A crucial element of creating new ICUs during a pandemic is combining experienced critical care staff with reassigned non-ICU personnel.
The Society of Critical Care Medicine (SCCM) is recommending a tiered staffing model for hospitals opening new ICUs in response to the novel coronavirus (COVID-19) pandemic.
To avoid rationing of critical care services, which has been reported in China and Italy, U.S. hospitals are scrambling to find ventilators and critical care staff to expand ICU beds for treatment of high-acuity COVID-19 patients. Severe hypoxic respiratory failure requiring mechanic ventilation is the most common reason that COVID-19 patients are being admitted to ICUs globally, according to a recent SCCM report.
"As large numbers of critically ill patients are admitted to ICU, step-down, and other expansion beds, it must be determined who will care for them. Having an adequate supply of beds and equipment is not enough. Based on AHA 2015 data, there are 28,808 privileged and 19,996 full-time equivalent intensivists in the United States; however, 48% of acute care hospitals have no intensivists," the SCCM report says.
ICU tiered staffing model for COVID-19 pandemic
To address the anticipated shortage of ICU staff during the COVID-19 pandemic, SCCM is proposing that U.S. hospitals adopt a tiered staffing model that integrates experienced ICU personnel with reassigned hospital staff members. The integrated ICU personnel would be used to staff non-traditional ICUs created in repurposed hospital spaces such as post-anesthesia care units, Lewis Kaplan, MD, president of SCCM and professor of surgery at the University of Pennsylvania's Perelman School of Medicine in Philadelphia, told HealthLeaders last week.
An SCCM graphic of the proposed tiered staffing model is not absolute—each hospital will have to determine the best combination of staff members based on available resources, Kaplan says.
"The graphic is a helpful guide to see how you could do things, where you might begin to deploy your resources or education, and what the staffing model could look like. There will be some hospitals that have a different way of looking at their staffing model—there can be several successful approaches that reflect the unique elements of a hospital's capabilities and staffing," he says.
In the SCCM graphic, one trained or experienced critical care physician would supervise four ICU teams, with each team providing care to 24 mechanically ventilated COVID-19 patients. Each team would have four tiers:
At the top tier, each ICU team could be led by an experienced ICU advanced practice practitioner or a reassigned non-ICU physician.
The second tier would focus on mechanical ventilation and could be staffed by a combination of experienced and reassigned doctors, respiratory therapists, advanced practice practitioners, certified registered nurse anesthetists (CRNAs), and certified anesthesiologist assistants (CAAs).
The third tier could be staffed by experienced ICU nurses.
The fourth tier could be staffed by reassigned non-ICU nurses.
Tiered staffing model keys to success
Four actions are necessary for a tiered ICU staffing model to function effectively during the COVID-19 pandemic, Kaplan says.
1. Limiting elective surgeries frees up acute and ICU care beds, staff members, and ventilators. On the staffing front, reducing elective surgeries increases the availability of anesthesiologists, OR nurses, OR technicians, CRNAs, and CAAs. "Anesthesiologists and CRNAs are very good at managing mechanical ventilation and helping to care for people with acute illness," Kaplan says.
Reducing elective surgeries also increases the availability of ventilators, he says. "OR anesthesia machines are in fact ventilators that happen to have several other features such as delivering anesthetic gases."
2. Training of non-critical care staff who are reassigned to ICU duty is essential. The training should focus on education for new skills as well as refreshing staff members on any earlier critical care training. "People who are being trained or refreshed in conjunction with staff members who know how to care for patients with acute illness can work together in a repurposed space," Kaplan says.
3. Combining experienced and inexperienced ICU staff helps ensure an adequate level of care. "When you put people in a space where they don't typically work, it can be very trying. So, you need to have a partner system where the new ICU is not entirely composed of many people who have never worked in an ICU. … This will ultimately allow inexperienced staff members to have a buddy who can help them, guide them, or provide comfort," he says.
4. Public health measures limit viral transmission and viral spread, which slows down the rate at which COVID-19 patients present for hospital care. "This is the so-called flattening of the curve," Kaplan says.
COVID-19 tests have been in limited supply since the first U.S. novel coronavirus patient was identified in January. As of March 20, 14,372 cases had been confirmed in the United States, with 217 deaths, worldometer reported.
Public health officials and healthcare providers should prioritize who is tested for COVID-19 for as long as the test shortage persists, the IDSA recommendations say. "Given current limited availability of near-patient, or point-of-care, testing, IDSA has developed recommendations for diagnostic testing prioritization. These recommendations will likely change as testing becomes more widely available or as new information becomes available. IDSA continues to advocate for policies and investments to expand capacity to testing."
The IDSA is recommending a 4-tier approach to prioritize COVID-19 testing for patients, officials, and members of the general public.
Tier 1
There are five categories of people recommended for the highest priority testing:
Any hospitalized patients who are critically ill and receiving ICU-level care with unexplained viral pneumonia or respiratory failure
Anyone with fever and signs of a lower respiratory tract illness who has had close contact with a confirmed COVID-19 patient within 14 days of symptom onset
Anyone with fever and signs of a lower respiratory tract illness who has traveled within 14 days of symptom onset to countries or areas of the United States that have experienced sustained community transmission of novel coronavirus
Anyone with fever and signs of a lower respiratory tract illness who is immunosuppressed, elderly, or has underlying chronic health conditions
Individuals who are critical to pandemic response such as health workers and public health officials who have fever and signs of a lower respiratory tract illness
Tier 2
People at the second highest priority for testing are hospitalized patients and long-term care residents who have unexplained fever and signs of lower respiratory illness. "The number of confirmed COVID-19 cases in the community should be considered. As testing becomes more widely available, routine testing of hospitalized patients may be important for infection prevention and management at discharge," the recommendations say.
Tier 3
Patients in outpatient settings who meet influenza testing criteria, including people with co-morbid conditions such as diabetes and congestive heart failure as well as individuals over age 50. "Given limited available data, testing of pregnant women and symptomatic children with similar risk factors for complications is encouraged. The number of confirmed COVID-19 cases in the community should be considered," the recommendations say.
Tier 4
People targeted for community surveillance by public health or infectious disease officials.
Optimal mitigation efforts, which focus on slowing the spread of the novel coronavirus, will not avoid critical care resources being overwhelmed, new report says.
A new report on the novel coronavirus (COVID-19) pandemic predicts that even an optimal mitigation scenario would result in as many as 1.2 million deaths in the United States.
Since December, COVID-19 has spread from China to 166 countries and territories, with more than 207,000 confirmed cases and more than 8,600 deaths, according to the World Health Organization. As of March 19, 9,477 cases had been confirmed in the United States, with 155 deaths, worldometer reported.
The COVID-19 pandemic is one of the most serious public health emergencies in a century, according to the new report, which was published this week by the Imperial College COVID-19 Response Team in the United Kingdom. "The global impact of COVID-19 has been profound, and the public health threat it represents is the most serious seen in a respiratory virus since the 1918 H1N1 influenza pandemic," the report says.
As a baseline, the report estimates the human toll and healthcare-demand impact of taking no public health actions and making no individual behavior changes to control the COVID-19 pandemic:
81% of the U.S. population would become infected during the pandemic
There would be 2.2 million deaths in the United States, "not accounting for the potential negative effects of health systems being overwhelmed on mortality"
The peak demand on ICU and other critical care capacity would be more than 30 times higher than available U.S. resources
Mitigation vs. suppression
There are two primary public health responses to the COVID-19 pandemic: mitigation and suppression, the report says. Mitigation seeks to slow down the spread of the novel coronavirus. Suppression seeks to reverse epidemic growth.
Based on modeling, the best mitigation scenario would involve a combination of case isolation, home quarantine, and social distancing for individuals at highest risk such as those over age 70. However, there would be dire consequences, the report says.
"In combination, this intervention strategy is predicted to reduce peak critical care demand by two-thirds and halve the number of deaths. However, this 'optimal' mitigation scenario would still result in an 8-fold higher peak demand on critical care beds over and above the available surge capacity in both [Great Britain] and the [United States]."
A combination of suppression measures would be the best strategy to control the pandemic in countries that could sustain the Herculean effort required, the report says.
"A combination of case isolation, social distancing of the entire population, and either household quarantine or school and university closure are required. Measures are assumed to be in place for a 5-month duration. Not accounting for the potential adverse effect on ICU capacity due to absenteeism, school and university closure is predicted to be more effective in achieving suppression than household quarantine. All four interventions combined are predicted to have the largest effect on transmission."
This suppression strategy would have the highest likelihood of keeping the number of severe COVID-19 cases within the surge capacity of critical care beds, but implementing the strategy would be daunting, the report says.
"The major challenge of suppression is that this type of intensive intervention package—or something equivalently effective at reducing transmission—will need to be maintained until a vaccine becomes available (potentially 18 months or more)—given that we predict that transmission will quickly rebound if interventions are relaxed."
Interpretation and reaction
The new report is a wakeup call for healthcare organizations, says Chris DeRienzo, MD, MPP, system chief medical officer and senior vice president of quality at Raleigh, North Carolina-based WakeMed Health & Hospitals.
"These projections are sobering at best. Acknowledging that any model comes with assumptions that may or may not bear out in real life, these results are appropriately driving massive efforts across America to dramatically increase hospital and critical care capacity," he says.
Regarding whether the COVID-19 pandemic will overwhelm critical care resources, U.S. hospitals should be prepared for the worst but hope for the best, DeRienzo says. "I am both a realist and an optimist by nature—doctors have to be. To borrow from Jim Collins, we have to confront the brutal fact that all evidence points to a tsunami of critical care needs. At the same time, we must also maintain an unwavering faith in our ability to join together and meet the challenge."
There is uncertainty over how long mitigation and suppression efforts will have to be in place, he says. "No one has lived through a global pandemic of this magnitude since the 1918 Spanish flu. In truly unprecedented times for 99% of people on Earth, I do not believe anyone can tell with certainty how long we will need to endure suppression and mitigation if we are to save as many lives as we can."
There has already been rationing of testing in the United States and rationing of critical care resources is likely if severely ill COVID-19 patients surge significantly.
The novel coronavirus (COVID-19) pandemic is raising thorny medical ethics dilemmas.
In China and Italy, there have been reports of care rationing as the supply of key resources such as ventilators has been outstripped by the number of hospitalized COVID-19 patients. China, the epicenter of the pandemic, has the highest reported cases of COVID-19 at more than 80,800 as of March 17, according to worldometer. Italy has the second-highest number of COVID-19 cases at nearly 28,000 cases.
The severest form of COVID-19 includes pneumonia, which can require admission to an ICU and mechanical ventilation. "Those are not just things, there are expertly trained healthcare workers who man those domains. There just isn't enough of these resources than what we anticipate needing," says James Tabery, PhD, associate professor in the University of Utah Department of Philosophy and the University of Utah School of Medicine’s Program in Medical Ethics and Humanities.
He says the COVID-19 outbreak poses four primary ethical challenges in the healthcare sector.
1. Treatment
In the United States, caring for the anticipated surge of seriously ill COVID-19 patients is likely to involve heart-wrenching decisions for healthcare professionals, Tabery says. "The question is how do you ration these resources fairly? With treatment—we are talking about ICUs, ventilators, and the staff—the purpose is you are trying to save the severely sick. You are trying to save as many of the severely sick as you can."
The first step in managing critical care resources is screening out patients who are unlikely to need critical care and urging them to self-quarantine at home, he says.
"But eventually, you bump up to a place where you not only have screened out all of the folks who are at low risk of serious illness, but you have millions of people across the country who fall into high-risk groups. If they get infected, many are going to need access to ventilators, and the way you do that ethically is you screen patients based on medical utility," Tabery says.
Medical utility is based on scientific assessments, he says. "You basically look at the cases and try to evaluate as quickly and efficiently as possible the likelihood that you can improve a patient's condition quickly."
Rationing of critical care resources would be jarring for U.S. clinical staff.
Under most standard scenarios, a patient who is admitted to an ICU and placed on mechanical ventilation stays on the machine as long as the doctors think the patient is going to get better, Tabery says.
However, the COVID-19 pandemic could drive U.S. caregivers into an agonizing emergency scenario.
"When there are 10 people in the emergency room waiting to get on a ventilator, it is entirely feasible that you would be removing people from ventilators knowing that they are going to die. But you remove people from ventilators when your evaluation of the medical situation suggests that patients are not improving. If a patient is not improving, and it doesn't look like using this scarce resource is a wise investment, then you try it out on another patient who might have better luck," he says.
2. Testing
There has been rationing of COVID-19 testing in the United States since the first novel coronavirus patient was diagnosed in January.
While there are clinical benefits to COVID-19 testing such as determining what actions should be taken for low- and high-risk patients, the primary purpose of testing during a pandemic is advancing public health, Tabery says.
"The primary purpose of the test is pure public health epidemiology. It's about keeping track of who has COVID-19 in service of trying to limit the spread of the disease to other people. When that is the purpose, the prioritization isn't so much about who is at greatest risk. It's about who is more likely to interact with lots of people, or who is more likely to have interacted with more people."
A classic example of rationing COVID-19 testing based on public health considerations is the first reported infection of an NBA player, he says.
"For the Utah Jazz player who had symptoms, it made sense to test him very quickly because it was clear that he had interacted with a lot of people. Once he tested positive, the testing of the other players was not because public health officials thought the players were more valuable than the average person on the street. It was because the players had come into contact with more people than the average person on the street."
3. Healthcare workers
The COVID-19 pandemic involves competing obligations for healthcare workers, Tabery says. "On the one hand, they have a set of obligations that inclines them to go to work when they get the call. On the other hand, healthcare workers have their own interests—they don't want to get sick, which can incline them not to work," he says.
"The punchline is there is an ethical consensus that healthcare workers have a prima facie duty to work because of everything that has been invested in them, because of their unique position where not just anybody can replace them, because society looks to them to serve this function, and because they went into this profession and are expected to go into work," he says.
However, the obligation of healthcare workers to show up for their jobs is not absolute, Tabery says. "If hospitals don't have personal protective equipment, they are in no position to tell their staff to show up and work. If a hospital cannot provide even a basic level of safety for their employees to do their job, then they are turning their hospital not into a place to treat patients—they are turning it into a hub to exacerbate the problem."
4. Vaccine
When a vaccine becomes available, policymakers, public health officials, and healthcare providers will face rationing decisions until there is sufficient supply to treat the entire U.S. population, Tabery says.
"When the vaccine comes out, the first group you are going to want to prioritize are healthcare workers, who are at risk of getting infected by doing their jobs and saving lives. You would also want to prioritize people who serve essential functions to keep society going—the people who keep the water running, the lights on, police, and firefighters. Then you want to start looking at the high-risk groups," he says.
Online medical ethics resources
The American Medical Association has the following online resources to help guide ethical decision making by clinicians and other healthcare workers during the COVID-19 pandemic:
Missed and delayed diagnoses lead patient safety list developed by the ECRI Institute.
In addition to issues related to the novel coronavirus, ECRI has identified 10 top patient safety concerns for 2020.
Twenty years after publication of the Institute of Medicine's landmark report To Err is Human: Building a Safer Health System, patient safety remains a significant concern for the healthcare sector. The Institute of Medicine report estimated 98,000 Americans were dying annually due to medical errors. Estimates of annual patient deaths due to medical errors have since risen steadily to 440,000 lives, which make medical errors the country's third-leading cause of death.
The scope of ECRI's top 10 patient safety concerns for this year is broad, the executive brief of the report says. "This top 10 report highlights patient safety concerns across the continuum of care because patient safety strategies increasingly focus on collaborating with other provider organizations, community agencies, patients or residents, and family members. Each patient safety concern on this list may affect more than one setting."
ECRI has been gathering patient safety event data through its patient safety organization, ECRI PSO, since 2009. "We and our partner PSOs have received more than 3.2 million event reports. This means that the 10 patient safety concerns on this list are very real. These concerns are harming people—sometimes seriously," the executive brief says.
1. Missed and delayed diagnoses can result in worse outcomes than timely diagnosis. "Accurate diagnosis requires the clinician to get a complete clinical picture of the patient’s relevant circumstances. It takes time to obtain an accurate history and perform a comprehensive physical, and clinician-patient communication is crucial," the executive brief says.
The electronic health record (EHR) can play a key role in the diagnosis process such as tracking the trajectory of a patient's condition and cataloging examinations and test results.
2. Maternal health is a pain point in the United States, which lags the industrialized world in this healthcare category. The federal Centers for Disease Control and Prevention have been monitoring maternal mortality since 1986. The number of pregnancy-related deaths has risen steadily since the monitoring effort began, from 7.2 deaths per 100,000 live births in 1987 to 18.0 deaths per 100,000 live births in 2014.
"Issues that impact maternal health in the U.S. include racial and ethnic disparities; care coordination between ambulatory, specialist, and acute care settings; provider-patient communication and engagement; higher rates of risk factors (such as pregnancy later in life); and access to quality care," the executive brief says.
3. Early recognition of behavioral health needs is an essential factor to reduce workplace violence in healthcare settings. About three-quarters of U.S. workplace assaults occur in healthcare settings, according to a report by the Occupational Safety and Health Administration.
Violent or threatening behaviors in patients are often not related to mental illness, the executive brief says. "Organizations can improve their recognition of and response to behavioral health needs by providing education, training and retraining, behavioral health assessment for patients, improving rapid response teams' response times by conducting drills, and instituting a culture change that begins with the organization's leadership."
4. Responding to and learning from device problems requires a comprehensive plan to investigate device-related incidents, the executive brief says. "The organization should also have protocols for investigating incidents involving specific types of devices, equipment, or disposables. Consider issues such as what data logs are kept, which accessories are included, how the equipment would be sequestered and tagged, additional devices or systems with which it interfaces, and what information must be documented."
5. Device cleaning, disinfection, and sterilization is generally the responsibility of sterile processing departments. SPDs face several barriers such as productivity pressure, lack of supplies, and communication problems with the departments they serve.
"ECRI recommends facilities establish effective workflows that involve SPD and clinical staff input, incorporate quality checks throughout the sterilization process, improve interprofessional relationships, and provide continuing education opportunities for staff," the executive briefing says.
6. Standardizing safety across healthcare organizations is challenging in this era of mergers and acquisitions, the briefing says. "The modern healthcare system stretches beyond hospital walls, across the continuum of care, and across state lines. A system's culture of safety must have the same reach. As the expansion of health systems continues, organizations find themselves facing many settings with differing cultures, processes, and resources."
Solutions include education as well as standardizing policies, processes, and procedures.
7. Patient matching in the EHR is essential to avoid creating duplicate records as well as overlay records, which occurs when one patient's information is included in another patient's record. "Strong matching practices should be applied in EHR systems, prescription drug monitoring programs (PDMPs), health information exchanges (HIEs), and other digital health technologies, to allow for the flow of correct patient information across the continuum of care," the executive briefing says.
8. Antimicrobial stewardship fights antimicrobial resistance, which limits treatment options for patients. "Despite the increased focus on the importance of antimicrobial stewardship in healthcare, and increased recognition among healthcare workers and patients alike, antibiotics are still being prescribed unnecessarily, when no longer needed, in the wrong dose, and with the wrong indication," the executive brief says.
9. Overrides of automated dispensing cabinets (ADCs), which control access to medications, can put patients at risk when overrides circumvent pharmacist review and approval. Overrides are designed for emergency situations, when medications are needed immediately. Measures to ensure patient safety include medication safety committee review of whether ADC override access is appropriate and retrospective pharmacist review of overrides, the executive brief says.
10. Fragmentation across care settings is a patient safety concern because there are multiple clinical settings for care delivery, the executive brief says. "Breakdowns in care from a fragmented healthcare system can lead to readmissions, missed diagnoses, medication errors, delayed treatment, duplicative testing and procedures, and general patient and provider dissatisfaction."
Healthcare workers must be supported as they man the front line of the struggle against the novel coronavirus.
As the novel coronavirus (COVID-19) spreads in the United States and globally, measures must be taken to protect and support healthcare workers and their families, a new journal article says.
In China, where the COVID-19 outbreak started in December, nearly 3,400 healthcare workers have been infected, with 22 deaths, the National Health Commission of the People's Republic of China has reported.
Although routes of COVID-19 transmission have not been thoroughly researched, the spread of the viral disease is believed to be mainly through person-to-person contact, such as by respiratory droplets from infected individuals who cough and sneeze, the Centers for Disease Control and Prevention reports. Transmission of the virus may also be possible from contaminated surfaces and objects, according to the CDC.
The COVID-19 pandemic is straining healthcare workers worldwide, according to the new journal article, which was published last week by the Journal of the American Medical Association. "The pressure on the global healthcare workforce continues to intensify. This pressure takes two forms. The first is the potentially overwhelming burden of illnesses that stresses health system capacity and the second is the adverse effects on healthcare workers, including the risk of infection," the article co-authors wrote.
They say six kinds of measures can protect and support healthcare workers and their families.
1. Infection prevention: Protective gear is essential to prevent healthcare worker infection when treating COVID-19 patients, the article co-authors wrote. "The CDC recommends the use of personal protective equipment including a gown, gloves, and either an N95 respirator plus a face shield/goggles or a powered, air-purifying respirator (PAPR)."
If N95 respirators or PAPR are not available such as in many outpatient settings, medical masks could be effective protection, the article co-authors wrote. "In a study of outpatient healthcare personnel in diverse ambulatory practices, medical masks applied to both patient and caregiver provided effectively similar protection as N95 masks in the incidence of laboratory-confirmed influenza among caregivers who were routinely exposed to patients with respiratory viruses."
2. Emergency department protocols: EDs are on the front line of the coronavirus pandemic and crowding is a concern for person-to-person contact among patients with respiratory symptoms, the article co-authors wrote. "Placing a facemask on the patient at arrival, supplying tissues, promoting cough etiquette, and providing for hand hygiene and surface decontamination are all important steps."
They say urgent actions should be taken for patients who present at EDs with COVID-19 symptoms, which are primarily fever, cough, and shortness of breath. Those steps include rapid triage and placing the patient in a well-ventilated space away from other patients until an isolation room is available.
3. Hand hygiene and surface decontamination: Hand hygiene is critically important for healthcare workers during the COVID-19 pandemic, the article co-authors wrote. "Healthcare personnel must focus on meticulous hand hygiene, avoiding contaminating workspaces."
The COVID-19 virus has been shown to live on surfaces for hours or days, so healthcare workers should disinfect personal items and workspaces such as cell phones and keyboards. "It is sensible for environmental services workers to increase the frequency of cleaning of commonly touched surfaces such as light switches, countertops, chair arms, escalator railings, elevator buttons, doorknobs, and handles," the article co-authors wrote.
4. Healthcare worker precautions: With community spread of COVID-19 reported in many states, U.S. healthcare workers are at high risk of exposure to the virus, the article co-authors wrote. "Healthcare workers must self-monitor, report signs of illness, and not engage in patient care while exhibiting infectious symptoms."
Just like elderly members of the general public, some healthcare workers can be at risk for severe outcomes from the COVID-19 outbreak, they wrote. "Many healthcare workers have conditions that elevate risk for severe infection or death if they become infected with COVID-19, so organizations will need to decide whether such workers, including physicians, should be redeployed away from the highest risk sites."
They wrote that healthcare organizations should consider restricting the travel of healthcare workers to reduce the risk of exposure and to keep clinical staff close to work and available.
5. Protecting family members: "For front-line caregivers, the concerns about transmitting the virus to family members will need to be addressed," the article co-authors wrote.
They wrote these concerns can be eased through communication with healthcare workers about ways to protect family members, including separation of living spaces and protocols for infection control after shifts such as removing and washing clothing at home. "The focus should be on supportive conversations, clear guidance when recommendations exist, attempts to minimize misinformation, and efforts to reduce anxiety."
6. Leadership: With the COVID-19 crisis likely to stretch over weeks or months, the leaders of healthcare organizations should engage healthcare workers to address their concerns, the article co-authors wrote.
"Transparent and thoughtful communication could contribute to trust and a sense of control. Ensuring that workers feel they get adequate rest, are able to tend to critical personal needs (such as care of an older family member), and are supported both as healthcare professionals and as individuals will help maintain individual and team performance over the long run."
The health system at ground zero of the U.S. novel coronavirus epidemic is taking a three-pronged approach to clinical care for the viral disease.
Providence St. Joseph Health, which cared for the first U.S. novel coronavirus (COVID-19) patient, is sharing how the health system has responded to the crisis.
Since December, COVID-19 has spread from China to 118 countries and territories, with more than 124,000 confirmed cases and more than 4,600 deaths, according to the World Health Organization. As of March 12, 1,336 cases had been confirmed in the United States, with 38 deaths, worldometer reported.
The first U.S. COVID-19 patient was admitted to Providence Regional Medical Center Everett in Washington State after testing positive on Jan. 20, Amy Compton-Phillips, MD, EVP and chief clinical officer at Providence St. Joseph, said yesterday during a HIMSS webinar.
Providence St. Joseph operates healthcare facilities in seven states, including Washington, Oregon, and California.
Compton-Phillips' webinar presentation included the Renton, Washington-based health system's three-part clinical response to the outbreak. "We have to prepare to triage patients, test patients, and treat patients," she said.
1. Triage
With little room to increase primary care visit capacity, virtual care has been a crucial element of Providence St. Joseph's triage efforts for COVID-19, Compton-Phillips said. "We worked with our digital innovation group and with Microsoft to build a chatbot to help people go online."
The chatbot on the health system's website engages people by asking questions about symptoms, travel history, and possible exposure to the COVID-19 virus to determine the risk level for infection. Through the chatbot, people at highest risk of infection are directed to seek immediate care. Other at-risk patients can be connected with the health system's nurse line telephone service or schedule a telemedicine appointment on Providence St. Joseph's telehealth platform, Providence Express Care.
In addition to triaging patients in emergency departments, urgent care centers, and online, the health system is planning to roll out "fever clinics" by the end of this week.
"To reduce community transmission for in-person visits, we are now working on setting up fever clinics separate from regular clinics as pediatricians have done for years. During flu season, they might have afternoon hours for people with a fever so that you minimize the contamination of other patients," Compton-Phillips said.
2. Test
Inadequate testing capacity has been one of the most daunting challenges since the beginning of the U.S. COVID-19 outbreak in January, she said.
"Because of the very stringent criteria we had initially, we could only get people tested if they had traveled and had all three symptoms—fever, shortness of breath, and cough. It was incredibly frustrating for even our caregivers who thought they might have been exposed. They might have two out of the three symptoms, so we couldn't get them tested."
Testing capacity has been insufficient, but since the Food and Drug Administration issued a key emergency use authorization on Feb. 29 "opportunities have definitely opened up," Compton-Phillips said. "Pretty soon we think the pipeline will improve so that we can significantly increase our testing capacity."
Providence St. Joseph plans to ramp up testing as soon as more kits become available, she said. "The tents are ready to go and deploy as soon as the testing capacity increases. We will be running drive through clinics for testing in the same way they have done in South Korea."
The health system has developed its own COVID-19 test, but necessary reagents are unavailable from their European suppliers, Compton-Philips said.
3. Treat
As is the case with patient triage, telemedicine is playing a crucial role in treating patients, Compton-Phillips said.
Patients who are identified as likely positive for COVID-19 in an emergency department but are not admitted are being sent home with a thermometer and pulse oximeter to monitor their symptoms at home under the supervision of the health system's telehealth team, she said.
"Patients can be OK for a while, then decompensate rapidly. So, having this capacity to monitor at-risk patients at home has made a huge difference and made our clinicians much more comfortable to leave patients at home rather than admitting them for observation in our acute care facilities."
In addition to the virtual patient monitoring, virtual grand rounds have been conducted regularly to foster "rapid learning" for Providence St. Joseph clinicians who are caring for COVID-19 patients, Compton-Phillips said.
Patients who are admitted to one of the health system's hospitals are under strict isolation protocols and cannot have visitors, she said. This is particularly problematic for older patients, who can develop delirium and other complications while in isolation. To ease the isolation burden on quarantined patients, they are being given iPads to stay in touch with friends and family, Compton-Phillips said.
Improving the communication skills of clinicians and nurses builds rapport and trust with patients.
Communication between staff and patients is a crucial component of patient experience at hospitals, the founder of a communication-focused patient experience training program says.
Making hospitals more consumer-friendly for patients has been a focal point of efforts to reform U.S. healthcare, with the emergence of online reviews and widespread adoption of formal instruments to measure patient satisfaction such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient survey.
Vidalia, Georgia–based Meadows Health, which features 70-bed Meadows Regional Medical Center, understood the importance of boosting clinician and staff member communication skills to improve the patient experience, so they began a focused training effort in December.
"We are the regional referring center, but we have limitations—we don't have an education department and we don't have the resources to fully develop a communication program. We wanted to take a programmatic approach to provider and nurse communication, so we reached out to several organizations to see who could help us the most," says Jeffrey Harden, BSN, MBA-HCM, chief nursing officer and vice president of patient care services at Meadows Health.
Anthony Orsini, DO, a practicing neonatologist and president and founder of The Orsini Way in Windermere, Florida, says communication training achieves cultural change at hospitals. Orsini has seen this come to fruition through his communication training program for healthcare professionals.
"The important thing is we are not just putting Band-Aids on the way doctors and nurses communicate. We are rewiring them and changing cultures at hospitals. Communication is not hard to learn, but it is a specialized technique and most physicians and nurses have not been trained in this area," he says.
Communication training generates positive results, Orsini says. "We have achieved significant improvements in HCAHPS scores and patient satisfaction scores in every program we have done so far. We had one hospital that achieved a 60% improvement in their overall HCAHPS score ranking."
In intensive care nurseries, he says the training program has achieved a 50% improvement in overall patient satisfaction, and 100% improvement in the subset of the HCAHPS survey for physician communication. In emergency room settings, he says the training program has resulted in 70% improvement in overall patient satisfaction.
Training at Georgia hospital
Meadows Health chose The Orsini Way for its training because the emphasis was not on HCAHPS score improvement, but how to better communicate, Harden says. "We found out the Orsini program focuses more on communication as a whole, how communication can make your day-to-day job easier, how communication improvement and certain skills can help avoid burnout, and how all of those factors can lead to improved outcomes and improved relations with the patient."
At Meadows Health, the training program has focused on the emergency department, he says. "Over the past couple of years, we have been working toward improving our emergency department patient satisfaction, and we knew one of our big opportunities was going to be communication."
Although Harden hopes to extend the training throughout Meadows Health, the ED was a logical place to start, he says. "If you look at the number of patient grievances that we have, about 70% of them come from the emergency room."
The primary training program at The Orsini Way is called "It's All in the Delivery." The program has three elements.
1. Series of three-hour workshops: Most hospital staff members participate in the workshops, including doctors, nurses, receptionists, and therapists. The workshops teach staff members how to build rapport and relationships with patients in a timely manner.
2. Digital learning: Hospital staff members complete a digital course over eight to 10 weeks. Through text messages or email, participants receive a training technique every week that is highlighted in a five-minute video. Participants are then asked to put the technique into practice.
3. Improvisational role-playing: Professional actors role-play with hospital leaders, who eventually become on-site trainers. The role-playing is videotaped and reviewed by Orsini instructors, who replay the videos with the hospital leaders to see how they performed. Instructors comment on verbal and nonverbal communication techniques in the videos to teach the hospital leaders how to train staff members.
Some hospitals choose not to conduct the role-playing component. The cost of the training ranges from $50,000 to $100,000 per hospital.
Meadows Health decided not to utilize the improvisational role-playing, Harden says. "We took advantage of the lectures with Dr. Orsini and the digital platform, which has been great for employees who could not get to a lecture but wanted access to the program. The digital platform provides reminders, tips, and check points to see whether the tips are being used."
So far, the results have been promising, Harden says.
"Even though we just started the training in December, we have seen some improvement in satisfaction scores. What we have seen in the ED is the biggest result for me. I'm not hearing from any ED nurses or providers that they are too busy to be polite. For the ED nurses and providers, the program has done a good job of highlighting that communication is just as important as a clinical component of their jobs—communication is a clinical tool."
The effort is well worth the investment, Harden says. "As a community hospital that is surrounded by three larger systems within a 30-minute drive, the way the community perceives us and the way we treat our patients is major. I need everybody in my organization from the frontline staff to the executive team thinking this way."
Communication training approaches
A key component of the training program workshops is teaching specific communication techniques as well as verbal and nonverbal language skills, Orsini says.
For example, Orsini encourages clinicians and nurses to sit down as soon as possible when they enter a patient's room. "The most common mistake physicians and nurses make when they go into a patient's room is speaking while standing up. The nonverbal message that is being sent is that they don't have the time to spend with the patient."
Other communication techniques are designed to build rapport and trust with the patient, he says. "Multitasking while you are visiting a patient such as typing into the electronic medical record sends a nonverbal message that the patient is not the most important person in the room."
Nurse managers can build trust with their patients while conducting rounds, Orsini says. "They should not just poke their head into patient rooms and ask whether they need anything. I teach nurse managers to go into the room, introduce themselves, and say they like to get to know their patients. Then they can ask the patient how it is going."
Benefits of telemedicine screening for COVID-19 include convenience for patients and safely assessing patients in their homes.
Some health systems are offering virtual screening for the novel coronavirus, COVID-19.
After reaching epidemic proportions in Wuhan, China, in December, COVID-19 has spread to 110 countries or territories, with more than 113,000 confirmed cases and more than 4,000 deaths, according to the World Health Organization. As of March 10, there had been 729 confirmed cased in the United States, with 27 deaths, worldometer reported.
Grand Rapids, Michigan-based Spectrum Health, which features 15 hospitals and 11 urgent care centers, began free telemedicine screening for COVID-19 last week.
"Telemedicine is a good fit for screening. For screening, it is a matter of asking the appropriate questions and ensuring that you have the right answers and a triage plan. We can't do a full examination of someone with telemedicine, but we can screen to determine whether someone is at low risk and can wait to see their doctor the next day, or is at high risk and needs to be seen right away, says Darryl Elmouchi, MD, MBA, chief medical officer at Spectrum Health.
He says the free telemedicine screening initiative has four advantages.
1. It is much more convenient for people to be screened in their homes rather than having to visit an emergency room or urgent care center. The convenience should lower the barrier to get screening easily.
2. From a public health standpoint, telemedicine screening can help avoid inundating healthcare settings with patients who are at low risk of having COVID-19, which maintains capacity to treat patients who are at high risk.
3. The telemedicine screening can help prevent the spread of COVID-19 because as long as patients are not critically ill, they can be triaged at home rather than visiting an emergency room or clinic, where other people could become infected.
4. The free screening lowers the cost barrier to getting a COVID-19 assessment.
How the screening works
The screening process is simple, Elmouchi says.
"A person can call a hotline number, which is answered by someone who walks them through downloading our app if they don't have the app already on their phone or tablet. They can also log in on a computer. Then a time is scheduled when a provider will be available for the virtual visit, which is a video visit much like FaceTime or Skype," he says.
The telemedicine screening is following Centers for Disease Control and Prevention guidelines such as asking about COVID-19 symptoms—fever, cough, and shortness of breath—and travel to infection hotspots such as China, Iran, and Italy.
Ideally, if a patient is at high risk of COVID-19, testing can be conducted at the patient's home, Elmouchi says.
The virtual visit is conducted by a physician, physician assistant, or nurse practitioner. Most of the clinicians work at the health system's telehealth platform, Spectrum Health Now, but they are being supplemented with clinicians from urgent care centers and primary care clinics who have spare time, he says.
For now, there is enough staff to provide the telemedicine screening, Elmouchi says. "We launched this on Friday evening, and on Saturday and Sunday we averaged about 20 patients each day. By 11 a.m. Monday morning, we already had 33 people who had called to schedule visits. At this point, we have untapped capacity through the rest of our medical group, but if we had to screen several hundred people per day that would be challenging.
Telemedicine opportunity
The screening initiative has revealed a largely unexplored frontier of telemedicine, Elmouchi says. "This is definitely an example of the untapped potential of telemedicine. There are many different areas where talking with someone and looking at someone virtually can be important for communication, getting information, screening, and reassurance."
The screening is an opportunity to rise to a public health challenge, he says.
"We think this is our duty as a caretaker for the community. We want to make sure that we prevent infections and we make it easy for people to dispel concerns. We are not directing any of the care to our own settings specifically. We are redirecting people back to their primary care doctor or a health system where they already get their care. The goal here is not to increase business. The goal is to make sure people get the right care, where they need it, and when they need it."
Other health systems offering telemedicine screening for COVID-19 include Indianapolis-based IU Health and Charleston, South Carolina-based MUSC Health.
Researchers find that amenities such as private rooms have a greater impact on hospital patient satisfaction than quality measures such as mortality rates.
Consumer satisfaction is a weak driver of quality and safety at hospitals, recent research indicates.
Viewing patients as consumers has been a focal point of efforts to reform U.S. healthcare, with the emergence of online reviews and formal instruments to measure patient satisfaction such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient survey. However, hospitals are a challenging setting to have consumer satisfaction impact quality of care because most medical services are provided out of patients' view.
The recent research, which was published in the journal Social Forces, found that amenities such as private rooms have a greater effect on patient satisfaction than the quality of medical services.
"We find that neither medical quality nor patient survival rates have much impact on patient satisfaction with their hospital. In contrast, patients are very sensitive to the 'room and board' aspects of care that are highly visible. Quiet rooms have a larger impact on patient satisfaction than medical quality, and communication with nurses affects satisfaction far more than the hospital-level risk of dying. Hospitality experiences create a halo effect of patient goodwill," the study co-authors wrote.
Research data
The researchers examined Centers for Medicare & Medicaid Services data for 3,000 acute care and critical access hospitals nationwide.
Medical quality was measured based on adherence to standards of care for heart attack, heart failure, general surgical practice, and pneumonia. Patient safety was measured based on hospital mortality rates. Hospitality was measured based on several metrics in the HCAHPS patient survey such as quality of nurse communication, cleanliness of rooms, and room noise levels at night.
The research includes several key data points.
Hospitals with the highest mortality rates have patient satisfaction scores only 2.0 percentage points lower than hospitals with the lowest mortality rates.
Hospitals posting medical quality scores in the highest decile have patient satisfaction scores only 3.3 percentage points higher than hospitals with medical quality scores in the lowest decile.
Nurse communication has a major impact on patient satisfaction. Hospitals with the lowest decile score for nurse communication have an average patient satisfaction rating of about 50%. Hospitals with the highest decile score for nurse communication have an average patient satisfaction rating of more than 75%.
The noise level in patient rooms has an 86% larger-in-magnitude impact on patient satisfaction than the hospital mortality rate.
The noise level in patient rooms has a 40% larger impact on patient satisfaction than medical quality.
For more than 300 of the hospitals, the researchers examined 18 measures of local competition to determine the association of competitive markets with patient satisfaction and medical quality. For 17 of the measures, competitive markets lowered patient discontent. For 14 of the measures, competitive markets lowered medical quality. "Local competition among hospitals leads to higher patient satisfaction, but lower medical quality. This provides further evidence of decoupling between medical excellence and patient satisfaction," the study co-authors wrote.
The data shows the hospitality halo effect in how patients view their hospitals, the co-authors wrote. "When patients complain about their hospitals, it is primarily due to the room and board aspects of their stay—and especially about the personal interaction with nurses. … Hospitality is the fast track to customer satisfaction in medicine."
Interpretations and solutions
The lead author of the study told HealthLeaders the finding that hospital competition for patients leads to lower medical quality and higher patient satisfaction is troubling.
"I take it as a sign that high pressure incentives to attract and please patients change hospital priorities and investments," said Cristobal Young, PhD, an associate professor in the Department of Sociology at Cornell University in Ithaca, New York.
He said it is highly unlikely that private patient rooms improve medical service quality—even though patients love the privacy of a hotel-like experience, private rooms are an expensive capital expenditure.
"Stanford Health Care spent a whopping $2 billion on a new hospital building with private rooms—largely because the old one had shared rooms and it was hurting their reputation, as one of the vice presidents told me. If you start to think about all the things that could be done with $2 billion, it is hard to believe that building private rooms is the best medical use of those resources," Young said.
Rather than focusing on metrics of customer satisfaction, hospitals should focus more on customer health and longevity, he said. "No one really wants to talk about patient survival rates, but those metrics exist on Medicare's Hospital Compare website. They are available, and informed patients should know about them."
Downgrading the emphasis on customer satisfaction in favor of customer health and longevity would be challenging, he said. "The analogy I use is that no restaurant wants to talk about food poisoning or health and safety standards—even if they are the best and safest restaurant in the city. They don't want the minds of their potential customers drifting into something that is a negative."
Despite the challenge, hospitals have an obligation to elevate the importance of medical quality and safety, Young said. "Hospitals are not supposed to be selling patients a happy, feel-good marketing campaign. They have a responsibility to the best interests of their patients, and that means being honest about medical quality and patient survival."
