Home Cover Story Coronavirus: Stories from the front lines

Coronavirus: Stories from the front lines

Unprecedented changes upend clinical practice

May 2020
may 2020 covid front lines

AS THE HOSPITAL with the first reported coronavirus death in the U.S., Seattle’s Harborview Medical Center was also one of the first to send out an e-mail to its hospitalists: Who among them wanted to volunteer to work a dedicated covid service?

When he opened that e-mail, hospitalist Daniel Cabrera, MD, MPH, says he stared at it for an hour before responding.

“I called multiple people and said, ‘Should I do this or not?’ ” recalls Dr. Cabrera, who’s with UW Medicine. “I also had a frank discussion with my wife about what this would mean for me coming home.” After making those calls, he volunteered. “I felt that this is what I signed up for when I went into internal medicine and became a hospitalist, and that this was the time to put those skills to work.”

That was late February, when some people at Harborview thought setting up a covid-only service was “overkill,” given that most of the few patients admitted for possible covid were rule-outs.

“It’s more about the moral distress from caring for these patients that I find challenging.”

Daniel Cabrera, MD, MPH

~ Daniel Cabrera, MD, MPH
Harborview Medical Center

“And then it started to balloon,” says Dr. Cabrera. “We’re probably going to need additional services in the next week or so.” While the hospital isn’t past capacity and he’s confident about the amount of PPE he has available, Dr. Cabrera points out that the number of covid patients at Harborview now “is equivalent to what we would normally have on our inpatient medical service.”

Like just about everyone in hospital medicine, Dr. Cabrera has thrown himself into either the care of—or preparation for—patients with coronavirus. And like everyone else, he is managing unprecedented changes in his workflow and schedule, patient interactions and stress levels.

Since the beginning of the pandemic, regulations governing just about everything—from credentialing new providers to HIPAA violations—have been swept away. And clinicians say their entire approach to medicine has similarly been upended, given how little evidence they have to fall back on to treat the virus. That’s left them engaged in what one source calls “a continuous, daily quality improvement process” and another describes as “flying blind.”

Staffing changes
At Morristown Medical Center, a hospital with almost 700 beds in northern New Jersey that is part of Atlantic Health System, the facility had some time to prepare, says hospitalist medical director Peter Roytman, MD.

Plant management, for instance, did a staggering job, converting hundreds of general floor rooms—as well as ICU beds—to negative pressure. And the hospital was “phenomenally lucky,” Dr. Roytman says, in that the CMO it hired just months before was a critical care pulmonary specialist with expertise in emergency response and a background running Ebola units.

“We came very well-prepared,” says Dr. Roytman, “but we did not expect what came to us.” The first patient with suspected covid was admitted in early March. Within 10 days, that number had grown into the hundreds.

“The anticipation of risk from going into their rooms has subsided. We’ve gotten used to that.”

 Peter Roytman, MD

~ Peter Roytman, MD
Morristown Medical Center

The hospitalists traditionally practiced in three separate groups: one big employed group that Dr. Roytman headed up, a small family medicine teaching team that’s also employed and a private group. Their first collective move was to combine all three groups into one under his leadership.

“We realized we couldn’t continue this kind of piecemeal, unit-by-unit management,” he points out. The hospital has now opened 10 covid units, seven of which are staffed by his original group, one by the family medicine team and two by the private group.

To further flex up staff, Dr. Roytman helped devise a three-wave plan. The first strategy was to bring in NPs/ PAs. “We can redeploy them very rapidly,” he says. “They’re usually very versatile.”

The second strategy was bringing back to the hospital primary care physicians with some recent inpatient experience as well as former residents. The third wave—and the only one he hasn’t yet had to use—is bringing on specialists including endocrinologists and GI physicians to treat covid patients.

Malleability
Gerard Salame, MD, a hospitalist with Denver Health, says his facility has seen some “blunting” in its rise of cases, although its ICU is projected to be crushed in June.

For now, “everybody in every department stepped up as soon as we saw this coming,” Dr. Salame says. “We all flexed up to work in places where we maybe weren’t originally comfortable.” All the hospitalists were taken off teaching blocks, with primary care physicians and subspecialists stepping in to fill that teaching gap.

That allowed the hospitalists to focus on treating covid patients, minimizing other doctors’ exposure. To limit exposure even further, the medical center has designated one hospitalist as the covid flex person who triages and admits most covid patients. That physician also follows up with covid patients who are discharged home from the ED. While all the hospitalists—other than those who are exempted—rotate through covid units, some like Dr. Salame volunteered to form two teams to work with intensivists in what is usually a closed ICU.

“I’m trying to do just about all my documentation outside the hospital.”

Christopher Song, MD

~ Christopher Song, MD
Lawrence+Memorial Hospital

“I hadn’t done critical care in more than a decade,” he says. “The intensivists gave us a crash course on vent management, septic shock and pressor support.” While a part of him was thrilled with what he was learning, “another part was horrified that I was going to be treating not only covid patients but the sickest of the sick.”

At Harborview, Dr. Cabrera says the hospitalists dissolved first one, then a second surgical comanagement service. In addition to fielding their first set of volunteer hospitalists for a dedicated covid service, group members determined their first pool of back-up covid physicians and APCs, and then their second.

“We were transparent in that process,” says Dr. Cabrera, “and also in the fact that an ‘ask’ may not be an option.” Sources report that group members exempted from covering covid are those who are pregnant or have a newborn, those with medical conditions or with immunocompromised or elderly family members at home, or those partnered with other first responders.

“We had a handful of people who volunteered at first,” he says, “but those numbers have gone up along with our number of covid patients. We haven’t had any shortage of clinicians who want to work that service consistently.”

Changing work blocks
For hospitalists treating covid patients, hewing to a familiar seven-on/seven-off schedule is too grueling.

In Morristown, Dr. Roytman says his group has experimented with different blocks. They’ve now settled on working five-on/two-off one week, then two-on/five-off the next.

“Most of our families are staying at home, but some spouses are still working, so weekends are still important for family time,” he says. “We’re trying to preserve that, so we want doctors to work only every other weekend if we can.”

“We need to become a little more than colleagues, so we’ve become sources for resources and support.”

Gerard Salame, MD

~ Gerard Salame, MD
Denver Health

In Seattle, Dr. Cabrera says that group management has given the physicians on the covid service the flexibility to decide how many days in a block they want to work. He finds that the more days in a row, “the better rhythm and flow you develop. Plus you form relationships with nurses and staff on the units,” he says. “You don’t want too much stutter and stop.”

At the same time, while he feels adequately protected against being infected in terms of equipment, “it’s more about the moral distress from caring for these patients that I find challenging.” As a result, he’s opting to work three- or four-day blocks.

Denver Health’s Dr. Salame agrees with that assessment. While he believes that he, his fellow health care workers and administration have taken “a very complex situation and handled it remarkably well,” there’s no doubt that treating covid is much more exhausting than his regular workload.

That’s been both gratifying and “truly traumatic,” he says. “The chronicity of these last weeks and months really peels away your defenses.” He and the other hospitalists working in the ICU are doing 12-hour shifts in five-day blocks, followed by 10 days off.

“That’s in case we become infected,” Dr. Salame says. “We’d hopefully manifest symptoms while we were off so we wouldn’t put anyone else at risk.”

Limiting patient encounters
In New London, Conn., Christopher Song, MD, is associate director of the TeamHealth hospitalist program at Lawrence+Memorial Hospital, which is part of Yale New Haven Health. With the surge in his hospital projected for late April, Dr. Song estimates that his hospital has treated about 100 coronavirus patients.

For many weeks before, hospital preparations were in full swing, particularly around how to conserve equipment. The hospitalists and other staff were initially reusing masks for up to a week to extend their use, unless they were damaged or soiled. That practice is no longer in effect.

“We knew at the time that it was suboptimal,” says Dr. Song, “but considering the supply constraints, we had to take that step.” Masks are now being decontaminated with hydrogen peroxide vapor, and PPE inventory is being continually monitored. Given “my hospital’s work with reprocessing and my company’s efforts in acquiring additional PPE, we are well-equipped and feel well-protected.”

The health system the hospital is part of is also taking the approach of not masking patients in their rooms. But every staff member who has any patient contact is masked, and clinicians treating covid patients use N95s and face shields.

A great deal of thought has also gone into how to minimize clinicians’ risk of exposure by limiting patient encounters. That has led to an explosion in the use of tablets and other technology for virtual visits. (See “ A critical need for virtual visits.“) It’s also led Dr. Song to completely change up his workflow.

Now that his hospital is much more flexible about what time physicians need to arrive on their unit, Dr. Song says he pre-rounds at 7:30 a.m.—from home.

“When I arrive at the hospital, it is purely to see my patients,” he says. He sees them all in a row, trying to avoid picking up a phone or touching a hospital computer, although that’s not always possible. He communicates in-person with nurses, double-checks on and resolves any urgent matter, and then leaves the hospital.

“I’m trying to do just about all my documentation outside the hospital,” says Dr. Song. “That’s how I’m choosing to approach this.”

A new normal
After treating covid patients for more than a month, “the anticipation of risk from going into their rooms has subsided,” Dr. Roytman points out. “It’s the new normal, and we’ve gotten used to that.” In his facility, three hospitalists as well as an emergency physician and an anesthesiologist became infected. They’ve all recovered, and none needed to be admitted.

What they don’t get used to is having to communicate with family members who aren’t allowed in the hospital, “particularly when things are not looking good and we have to make decisions,” he says. He also estimates that as many as 60% of the covid patients in his hospital are younger than 70.

“When they start to decline rapidly and there’s nothing you can do, that is very unsettling.” At the same time, he takes a great deal of encouragement from the fact that his hospital has discharged scores of covid patients.

As for clinical medicine, “everything has changed,” Dr. Roytman says simply. “We used to wait years for randomized controlled trials, but we don’t have time for those now.” He and his colleagues—like clinicians everywhere—have started to utilize data found in small studies out of China and Europe.

First is anticoagulation. “We immediately noticed the positive D-dimers,” he says. “For us, that’s one of the markers of covid.” He and his colleagues still don’t know, however, if they have to use therapeutic anticoagulation or if prophylaxis is enough.

They are also using hydroxychloroquine and have developed a protocol for initiating it and for monitoring patients’ QT interval. And they’re having some success with steroids.

“We’ve had a good response, particularly in select patients on days five or six of their admission,” Dr. Roytman says. They are initiating methylprednisolone at a dose of 125 mgs, followed by 1 mg/kg/day divided in two separate doses. To get a handle on how rapidly treatment strategies are evolving, they update their own guidelines daily and post those to their EHR.

An “almost random” clinical course
Dr. Salame at Denver Health also says that “we’re bombarded every day with new data and evidence.” He’s also never experienced anything like this disease in his career.

“I’m OK with diagnosing these patients, but their clinical flow seems almost random,” he says. “As physicians, we’re used to living in the realm of probability, but this has taken that to a whole new level.”

Working in the ICU, Dr. Salame says he takes some reassurance from realizing that the intensivists are struggling as much as he is to figure out how to treat. “It’s hard to accept the feeling of powerlessness,” he adds. “Despite all the institutional support, I don’t have much to go off of.” Other than using a few basics, like early proning, “we just don’t have enough evidence.”

The fact that “we’re all in this together, especially our hospital medicine group, is extremely helpful,” he notes. They all use a group chat to stay in touch and look out for one another. “We need to become a little more than colleagues, so we’ve become sources for resources and support.” He’s also decided to continue to live at home, although he’s careful to follow a meticulous work-home routine.

“I come to work in normal clothes, then change into scrubs,” Dr. Salame says, making sure to not keep personal items like his phone and wallet with him while he’s working. When his shift is over, he changes out of his scrubs and does what he calls a “terminal clean,” including wiping down the soles of his shoes with bleach. Then he drives home, strips down in his backyard—”we have high fences”—and rushes to the shower.

“I feel I need my family’s support,” he points out. “That way, at the end of the day, the world isn’t all about covid.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

A critical need for virtual visits

ASK SAJID NOOR, DO, what the impact of coronavirus may be on hospital medicine and he raises an issue that has come rapidly to the fore: Will the pandemic permanently sweep away all the red tape that’s stymied having virtual patient visits?

Dr. Noor is assistant director of quality and safety for the acute medicine service at Delaware’s ChristianaCare and medical director of the transitional medical unit at Christiana Hospital in Newark, Del. He points out that boosting the use of telehealth has been a hot topic for at least a year at his health system’s Health & Technology Innovation Center.

“Given the severity of the situation, adoption progressed rapidly.”

Sajid Noor, DO

~ Sajid Noor, DO
ChristianaCare

But while telemedicine has ramped up in the ChristianaCare outpatient community, it wasn’t until this pandemic that its application took off in the hospital. Now, virtual inpatient visits are a vital tool helping conserve protective equipment and reduce clinician exposure.

“We outfitted each room in our covid units—on the floor and in the ICU—with an iPad on a stand, then put iPads for clinicians and staff to use in every nursing station,” says Dr. Noor. “And we did all that in under a week.” While getting people to try an innovation usually takes a lot of time, “given the severity of the situation, adoption progressed rapidly.”

While doctors still don protective equipment to go into patient rooms if they need to do an exam, they’re doing virtually all their history-taking as well as their conversations about care plans via iPad and Skype, he explains. Each room’s iPad has been assigned that particular room number, and doctors can call into any iPad from any nursing station. Doctors at ChristianaCare can also use the iPads there to connect to patient rooms at the health system’s Wilmington Hospital as well.

Nurses, social workers, consultants and dieticians are also using the iPads to limit—or eliminate—the need to physically interact with infectious patients. Feedback he’s received since the go-live in early April has produced some tweaks, including a sample video now available on each iPad.

“It’s a visual aid that walks providers through how to use the iPad to communicate with patients and where to click,” says Dr. Noor. “We also put a sample video on the iPads for patients too.” (Patients also get a simple printed sheet with instructions.) The goal now: to have an iPad for every hospitalized patient in the system.

How might coronavirus change hospital medicine?

WE ASKED HOSPITALIST sources in this month’s issue what impact treating coronavirus patients may have on the field. Here’s what they had to say:

hospitalists sound off on covid

Published in the May 2020 issue of Today’s Hospitalist

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