As a spot from which to face a pandemic, a community hospital, especially a rural one, carries both pros and cons for hospitalists.
“The benefits of being in a rural setting arise from the same factors which hurt our population during normal times, … limited mobility and low population density,” said ACP Member Atul Bali, MD, a nephrologist and chair of medicine at a community hospital in Farmville, Va. “This equates to relative ease in achieving social distancing and reduced frequency of travel to areas of high disease burden, making it less likely that people in our community get infected and introduce the disease to our small town.”
On the other hand, community hospitals have fewer resources than the urban centers that have seen the most COVID-19 patients early in the pandemic. “All those big tertiary care hospitals, they have a lot of resources in terms of infectious disease doctors and infection control programs and emergency preparedness,” said Pankaj Agrawal, MD, an ACP Physician Affiliate Member and hospitalist program director at South Georgia Medical Center in Valdosta, Ga.
In late March and early April, community and rural hospitalists around the country—some already with cases of COVID-19, some still anticipating the virus's arrival—were marshalling all available resources and brainstorming solutions to the challenges of treating COVID-19 while maintaining staff safety and caring for inpatients with other conditions.
“We've done a lot over the past several weeks, but we know that more is coming. And we are fortunate to have had that luxury of even just a few weeks to prepare for the impact ... including staffing, surge planning, and resource allocation,” said Colleen O’Connor, MD, hospitalist lead at Lankenau Medical Center in Wynnewood, Pa.
Handling COVID-19 patients
One of the first steps in preparation for most hospitals has been to figure out where to put patients with COVID-19 to reduce the risk of spread.
“A lot of discussions really went into cohorting patients to certain teams and certain providers to minimize the number of us that might be exposed,” said ACP Member Philip Montemuro, MD, associate hospitalist lead at Lankenau. “We've designated two of the eight medical teams that we have as either the COVID rule-out or COVID-positive teams.”
Naturally, even smaller hospitals condensed their potential COVID-19 exposures even further. “We had essentially a dedicated hospitalist for the unit,” said Dr. Agrawal. “We decided to do a complete unit with restricted entry, doors locked, family not allowed, dedicated staff with a limited number of nurses, no techs, no other people coming in.”
There are some competing priorities in the decision making about assigning staff entirely to COVID-19 care, however. “We take turns so the same hospitalist is not exposed to a lot of viral load constantly,” said Varun Malayala, MD, FACP, chair of medicine at Bayhealth Sussex Campus in Milford, Del.
Those planning new or expanded medical and ICU COVID-19 units often took advantage of declines in other types of inpatient care, such as elective surgery. “Our CT surgical volume has fallen significantly. We've repurposed some of those rooms that are closer to the medical ICU for our overflow and surge volume that we anticipate,” said Dr. Montemuro.
When planning care on the cohorted units, hospitalists developed additional strategies to reduce exposures. “We made a protocol for the metered-dose inhaler to be used more than a nebulizer treatment to prevent the aerosolization of the virus,” said Dr. Agrawal. Other common infection control tactics included reducing the frequency of medications and labs when possible.
“We also considered doing a long IV tubing so that the IV pole essentially can stand outside the room and nurses don't have to go into the room to change the bags,” said Dr. Agrawal.
Even with the best-laid plans, though, unexpected questions arose when patients began to arrive. “A lot of unique scenarios came up,” said Dr. Montemuro. “Like an MRI for a patient that [had altered mental status] and was COVID-positive and wasn't able to properly wear a mask—how can we get them to the testing that we would normally obtain without potentially contaminating our only MRI machine that we have in the hospital”?”
The first response to that question was increased scrutiny of the medical necessity of a scan or procedure. “Echocardiogram, ultrasound, any kind of test that we would usually get on most of these patients came with a second thought, ‘Is this really going to change management?’” Dr. Montemuro said.
For patients in whom COVID-19 was suspected but not yet officially diagnosed, the next question was whether the test or scan had to be done immediately or could be delayed until COVID-19 test results came back, he added.
Another challenge for hospitalists was the limited available knowledge about the disease. “From residency and medical school and a few years as an attending, you get a sense for most disease processes, who's safe to discharge and who's not,” said Dr. Montemuro. “This new disease that we're really seeing for the first time, it was one of those tricky things. People can get sick fast, but at the same time, if they look OK and they're stable, is it really worth keeping them here?”
The reports of rapid acute decompensation among COVID-19 patients are a worrisome problem, hospitalists said. “The one thing that we have not experienced with flu and with other respiratory illnesses that come through here is how quickly the decompensation happens,” said Dr. O’Connor. “We have a separate code call and code response if someone has COVID or is in a COVID rule-out status.”
This concern is even greater for hospitals that don't have ICU-level care on site. ACP Member Ramesh Adhikari, MD, is a hospitalist in Lafayette, Ind., who covers three community hospitals, two of them very small. At the bigger hospital, “we've been getting multiple calls for [potential transfers of] anyone who's suspected to be COVID or has some symptoms worsening because people are worried that if the patient deteriorates faster, they need to have critical care,” he said. “We are trying to see if we can keep the patients where they are and provide telehealth critical care services.”
Transfers are generally being avoided whenever possible, all agreed. “Every hospital is preparing for their own patients,” said Dr. Adhikari. “In this scenario, most of them are trying to say, ‘Please keep your patient where you can.’”
In addition to concerns about keeping beds open, transfers of patients with COVID-19 raise a lot of infection control issues, from personal protective equipment (PPE) for all of the staff involved to decontamination of ambulances.
One exception is that hard-hit hospitals are transferring their patients to less busy community facilities, as Ashwin Shivakumar, MD, FACP, has experienced as hospitalist chief for five hospitals at CHI Franciscan in Tacoma, Wash. “We don't have a significant presence of local diagnoses compared to Seattle, but we still had a significant number of patients as transfers coming from the Seattle area coming into our buildings,” he said.
Changes in non-COVID-19 care
Revised transfer policies are one of several ways COVID-19 has affected community hospital care for inpatients without the virus. The reluctance of tertiary centers to accept transfers in order to preserve their beds and staff for their own patients also applies to transfer requests for non-COVID-19 cases.
“What happens if there is someone with an acute MI or a GI bleed who needs to be transferred to a different hospital because we don't have interventional cardiology or a gastroenterologist on call? Nearby university hospitals which previously would have the bed availability may not be able to accommodate our patient,” said Dr. Bali. “It's not just the disease itself that we have to worry about. It is also the burden on other patients who need an inpatient level of care but cannot get it because of the system being overwhelmed.”
Other side effects on non-COVID-19 patients include limitations in certain supplies, for example, viral culture media. Initial recommendations from the CDC suggested that a testing for another respiratory virus could be used to reduce suspicion for COVID-19, Dr. Bali noted. But running those respiratory viral panels uses up culture media that could instead be used for COVID-19 testing, and the latter result is much more actionable than one for another common respiratory virus, he added.
“In the community's best interest, it is more important for us to know whether the patient is COVID-19 positive or negative so we could maintain or discontinue isolation measures, rather than positive or negative for rhinovirus or respiratory syncytial virus. This is why we have been rationing our supplies of viral culture media,” Dr. Bali said.
Discharge planning also has to be modified for all patients, given that primary care practices are currently avoiding in-person visits whenever possible. “Be really careful with the discharge, really making sure your note is accurate, and making sure that they're set up beyond the next couple of steps. … It's not a perfect scenario where [a test or treatment] can be pushed to the outpatient setting if it needs to be done next week,” said Ali Chisti, MD, a hospitalist at Queen's West Medical Center in Ewa Beach, Hawaii.
He recommended that a hospitalist discharging a non-COVID-19 patient in the current situation call the patient's outpatient physician to discuss the case, optimizing the handoff and reducing the risk of readmission.
If a patient is positive for or suspected of having COVID-19 at discharge, it's also important to take steps to keep them from having to leave home quarantine, Dr. Montemuro noted. “We really utilize our in-house bedside delivery from the pharmacy we have in the hospital. Any medications they need for the next month or so would be delivered to the bedside,” he said.
Hospitalists have also been considering how to get other inpatients the care they need when or if the hospitalists are overwhelmed treating COVID-19. One solution is advance planning with subspecialists. “A typical heart attack would come to us, but in the circumstances we requested the cardiology team to admit those patients and likewise, the usually co-managed surgical patients would be primarily managed by surgery teams,” said Dr. Shivakumar. “We haven't had to use those options yet, but I know we are prepared in case we need to get there.”
Backup staffing arrangements, including requests to clinicians who don't usually see patients at the hospital, have generally been a major part of preparations. “Many doctors have been reached out to by our chairman of medicine to gauge their comfort level and availability to help out in different roles if we were to reach a surge capacity,” said Dr. Montemuro.
Hospitals have also prepared current staff to come in at the last minute when necessitated by either a surge in patient volume or clinician unavailability. “We do have two backup providers available every day for the next few months,” said Dr. Shivakumar.
They should also be prepared to handle tasks other than their usual ones, suggested Simran Kaur Matta, MD, an intensivist at Bayhealth Sussex Campus in Milford, Del. “I have been requesting the administration to cross-train people across all specialties,” she said.
Dr. Matta's hospital has only two intensivists, so she is considering which physicians might be able to fill in if either got sick or add to their capacity if there are too many patients. She has her eye on both recently trained physicians and other specialties that share some of the same skill set. “For example, general surgeons aren't going to be doing elective cases. They at least know the basics of ventilator management,” Dr. Matta said.
This strategy could be applied across the hospital, for example, by bringing in outpatient physicians to have conversations about goals of care in the ED, she suggested. “These things are so important, but in practicality I can't imagine ED docs spending 30 minutes with each family.” An advantage of small-town life is that there's a good chance patients and families will already know local outpatient clinicians, Dr. Matta added.
To ensure that physicians are prepared to take on new tasks, she has proposed a shadowing program to her hospital administration. “I think shadowing is going to be so important in making sure that they are comfortable in at least the basics of everything,” she said.
Advance planning should also focus on allowing clinicians who can't be in the hospital to still contribute what they can, advised Dr. Shivakumar. “We were quickly losing physicians, nurse practitioners, and physician assistants to suspected testing,” he said. “For those that are either lost to testing or to mild symptoms and end up being isolated, one of the first things we did was to expand our virtual hospitalist program, which we only used at night prior to this situation.”
The hospitalist program found HIPAA-compliant software that would allow physicians who were either quarantined or had chronic conditions that made them high risk to video conference into the hospital. “We currently have three to five physicians that are working in that capacity every day,” Dr. Shivakumar said.
PPE and other worries
Telemedicine also helps with one of the biggest concerns of hospital clinicians heading into this crisis: availability of PPE. “Our usual level of inventory was only good enough to get us to about the first seven to 10 days. As soon as the situation hit us here locally, we had to find a way to extend PPE,” said Dr. Shivakumar. “We deployed virtual visits specifically to suspected or positive patients and in doing so, we also minimized PPE use.”
Community hospitals face some disadvantages in PPE acquisition compared to bigger centers, including less buying power and media attention to drive donations, but their smaller size may also allow them to develop innovative, effective solutions. “We got creative, got some hardware store supplies from Lowe's, and other places we got gowns and face shields,” said Dr. Agrawal.
Now is the time for hospitalists to be pitching their creative solutions to COVID-19 challenges, according to Dr. Chisti. “Use this as an opportunity to really collaborate with the leadership,” he said. “If the solution is sound and concise and data-driven, it's really a no-brainer to follow for the people who are writing the policy. … Everyone's really scared and really looking for that voice from the physician.”
Of course, physicians have many reasons to be scared, too. “The fact that the guidelines seem to be changing from the CDC on a fairly frequent basis as to what was safe and what wasn't, I think caused a lot of anxiety for many people,” said Dr. Montemuro. “One of the biggest strains for us in a community hospital setting is protecting ourselves, our families, and our coworkers.”
Another particular worry for many rural community hospitals is potential effects on the financial stability of their facilities, which was often tenuous before the pandemic hit. “Lots of hospitals are already thinking of cutting down the physician forces because they are not generating enough money in this crisis, with cancellations of elective surgeries, cancellations of outpatient visits,” said Dr. Adhikari. “People are scared that the hospitals will go bankrupt.”
Community hospitalists can't end nationwide PPE shortages or fix hospital finances, but they can work together to respond as best they can to the problems COVID-19 causes today and in the upcoming weeks or months, all agreed. “People are relying on us, and I think keeping a sense of reason, a sense of calm, and a sense of hope will help everybody,” said Dr. O’Connor.
She and the other hospitalists noted that frequent communication with their peers, whether in person with morning huddles or around the world through social media, has been very helpful in preparing for and responding to the pandemic. “People have been amazingly generous about basically providing what they can,” said Dr. O’Connor. “We are really keeping a close eye on best practices and CDC guidelines, but also just keeping your eyes on the prize. I do think there will be an end to this.”