Note: This article is based on interviews conducted the week of March 9, 2020.
WHEN THE FIRST coronavirus death in the U.S. was announced in Seattle on Feb. 29, the five-hospital Swedish Health Services in that metro area decided that all patients testing positive for COVID-19 would be admitted to only one of its hospitals. That way, the reasoning went, all infected patients would be cohorted in one building with dedicated providers, safeguarding the patients and health care workers in the other four.
But as the number of COVID-19 patients shot up, it became clear that original plan had to be scrapped.
“We realized we didn’t want to transfer these patients, so now all five hospitals are admitting them and cohorting them on separate floors,” says Per Danielsson, MD, Swedish’s medical director of adult hospital medicine. How long did it take the health system to rethink its original decision? “About five days.”
It was just one of a frenetic number of decisions being made in Seattle and throughout the country. Hospitals are racing to figure out how to safeguard what have become the nation’s most valuable and potentially vulnerable resources: its health care workforce and hospital capacity.
“Our docs are calm and our spirits are up.”
~ Per Danielsson, MD
Swedish Health Services
How widely coronavirus has spread in the U.S. remains unknown due to what has been—as this is being written in mid-March—a staggering fail in testing capacity. Still, hospital medicine leaders around the country are preparing their hospitals and programs for either a coming surge of infected patients or one that’s already arrived.
At press time, some hospital and health systems in the U.S. had yet to report a confirmed case of coronavirus. Others, like Dr. Danielsson’s, have already suspended elective surgeries and are treating scores of patients who are either under investigation pending COVID-19 test results or have already tested positive.
And while hospitals are following CDC guidance in terms of quarantines and personal protective equipment (PPE), “many hospitals are experiencing shortages in ventilators and PPE,” says Surinder Yadav, MD, MBA, a senior vice president with Vituity, a multispecialty physician-led partnership. As a result, “teams have been following WHO guidelines on surgical masks and face shields.” The CDC recently updated its guidance to align with WHO’s.
In Seattle, Dr. Danielsson reports that the Swedish hospitals are running at close to capacity, with the ICUs at two of its outlying hospitals “starting to fill up.” Across all five hospitals, the number of COVID-19 inpatients is increasing between five and seven patients a day.
Fortunately, he points out, Swedish has the University of Washington laboratory—one of the first in the country with functional testing—”in our backyard.” Unfortunately, the health system is also fielding “about 50 to 60 sick calls from health care personnel, primarily nurses, on a daily basis,” Dr. Danielsson says. Because of the health system’s aggressive hiring of agency nurses, about 200 are now being onboarded system-wide.
“Teams have been following WHO guidelines on surgical masks and face shields.”
~ Surinder Yadav, MD, MBA
As for physicians, “we’ve had a number of exposures, due to codes or to treating patients we didn’t know yet were positive,” he says. While those physicians were being tested and were “checking themselves daily,” they continued to work.
While doctors at Swedish who’ve been exposed are, so far, not opting for quarantine, Kimberly Bell, MD, MMM, regional director of hospital medicine for TeamHealth West, notes that about 30 physicians and advanced practice clinicians in her company are currently in quarantine.
That includes both ED and hospital medicine clinicians, says Dr. Bell, who has oversight of eight hospitalist programs in California, Washington and Hawaii. “That could be because of exposure or because of travel.”
TeamHealth’s hospital medicine practices, particularly in California, are cohorting coronavirus patients in one unit. The company is also, says Dr. Bell, working to develop cross-credentialing across multiple sites in specific locations. And it is talking to specialists about “off-loading” some hospitalist patients once volume surges hit.
For Dean Dalili, MD, MHCM, the Houston-based president of hospital medicine for Envision Healthcare, providers who need to be quarantined right now are a big concern.
His company’s first experience with coronavirus was treating several patients evacuated from the Diamond Princess cruise ship to the Lackland Air Force base in Texas. The patients who were acutely ill were hospitalized in an HCA facility where Envision staffs the hospitalist program. In that case, “the CDC actually came to the facility,” Dr. Dalili says. “Its team was actively involved in both the physicians’ preparation and the facility’s.”
“We need any licensed physician to be able to practice in any state.”
~ Kimberly Bell, MD, MMM
But a much more problematic situation took place in Sarasota, Fla. An Envision group there divides the hospital census with a private hospitalist group—one that inadvertently treated positive patients. When the private group members went into quarantine for 14 days, Dr. Dalili says the Envision hospitalists saw their patient volumes double.
In the short term, “we were able to take providers who weren’t working but were already credentialed at that facility,” he says. In addition, Envision—as well as TeamHealth and every other national staffing company—has internal locums and traveling teams it can deploy.
“We do have the ability to flex up for a surge,” he says. “But that isn’t unlimited.” As a sign of how serious the need to increase physician capacity may become, Dr. Dalili says his company has started talking with other national staffing companies about how they may pool their doctors and send them where they are most needed.
Vituity’s Dr. Yadav points out that his company likewise has some clinicians on the West Coast in quarantine.
It also has a cadre of what it calls “reservists” or “champions,” clinicians available for short-term regional staffing. He also notes that having those traveling doctors, who are typically used for start-ups, is possible because the company deliberately overstaffs its hospitalist programs. “We want to be able to meet contingencies such as colleagues getting sick,” Dr. Yadav says. “We aim for about 125% staffing.”
Another plus: While some hospitalists with Vituity choose to work seven-on/seven-off, most work shorter, more flexible blocks. “If you’re locked into a seven-on/seven-off schedule and someone is either sick or quarantined, you’re asking someone else to work 14 days in a row,” he points out. “That’s going to quickly lead to a high burnout rate, which has a direct impact on patient care.”
“We’re now asking people to think about how we can accelerate our ability to staff.”
~ Dean Dalili, MD, MHCM
Even community hospitals that don’t have access to national staffing reserves report some built-in physician capacity. At Cape Cod Hospital in Hyannis, Mass., which at press time didn’t yet have a confirmed coronavirus case, the ranks of the hospital-employed hospitalist group have long been boosted by a stable per-diem pool the hospitalists have relied on every summer when their volume surges 20%.
Many of those per diems, says hospitalist director Ricardo Nario, MD, are fellows in various internal medicine subspecialty programs in Boston. The hospital also has developed a connection with hospitalists in a health system in Providence, R.I., which is 70 minutes away. “They come and pick up shifts with us.”
One of Cape Cod’s per diems is already working full time, helping rounding teams during what’s been a busy flu season. And “our overflow unit has been open since January,” Dr. Nario says, although flu volume now is dying down. For most of March, he and other hospital leaders have met daily along with community outpatient and post-acute representatives and visiting nurses to set local COVID-19 priorities.
And while all the hospital’s coronavirus testing now needs to go through the public health department, a major bottleneck throughout the country, Dr. Nario is grateful that the hospitalists last year succeeded in pushing the hospital to invest in rapid PCR viral testing.
That can at least quickly rule out flu in patients who present, he says. “And we have been told the manufacturer believes that by April we may be able to test for COVID-19.”
In early March, the five-hospital WellSpan Health, a Pennsylvania-based integrated health system with eight hospitals, set up a system-wide COVID-19 unified incident command center in administrative space usually reserved for human resources.
“Our overflow unit has been open since January.”
~ Ricardo Nario, MD
Cape Cod Hospital
“We purposefully kept it separate from the hospitals,” says hospitalist Alyssa Moyer, MD. Dr. Moyer is chair of the department of medicine at WellSpan York Hospital and chief medical officer for WellSpan Surgery and Rehabilitation Hospital in York, Pa.
As for clinician capacity—particularly at WellSpan York Hospital, the health system’s level I trauma center with close to 600 beds—”we have a pool of internal locums, clinicians who rotate through the weekends who are either semi-retired or work part time,” she says. “They are our plan B.”
WellSpan, like many other health systems, is working to increase bed capacity, if it needs it. It also plans to cohort COVID-19 patients in dedicated wings or floors. That not only improves quality control but allows staff to use their PPE for an entire shift, rather than “having to don on and doff off to go into individual rooms,” she says. “Otherwise, for staff, that would be exhausting.”
Physician leaders also say that regulatory barriers may have to fall, and soon. While some hospitals, for instance, could convert more beds to negative airflow, those beds might not now be so licensed. That would require input from state health departments, which are tremendously strained.
Dr. Bell also points out that TeamHealth has advocated with state licensing boards to relax or even sweep away the need for physicians to be licensed in a state to practice. “In an emergency,” she says, “we need any licensed physician to be able to practice in any state.” The HHS in mid-March announced that physicians will be able to practice across state lines.
On the ground, Envision’s Dr. Dalili says that now is the time for all hospitals and health systems to either update— or craft, if they don’t already have them—protocols for emergency credentialing.
“Clinicians who rotate through the weekends and are either semi-retired or work part time are our plan B.”
~ Alyssa Moyer, MD
“We’re now asking people to think about how we can accelerate our ability to staff,” he says.
In Seattle, Dr. Danielsson says that discussions on how to accelerate capacity include redeploying resources that would be underutilized if the coronavirus crisis gets worse. “Those include primary care and cardiology clinics,” he says. “People won’t be coming to appointments because they’ll be told to stay away.”
As part of its staffing contingency plans, Swedish may bring some outpatient physicians—primary care, cardiologists, even GI doctors who are coming forward—into the hospital.
“We would probably go to a simplified note template and have those physicians handle the less sick patients,” Dr. Danielsson says. “The hospitalists would manage those with multiple comorbidities who are more sick.” And while all of the ICUs, even in outlying Swedish hospitals, have now switched to 24/7 intensivist staffing, “if we get into a situation like they’re facing in northern Italy, then hospitalists will have to be active in the ICU,” he explains.
“Intensivists would run the vents and manage pressors, while anesthesiologists would do the procedures, and the hospitalists would manage the ICU patients at large.”
Where to discharge patients to?
Such a plan hasn’t yet been put into effect, Dr. Danielsson notes. But disposition problems have already cropped up, including how—and where—to discharge COVID-19 patients if they are homeless or not ready to go home.
“We’ve had a significant problem discharging patients back to skilled nursing facilities,” he says. Some SNFs are demanding a COVID-negative test for any incoming patient. And the CDC in March issued guidance for western Washington, suggesting that SNFs consider suspending all admissions.
“That’s going to potentially clog up our system,” Dr. Danielsson predicts. While the county has purchased an 80-bed motel to house COVID-19 patients post-discharge, “that’s not up and running yet.” Further, “it’s unclear who would be eligible to go there or who would staff it.”
According to Dr. Danielsson, “our docs are calm and our spirits are up.” But he has several concerns. For one, “there are a lot of cooks in the kitchen, for sure.” With everyone weighing in—local officials, federal agencies, state and county health departments, even local academic centers with guidelines and testing criteria—it’s critically important to keep communication lines open to local clinicians and to use them at least daily.
He also worries that societal restrictions may be too little, too late. While he can now drive to work in record time, “pedestrians are still walking around downtown Seattle,” he says. “We may need more stringent measures to limit the spread of the virus.”
Most of all, he’s concerned that health care personnel may become infected and symptomatic. “I worry our system could be overwhelmed in a week or two.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
For timely updates on COVID-19, click here.
What hospitals need to do right now
Across the country, hospitals and hospitalist programs have banned travel, suspended paid time off, cancelled in-person meetings as much as possible, revisited their credentialing protocols, and locked up their N-95s.
Meanwhile, health departments and hospitals are setting up tents—some outside EDs, others away from hospitals altogether—to screen and test potential coronavirus patients (at least those that have access to testing). What else should hospitals be doing? We asked several hospital medicine leaders about the plans they’re making:
• Prioritize surgeries. Even before they’d identified any coronavirus-positive patients, system leaders with WellSpan Health in Pennsylvania had worked out what hospitalist Alyssa Moyer, MD, chair of the department of medicine at WellSpan York Hospital, calls “a prioritization rubric for all surgeries.” They assigned all surgeries to four separate tiers, with priority No. 1 being “life and limb, no delays,” to priority No. 4 being elective procedures.
“We essentially calculated the burn rate for protective equipment for each of those surgeries,” Dr. Moyer says. “So if our levels of protective equipment start to run low, we’ll know which cases to hold.”
• Find alternate sites of post-discharge care. In Seattle, Per Danielsson, MD, medical director of the adult hospitalist program with the five-hospital Swedish Health Services system, says that skilled nursing facilities are close to suspending admissions.
That leaves hospitals scrambling to find sites where patients recovering from COVID-19, including those who are homeless, may be discharged to.
That’s also true, says Dr. Danielsson, for elderly coronavirus patients who don’t want aggressive measures and are not expected to live. “Goals-of-care discussions are probably very appropriate for select patients.”
One silver lining of the coronavirus crisis is that a relief bill passed by Congress now reimburses telemedicine for Medicare beneficiaries. And hospitals and health systems that already have telemedicine capacity plan to crank those capabilities into high gear.
They’re also exploring how to use such capabilities in ways they haven’t so far. In addition to having several inpatient service lines, for instance, national staffing company Vituity also staffs skilled nursing facilities and urgent care centers.
Surinder Yadav, MD, MBA, a senior vice president with Vituity, says the company is now considering how to take advantage of tele-urgent care. “That’s one place we may be able to steer patients who feel sick but don’t need hospital care,” he says. “It may become critical to keep those patients away from the ED.”
Within the five-hospital Swedish Health Services in Seattle, patients who test positive in the ED for COVID-19 but who don’t need acute care—as well as hospitalized COVID-19 patients being discharged home—are sent home with “a thermometer and a pulse oximeter,” says Per Danielsson, MD, Swedish’s medical director of adult hospital medicine. “They’re also given a Zoom videoconferencing link to enable them to interact with a nurse in our tele-ICU center.”
Dr. Danielsson also points to a telehealth capability that his hospitals can take advantage of, thanks to a partnership with Microsoft. Patients in isolation are given tablets, allowing clinicians to round on and communicate with them via tablet. “That way,” he says, “you can check on patients without putting on full PPE.”
That’s likewise an option that national staffing company Envision Healthcare has in some of its hospital medicine sites.
“We can use robots for our maintenance visits,” says Dean Dalili, MD, MHCM, Envision Healthcare’s president of hospital medicine. “We don’t plan to rely on that for a patient’s entire length of stay, but perhaps every other day to minimize provider exposure.”