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Image by Getty Images

Puzzling it out together

Hospitalists share strategies for pandemic problems.

Since their role was invented back in the 1990s, hospitalists have worked to develop and improve hospital systems. Those efforts provided gains in the quality, value, and safety of inpatient care, but also, it turns out, practice for perhaps the biggest medical innovation challenge of all: a pandemic.

Almost every aspect of care, from treatments to discharge to communication, required rapid change. Not surprisingly, hospitalists had ideas.

Several of them described their programs' strategies to deal with the many problems caused by COVID-19 during HM20 Virtual, the online version of the Society of Hospital Medicine's annual meeting, posted in August.

Tracing contacts

Preventing disease spread in the community is not typically on hospitalists' task lists, but when COVID-19 started making its way through Texas, hospitalists at Dell Medical School at The University of Texas at Austin saw the need for action.

“We saw many husband/wife duos or brothers in our hospital, and that bothered us. We felt like we needed to intervene and slow the spread of the disease in our community,” said ACP Member Kirsten Nieto, MD, assistant professor and the interim chief of the division of hospital medicine.

The traditional system for reporting and responding to communicable disease outbreaks couldn't keep up with the escalating case counts. “The faxes would be sent once a day by our infection prevention team,” she said. “You can imagine there were piles of papers next to the antiquated fax machine at our public health department.”

In addition, these faxed forms didn't cover all the necessary information. “They excluded any triage information or risk of transmission, specifically the patient's employment history. We do need to know if this is a fast-food worker,” said Dr. Nieto.

In collaboration with the hospital's infectious disease experts, the hospital medicine team began collecting these data as they saw patients. “Essentially this was an expanded social history that we included in our history and physical,” she said. “This was especially important in critically ill patients. We could gather information before they got intubated, so that we knew enough to give that to contact tracers.”

However, this solution led to a new problem, explained her colleague and co-speaker F. Parker Hudson, MD, MPH, FACP, assistant professor of internal medicine and infectious diseases. “The challenge, of course, was that cases [were] coming, and it was difficult to expand [contact tracing] fast enough.”

The hospital recruited volunteer contact tracers from the university community, many of them medical students who had been sidelined early on in the crisis. “They quickly jumped in . . . to help,” he said. “After a few weeks of this, we actually put more structure to it and made it a public health elective.”

The students became leaders in the contact-tracing efforts and, in addition to providing a public service, picked up valuable skills. “So many of the key learning objectives we have for our students in general [include] communication and use of the telephone and avoiding jargon,” said Dr. Hudson. “In contact tracing, it is so important to have a nonjudgmental, really kind, supportive attitude.”

The students learned to handle sensitive health information and incorporate rapidly changing guidance into patient education, as well as observed the inequalities of the health care system. A few students even got medical publishing experience by coauthoring a paper about a COVID-19 cluster investigation, which was published in the July 3 Morbidity and Mortality Weekly Report.

The experience also showed them the rough parts of medicine. “We actually ended up having to reach out to our social work and psychiatry colleagues, who developed a sort of hotline for all of our staff to provide additional support, because if you're doing this for six hours a day, you're really hearing about a lot of suffering and a lot of challenges that people are experiencing as their loved ones are sick or dying,” Dr. Hudson said.

Protocolizing care

Meanwhile, hospitalists were racing to prevent those deaths with optimal treatment for COVID-19. But at the beginning of the pandemic, it was difficult for any individual hospitalist to know how best to do so, explained ACP Member William Michael Brode, MD, an assistant professor of medicine at Dell Medical School.

“As we [were] starting to take care of patients with COVID-19, we kept on talking. ‘Oh, we're seeing high rates of venous thromboembolism, what are we doing about anticoagulation? What should we do about antibiotics? Should we be using hydroxychloroquine?’” he said. “We're talking back and forth and really realizing that we need to just sit down and hash it out.”

That took the form of a therapeutics and informatics committee, which was led by hospitalists and included subspecialists (infectious diseases, critical care, hematology) and other relevant experts, such as pharmacy and nursing staff, with additional specialists invited as needed.

“The meetings themselves had a little bit different focus than a traditional guideline committee. We weren't trying to say, ‘This is the way to do things, and this is the evidence,’ because that didn't exist, and so we focused on reaching consensus recommendations,” said Dr. Brode.

The recommendations were also based on the local situation. His colleague and co-speaker, ACP Member Johanna Busch, MD, offered convalescent plasma as an example of how the committee's process worked. “First, we delegated several members—one infectious disease and several from the internal medicine group—to closely analyze the existing literature and, secondly, to investigate the feasibility of implementing convalescent plasma at our institution.”

The group concluded that all patients admitted within 14 days of COVID-19 symptom onset should receive two units of plasma. “As the pandemic continued, this recommendation was revisited at every committee meeting and open for discussion, [and it was] also re-evaluated whenever emerging data came out,” said Dr. Busch, who is an assistant professor of internal medicine.

At one point, the committee had to change the recommendations when a surge in cases limited the plasma supply. It reduced the suggested dose to a single unit and tightened eligibility criteria to include only patients requiring at least 2 L of oxygen.

Dealing with this kind of dilemma was one of the goals of the committee: “to make sure there's equity in who's receiving this and [that] individual providers aren't left to their own devices to work through these difficult decisions,” Dr. Brode explained.

The group structured its meetings to help make the hard choices as efficient as possible. “The providers were expected to come prepared,” Dr. Brode said. “We ask the presenters quite clearly that they should really be bringing a near-finished product to the committee for feedback and with a clear plan for operationalizing it. We don't want people riffing off the top of their heads in the meeting.”

Committee leaders also emphasized the need for decisiveness. “Internal medicine providers can be quite slippery at times. Nobody wants to take a firm stance,” he said. “You've got to set a cutoff, whether that's 14 days or 6 L of oxygen, that we all recognize can be arbitrary, but it's a point that we all agree is reasonable and practical.”

The next challenge was how to get the word out once a recommendation was made. At first, there were frequent emails to clinicians. However, “It became quickly apparent that we should assume no one is reading the emails,” said Dr. Brode. Better solutions included saving the latest recommendations on the cloud, creating one-page summaries of highlights, and standardizing order sets.

The last of these was a little complicated to implement in a updatable format. “We had to basically create a customized order set and have providers go in and copy it and save it as their own favorite so they could reuse it, and that required focused electronic health record training, which we're able to deliver through video tutorials,” Dr. Brode said.

Communicating distantly

Communication among clinicians was a common challenge early in the pandemic, with so much more to say and so few opportunities to talk face-to-face.

Secure group text messaging proved to be a major part of the solution for Dell Seton Medical Center at The University of Texas at Austin. “Before COVID, we were already high utilizers of secure texting,” said physician assistant Elizabeth Blankenship, PA-C.

During the pandemic, the hospitalist service created a number of texting groups, explained ACP Member Stewart Schaefer, MD, another hospitalist at Dell Seton. One group included the hospitalists, ICU physicians, residents treating COVID-19 patients, and palliative care clinicians. “A big item we use it for is patients that are starting to deteriorate,” he said. “We can alert the critical care team about these patients that need to be seen sooner rather than later.”

The group format enables the ICU physicians to determine which of them is currently available to check on a particular patient. The thread was also used to coordinate rounds and clarify who was covering overnight.

Another texting group included the internal medicine department, the infectious diseases team, and the chief medical officer. “What do we use this for? Early in the pandemic, we had a problem with testing,” said Dr. Schaefer. “Should we test this person if they're really low risk? Or a person who has a high pretest probability who tests negative, do we have the resources to send a second test?” More recently, the department used the thread to discuss provision of such therapies as remdesivir and convalescent plasma.

There are some pitfalls of secure texting as a communication strategy, noted Ms. Blankenship. “You've got to be aware of texting fatigue and missed messages,” she said. “A read-receipt is super helpful, but . . . people get busy and they may forget to respond, so you have to make sure that you set the example that it's OK to repeat the text, call, page, whatever.”

Clinicians should also know it's OK to leave the group. “Initially, we thought adding our rehab members was a great idea, but after a while, they were like, ‘Look, we're not getting much out of this group text, and it's a lot of text traffic,’” she said. The system was also set up so that participants could mute the conversation when they went off service.

To keep track of who was on service during the pandemic, the hospitalists also relied on electronic tools that list the contact information of the clinician currently caring for a patient (CORES and Google Sheets) and provide detailed information for handoffs (I-PASS). “With the uncertain provider-nurse communication, we were able to establish 24/7 updated contacts for each patient,” said Dr. Schaefer.

The main challenge with these tools is getting everyone to actually use them—signing in when they arrive on shift and updating the handoff with the most relevant information before they leave. Luckily, the hospital had already implemented them before the pandemic, noted Dr. Schaefer, but programs that haven't already should find some strategy to meet the same end. “The goal is to overcommunicate because when you're doing that, you can be confident that you're communicating enough,” he said.

Isolating effectively

Another thing that hospitalist programs couldn't get enough of when the pandemic hit was full isolation for patients with COVID-19. In the University of Pittsburgh Medical Center (UPMC) system, UPMC McKeesport found a solution to that challenge.

“We took advantage of this 125-year-old hospital, which probably has a bigger footprint in it than the community really needs,” said Jeffrey Alvarez, RN, MSN, director of nursing. “We have licensed beds that probably haven't been opened in a few years here, so we said, ‘OK, we know that it's best practice to put these individuals in a negative-pressure environment while we start learning more about the disease.’”

The hospital created a negative-pressure pod area for patients with COVID-19, which was staffed by hospitalists from internal and family medicine who volunteered. “Our scope was truly extensive. It ranged from ICU-level patients to comfort measure-only patients,” said co-speaker ACP Member Victoria McCurry, MD, physician lead for the pod and clinical assistant professor of family medicine at University of Pittsburgh.

Critical care and infectious diseases subspecialists were the only consultants who routinely saw the patients in person. “If other hospital consults were needed in the care of the patient, these were done almost exclusively by telemedicine rounding from outside the pod,” she said.

The video set up directly outside the pod allowed outside clinicians to see what was going on inside the pod and allowed clinicians on the inside to communicate requests. “They had a lifeline to the outside world there to say, ‘Hey, I need this. Can you send for that quickly?’” said Mr. Alvarez.

When clinicians did have to cross the border, other staff helped keep them safe. “Observers made sure that we donned appropriately and, even more importantly, that the doffing was occurring, because . . . that's where we know that cross-contamination could occur,” he said.

The pod faced challenges. It turned out that its video setup did not have high enough resolution to allow backup coverage by the health system's offsite telehospitalist team when patient numbers required reinforcements. However, brief consultations with the system-wide tele-ICU team where no physical exam was needed could still occur. The negative pressure also meant that medications couldn't be sent by pneumatic tubes.

But team efforts have overcome most problems, such as the need to prevent deconditioning in patients with COVID-19. One solution was to gather rehabilitation armchairs from around the hospital and move them into the unit so that patients could get out of bed. More dramatically, “Within a 24-hour period, we took half of the unit and turned it into a licensed acuity-adaptable physical medicine and rehabilitation unit,” said Mr. Alvarez.

Such rapid transitions have been an ongoing component of this project, which has adapted to changing infection rates. “Back in early April, we actually opened up our COVID pod, and after a month, we were able to discharge all the patients. A little over a month later, we reopened it and closed it within a few days,” said Mr. Alvarez. At the time of this talk in August, the pod had been reopened again for about a week.

Discharging safely

By late summer, the start of the pandemic may have felt like the distant past to many hospitalists. But Maralyssa Bann, MD, still remembers starting to worry about discharging patients with COVID-19 soon after Harborview Medical Center in Seattle, where she works as a hospitalist, first activated its emergency response on March 1.

“Discharge planning is just such a key, central part of what we do as hospitalists,” she said. “There were a couple of important questions that started rattling through my mind: . . . ‘How do we get our patients safely back into their home environments? How do we make sure they have the information they need and the resources they need to recover from illness?’”

The first patients diagnosed with COVID-19 in the area (and in the U.S.) were coming from a skilled nursing facility, adding even more uncertainty about where they could safely go after discharge. “And our usual patient channels getting people to follow-up appointments were altered because of clinic closures. The switch to telemedicine had not yet begun in earnest,” she said.

Dr. Bann wasn't alone in wondering about these issues. Her co-speaker, S. Ryan Greysen, MD, reported on data that he and colleagues recently collected through the Hospital Medicine Reengineering Network (HOMERuN), a collaboration founded in 2011 to improve hospital care.

“Our leadership group has set up a call to review progress on a regular basis and identify and prioritize areas of greatest need. Discharge practices surfaced early,” said Dr. Greysen, who is chief of the section of hospital medicine at Penn Medicine in Philadelphia.

The network surveyed hospital medicine programs around the country on their approaches to discharges of patients with COVID-19. They found that temperature and need for oxygen were common criteria for discharge, but the specific cutoffs for these measures varied widely.

“Some sites require patients to be afebrile for 24 hours. Others said 48 or 72,” Dr. Greysen explained. Variation was also found in less quantifiable criteria. “There was large consensus around the need to address the level of social support available to patients being discharged, but there was variability in how sites defined social support.”

Some hospitals left most discharge decision making to the treating clinicians. “At the other end of the spectrum, we had a handful of sites give very, very specific guidance,” said Dr. Greysen.

Harborview falls into the former category, but the hospitalists created a checklist, which reminds them to make sure patients can get needed durable medical equipment and medications and are transported home with infection precautions. The checklist also links to the latest patient-education materials.

Other solutions to improve discharge included making exceptions to no-visitor policies to include caregivers in discharge teaching whenever possible, as well as providing written instructions in multiple languages, Dr. Bann said.

The hospitalists also made a point of smoothing transitions to outpatient follow-up. “We did our best to reach out to the clinics themselves, and also reminded patients to call and notify their [primary care physician] of the COVID diagnosis and inquire about how they should proceed if they needed to come back in,” she said. Eventually, the hospital launched a dedicated clinic for discharged patients with COVID-19 who needed additional in-person care.

Since Seattle-based University of Washington Medicine, which manages the hospital, had to tackle these problems before many other parts of the U.S., it made an effort to share its solutions, posting resources like the checklist online. “When people emailed me . . . asking what we were doing, I was able to just send this and say, ‘Here's what we have at the moment,’” said Dr. Bann.

In the months since, her colleagues have returned the favor. “Taking something that someone else created and being able to just tweak it a little bit for my site and implement it was an incredible timesaver,” she said. “We're all working together towards this goal. Being a member of the hospitalist community during this time has really brought me a tremendous amount of pride.”