Illness Universal Study registry includes mechanical ventilation duration and ICU length of stay.
Mayo Clinic and the Society of Critical Care Medicine have launched a global coronavirus registry to track ICU and hospital care patterns.
Since the coronavirus disease 2019 (COVID-19) outbreak began in Wuhan, China, in December, scientists and clinicians have been scrambling to determine the pathology and care pathways for the novel virus. Much remains to be learned such as amassing data about treatments and outcomes.
A key goal of the Viral Infection and Respiratory Illness Universal Study (VIRUS) registry is to gather information about practice variations in the care of seriously ill COVID-19 patients, says Rahul Kashyap, MBBS, MBA, a researcher and VIRUS registry principal investigator at Rochester, Minnesota-based Mayo Clinic.
"It will include use of novel experimental therapies including antivirals, as well adherence to best practice guidelines for critically ill patients," he says.
VIRUS launched March 31 and includes a data dashboard. As of May 27, the registry had collected data from more than 5,300 COVID-19 patients at 109 care sites in 11 countries. At 89, most of the care sites are in the United States. In addition to patient demographics, the data includes mechanical ventilation duration, ICU length of stay, and ICU discharge details.
All healthcare facilities that are treating COVID-19 patients are eligible to participate in the registry.
Kashyap says the registry can support several lines of research, including modifiable risk factors, associations of presenting symptoms and medical history with patient outcomes, and the effect of novel experimental therapies on care processes and patient recovery.
He optimistic that the registry will play a pivotal role if there is a second wave of COVID-19 cases in the upcoming fall or winter. "Before the second wave of the pandemic, the data automation efforts within registry, inclusion of seasonal variation data points, and rapid cycle dissemination of aggregated knowledge about adults and children with COVID-19 will be an ultimate game changer."
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."
