Best Laid Plans: Managing COVID-19 in Hospital Settings

A series of papers to be published across a variety of journals provides a potential roadmap for treating COVID-19 patients within a hospital setting. It tells practitioners in these healthcare environments how to prepare for the unexpected.

On April 30, an article appeared in the New England Journal of Medicine titled “Best Practices for a Covid-19 Preparedness Plan for Health Systems,” a collaborative effort among a national team of healthcare experts representing the Presidential Leadership Scholars, Aspen Institute Health Innovators, and Eisenhower Fellows.

This was the first in a series of papers written to address potential gaps in the healthcare system as the novel coronavirus continues to sweep over the U.S. “By acting early, health systems may avoid being crippled by crisis and continue to be operational and provide critically important care,” the authors write.

These papers were born out of a WhatsApp group of physicians and other healthcare leaders who were sharing their experiences on the front lines of treating patients with COVID-19. “We started talking about  the needs we were seeing in different places around the country, [as well as]  the needs of the healthcare system and how to prepare healthcare systems for something that we saw coming,” says Ricardo Correa, MD, EsD, FACP, FAPCR, FACE, CMQ, program director of the Endocrinology, Diabetes and Metabolism Fellowship at the University of Arizona College of Medicine, and one of the authors of these papers from the Presidential Leadership Scholars cohort.

As it turns out, these authors had a lot to contribute; initially, the paper was going to be a single publication, but the early draft of a Google document grew to around 20 pages, so the authors decided to release these papers as a series across several journals. (At press time, these papers had been accepted, but not published.) “When you have 18 to 20 people involved in this, everybody wants to give their own take,” Correa says.

For this NEJM article, Correa and his colleagues focused on the dire need for health systems to brace for the worst, even the unexpected, as we still know very little about this novel coronavirus, and we know even less about what might happen as the country begins to “reopen.” “The cornerstones of an effective Covid-19 preparedness plan for a health system are: (1) mitigating local transmission; (2) conserving, supporting, and protecting staff; (3) eliminating nonurgent strains on the system; and (4) coordinating communication,” the authors write.

“Health systems should not wait until they face a surge in Covid-19 cases to implement a comprehensive response,” they go on to warn.

Telemedicine: A Default Approach

The authors of the NEJM paper point out that patients are at risk of exposure to COVID-19 not just during their visit to a hospital, but also while in transit to receive medical attention. In that case, patients should remain home unless it’s an emergency.

“Instead, telemedicine should be utilized as the default approach,” the authors write. “Telemedicine allows continued care while reducing unneeded exposure to patients and health care workers.” The authors go on to write that while policy barriers have prevented more widespread adoption of telemedicine, recent legislation has relaxed some restrictions surrounding this still-emerging technology.

As an endocrinologist who adopted telemedicine relatively early (in 2015), Correa has seen the value of treating his patients via computer or smartphone. He primarily practices in the outpatient setting and says that telemedicine not only promotes more adherence to treatment, it allows for social determinant of patients’ health. For example, Correa explains, if patients are no-shows, it’s likely they didn’t have the money to take a bus or taxi to the clinic, or they couldn’t find someone to watch their kids, or they didn’t eat the day before, and so on.

In his clinic, Correa sees many patients from underserved populations, but everyone has a smartphone, and when he connects with them through their smartphones, he can see some of their realities. “Sometimes they introduce you to their family, so you can see  their caregivers are there,” he says. “You can talk directly to the family and tell them what they need to do to help care for a patient with diabetes. It creates an interpersonal relationship that might not otherwise exist in a traditional office visit where you would typically see the patient alone.”

Novel Conversations

Since the COVID-19 pandemic spread across the world, there have been myriad social media posts and viral videos thanking healthcare workers and first responders and everyone else essential to maintaining some semblance of peace of mind for the rest of us. And while that’s definitely deserved, providers are still reporting shortages of personal protection equipment (PPE) and other hospital resources.

“There is a lot of anxiety of what will happen in the future, but I think that we have to embrace technology as part of our life. And this is the beginning of a new era where we will not stop the interaction, because social interaction is so important.” – Ricardo Correa, MD, EsD, FACP, FAPCR, FACE, CMQ, program director, Endocrinology, Diabetes and Metabolism Fellowship, University of Arizona College of Medicine, Phoenix, Ariz.

It’s more important than ever to protect and support those whose efforts have been saving lives. The NEJM paper authors write that the first documented case of community spread in the U.S. “resulted in 200 hospital workers being quarantined and unable to work for weeks.” Rotating staff, postponing elective procedures, and running virtual clinics will help preserve PPE, allow for anesthesiologists to provide care in the ICU, and conserve staff for when they have to take over for incapacitated colleagues, the authors write.

The novel coronavirus has impacted virtually every aspect of healthcare and has forced some novel conversations among providers about the best ways to protect themselves, even in a purely endocrine space. If a patient with thyroid cancer needs a fine needle aspiration, the discussion among thyroid experts is now whether this biopsy needs to be an aerosol procedure, Correa says. He goes on to say that he expects  organizations like the Endocrine Society and American Thyroid Association to recommend the best decision, but if this procedure does need to be aerosol, it will totally change the approach. “If this is aerosol, we have to have complete PPE from face to feet, to the mask, to the gloves, everything,” he says. “They have to be in a room that is aerosol protected. You have to clean the room after each patient. So you will have to use a lot of PPE and if you are in a training setting, like I am, you have to provide the same thing to the residents and the fellows.”

A Virtual Renaissance

The authors of the NEJM paper write that this coronavirus crisis changes daily, which makes the need for effective communication crucial. They recommend forming central COVID-19 response teams, disseminating daily staff-wide information, and hosting virtual town halls, which should be recorded so those who can’t leave the clinic can get the information later. Coordinating communication with patients is also just as important, since patients may need instructions on how to properly quarantine themselves.

Even communication among respective healthcare teams can be valuable – again, supporting staff, since healthcare providers are already prone to burnout, and COVID-19 has certainly heightened and sharpened that phenomenon. Correa says he calls his fellows at least once a day to check in (the fellows were all sent home March 15 to practice telemedicine), and provides meditation and other healthcare resources, as well as organizing Zoom happy hours to help decrease burnout and improve wellness.

Some states are beginning to see a decrease in cases, but as the country begins to reopen, Correa says he’s not sure whether that trend will hold. “[If cases start to rise, we] will have to go back and attend to our plan, including those four points that the [NEJM] article mentioned — mitigation of transmission, all the isolation, the quarantine, the use of masks when you go out, the social distancing,” he says.

For now, providers are adopting new technologies and even finding innovative uses for them. These emerging technologies got a jump start because of the pandemic, but as more providers warm to them, coordinating communication has become simpler thus providing easier access to vital information.

Correa points to the Endocrine Society’s virtual meeting in June, which is on track to have 20,000 attendees, more than double the previous record. “People that were in the past unable to attend because of some X, Y reasons, always somebody had to stay in the hospital because you have to cover the hospital,” he says. “There’s a fellow who stays there, an attending who stays. Now with the opportunity of being online, they will be able to obtain the knowledge that they in other times would lack.”

Correa acknowledges there are still some wrinkles to iron out (his team was visited by a few “Zoom bombers” during a meeting – protections have been added since), but he says he tries to see the positive possibilities from all this uncertainty. “There is a lot of anxiety of what will happen in the future, but I think that we have to embrace technology as part of our life,” he says. “And this is the beginning of a new era where we will not stop the interaction, because social interaction is so important. However, now we have the opportunity to interact with many more people.”

“Healthcare systems should realize that we are moving from the old paradigm to the new paradigm, and that everybody should get used to it — from the payers to physicians,” Correa continues, “finding a middle line that everybody can benefit from.”

— Bagley is the senior editor of Endocrine News. He wrote about glycemic control in COVID-19 patients in the May issue.

 

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