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Innovating during the pandemic

Can hospitalists keep up the pace?

May 2021
innovation-pandemic

IN PUBLIC SERVICE ANNOUNCEMENTS running on TV stations in Amarillo, Texas, Sheryl Williams, MD, hospitalist and medical director of quality, stands in a hospital hallway in PPE, talking about how exhausting it’s been to work the pandemic. Her sound bites have been edited together with those of several other hospital providers, all with one message: Wear a mask so you don’t become one more patient we need to treat.

Dr. Williams has long experience with local media, so it’s not her first time on television. But here is a first: The PSAs, which were commissioned by the city, are a collaboration between the clinicians and marketing departments of both the hospital where Dr. Williams works—Baptist St. Anthony’s Hospital—and its competitor, Northwest Texas Healthcare System.

“Pre-covid, the two hospitals didn’t speak to each other, and it was a real competition,” Dr. Williams points out. “Now, at the corporate and CMO levels, we’ve worked through the pandemic hand in glove.”

“Everyone at that time was adaptable.”

Jessica Pacifico, MD

~ Jessica Pacifico, MD
Montefiore Health System

Unprecedented collaboration—even across competitors—is just one in a staggering wave of innovations that has swept through hospitals as they battled covid. Traditional mechanisms that have long dictated how decisions get made and change implemented were tossed aside, replaced with speed and agility.

While the pandemic continues to leave trauma in its wake, it’s also produced seeming miracles of engineering, complete clinical overhauls, fluid job descriptions and reconfigured work roles, and a hive of new relationships and networks. While sources say the dread has been real, the pace of innovation has been thrilling.

It remains to be seen which innovations put in place to manage the pandemic will survive and in what form. It’s also up in the air whether becoming comfortable with so much rapid change will become a permanent feature of health care culture.

Accelerating factors
Crisis has certainly proved to be the mother of invention, says Gregg Miller, MD, chief medical officer for Vituity, a multispecialty physician-led partnership with more than 500 hospitalists across the country. As Dr. Miller notes, the pandemic has been “hyper-local” in both the pattern of outbreaks around the country and the range of innovations that individual hospitals have been able to take on.

“We found strength in teams that we didn’t know were teams until they happened.”

Sheryl Williams, MD

~ Sheryl Williams, MD
Baptist St. Anthony’s Hospital

But collaboration at all levels radically changed health care everywhere. Hospitals in local markets shared ventilators, supplies, data, even patients. National physician companies like Vituity got their CMOs together for the first time to make recommendations about state licensure and about how to manage hospital clinicians at high risk from the virus.

“We also created guidance on appropriate PPE, which is now pretty standard,” Dr. Miller explains. “But in the early days of the pandemic, that guidance was more aggressive than what we were hearing nationally.”

He points to other factors that accelerated innovation nationwide. First among them were regulatory and payment waivers. “Certain barriers that have been in place stifling innovation got removed,” Dr. Miller says. “That is why we could innovate much more quickly around hospital at home and telehealth.”

Perhaps even more important was what Dr. Miller calls “the single-minded focus and determination of the entire health care team,” from administration and materials management to clinicians. Usually, he adds, everyone in health care has her or his own projects and areas of expertise. But over the past year, “everyone was focused exclusively on covid, and everyone was pulling in the same direction. That’s why we could drive so much change so quickly.”

Jessica Pacifico, MD, associate director of the medicine service at Montefiore Health System in the Bronx, saw just what can be accomplished with that singular focus.

“Covid was a war situation where we didn’t have time to really think.”

Venkatrao Medarametla, MD

~ Venkatrao Medarametla, MD
Baystate Health

As covid cases became catastrophic in New York City last spring, Montefiore converted nonclinical space consisting of a large, open lecture hall and several smaller conference rooms into a medical unit with close to 40 beds. Those beds came complete with oxygen piping, suction capability, workstations, sinks and hand sanitizers, PPE stations, a satellite pharmacy, and even a break room—all set up within a week.

(Those efforts were described in a Journal of Evaluation in Clinical Practice report published in March of this year.)

New workflows
That took the participation of every department, says Dr. Pacifico, who helped plan out the logistics of the converted unit and coordinated efforts across disciplines. (Two other Montefiore campuses in the Bronx likewise created medical units out of nonclinical spaces, one by retrofitting the hospital’s gym.) Part of her efforts went into helping decide which covid patients to treat in that unit.

Given the limited space and lack of walls and doors, the decision was made to use the converted unit only for adult covid patients who were clinically stable and approaching discharge. None of the patients would need high-flow nasal cannula or non-rebreather masks.

“Finding the appropriate patients for that unit took considerable effort because it was a brand new workflow,” Dr. Pacifico says. “I went to every unit in the hospital every day, talking to providers and discharge-planning teams. They needed to know there was this new space available so they could free up other beds.”

“We now know that if it’s something we’re passionate about that needs to happen, we can make it happen.”

Gregg Miller, MD

~ Gregg Miller, MD
Vituity

Screening patients for that unit through chart review was assigned to those clinicians who, because of their own medical conditions, couldn’t treat covid patients in person. Initially, the converted unit was staffed by two medicine-led teams. But as the surge built and one of those teams was assigned elsewhere in the center, it was replaced by a team of pediatricians.

“Even though they were treating adult patients, the patients were lower acuity so it was a good fit,” says Dr. Pacifico. “Everyone at that time was adaptable, so it was something we could accomplish.”

In Amarillo, Dr. Williams’ hospital also pulled off a building feat, creating a respiratory care pod next to the ED— nicknamed the “sod pod” because it started with a dirt floor—in 10 days. The sod pod, which is still in use, is where patients with suspected covid are tested to keep them out of the ED. The pod is also now doubling as an infusion site for patients being given monoclonal antibodies.

And with tubing and fans, the hospital swiftly created negative pressure for all its ICU beds, as well as negative pressure rooms on two hospital floors. “It was ‘MacGyver,’ ” Dr. Williams says, “but it worked.”

Teams and speed
For Dr. Williams, the pandemic was a constant reminder that, when “right away” is the only timeframe available, talking to the right person at the right time is the only way to get that done.

“We now have all these networking relationships we didn’t have before,” she points out. Early last spring, she worked with the lab director to get covid test results to hospital units throughout the night until PCR testing was brought on board.

Dr. Williams worked with employee health to have ED nurses rapidly test employees who called in sick, to find out if they were positive. She also worked with the pharmacy on a covid therapeutics committee. The initial goal was to make sure the hospital wouldn’t run out of paralytics for ventilated ICU patients.

That committee, says Dr. Williams, became one of the most important in the hospital, tasked with figuring out best practices for every covid therapeutic and disseminating those practices to providers. “We found strength in teams that we didn’t know were teams until they happened.”

At Baystate Medical Center in Springfield, Mass., the hospital medicine division decided very early to create an entirely new team of physicians. As Venkatrao Medarametla, MD, Baystate Health’s medical director of hospital medicine, explains, the “covidists” were a core group of 10 physician volunteers, all with some ICU experience. (At the peak of the hospital’s covid surges, as many as 20 hospitalists at a time became part of the covidist cadre.)

The goal, which the team achieved, was to have covidists provide all the care to hospitalized covid patients and to interact with their family members. They also helped the covid intensivists in the ICU, and they made it possible for other clinicians—hospitalists and specialists alike—to minimize their exposure to covid patients.

(More on the covidist team was published in an article by The Hospitalist.)

The hospital medicine group designed the model, identified the volunteers, trained them with refresher courses on ventilator management and advanced cardiac life support, and deployed them on newly-formed covid units, all within one week. (The same identification and training took place for covidists in four community hospitals that are part of the same health system.)

Pre-covid, Dr. Medarametla points out, such an innovation wouldn’t have happened within weeks. “It would definitely have taken between five and six months,” he says.

No time to work through problems
Moving forward, would Dr. Medarametla want to continue to implement other innovations within a week instead of months?

Absolutely not. “One week isn’t the way to go,” he says. “Covid was a war situation where we didn’t have time to really think.” In designing an innovation, he adds, people need time to work through any problems they may have. But he and his colleagues also don’t want to go back to the same plodding pathway of taking months to enact any change.

“You realize how much red tape always hampers the ability to implement any policy,” he says. “We all now think that we used to be too detail-oriented and we overthought whatever we were trying to do.” His pandemic takeaway about innovation: “You don’t need to be 100% perfect going in. Even 70% is good enough, then you can learn and change as you go along.”

Dr. Medarametla has already seen the pace of change accelerate throughout his institution. Pre-covid, a revised COPD order set took more than a year to design and be integrated in Baystate’s electronic medical record. Since covid, he and his colleagues were able to revise and implement an alcohol withdrawal protocol—within three weeks.

A permanent form
Several covid-driven innovations in Dr. Medarametla’s group will live on in some form.

When they were launched, the covidists immediately adopted WhatsApp secure messaging to relay information to one another. That forum was quickly adopted by the entire hospitalist group, where it become the place to not only exchange clinical information but to socialize and even vent.

One year later, the hospitalists’ use of WhatsApp isn’t going anywhere. “The hot topic everyone is now discussing is Bitcoin,” Dr. Medarametla says.

The covid updates he started e-mailing every day early last spring have since morphed into a monthly six-page newsletter. “People wanted to see it continue,” he points out. “The feeling was that it helped unify us as a systemwide group, allowing us to know what’s going on with the hospitalists in the main hospital and in the community ones.”

Another change that looks permanent: Hospitalists are much more comfortable managing sicker patients. The doctors who served as covidists are certainly more willing to treat patients longer on the wards before transferring them to the ICU.

And “all of us are calling fewer consults,” says Dr. Medarametla. “Assuming that every consultant may increase length of stay by 0.5 days, hopefully our length of stay will improve along with the quality of care.”

A change in culture
At Montefiore, Dr. Pacifico says the innovations ushered in during the pandemic have driven a culture change, firing up many of her colleagues to take on new quality improvement and patient safety projects and to move into new leadership opportunities.

She herself took on a much bigger administrative role last spring, stepping in as acting director of the medicine service. And while research and publishing aren’t the primary focus of her career, she was the lead author of a write-up about her center’s medical unit conversion in the Journal of Evaluation in Clinical Practice.

“I thought it was important,” says Dr. Pacifico, “to communicate to others that this was something we achieved that could be replicated and safe.”

Vituity’s Dr. Miller notes that the pace of change maintained this past year can’t be sustained. For one, hospitalists are exhausted and are just trying to hold on until the pandemic ends.

And while it drives innovation, having everyone pull in only one direction comes at a very high price. “A lot of care outside covid really suffered, and I worry we’ll see a wave of cancers coming out of all this missed screening,” Dr. Miller says. “Health care needs to be able to move in many different directions at the same time.”

But due to the pandemic, clinicians have now had an indelible experience of rapid change. “I think one reason why innovation is hard in health care is that we have this sense of learned helplessness,” Dr. Miller says. “Whether it’s regulatory or financial pressures or competing priorities, we’ve all learned that change doesn’t happen quickly in health care.”

Until it did. “We now know that if it’s something we’re passionate about that needs to happen, we can make it happen,” he explains. “Hopefully, we’ve broken free of that learned helplessness, and we’ll be able to innovate more quickly.” While clinicians going forward will have to “dial down a bit” the brutal clip of change they’ve lived with this past year, “we can’t go back to where we were pre-pandemic.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Time to figure out telehealth?

ASK GREGG MILLER, MD, an emergency physician and chief medical officer for Vituity, about pandemic-driven innovations, and he cites two of the most robust and far-reaching: hospital at home and telehealth. Several of Vituity’s hospitalist programs around the country have implemented either one or the other, or both.

Will those innovations become permanent? That depends on whether the financial and regulatory waivers that made them possible are here to stay. It also depends on their particular application.

“Some models will be retired,” Dr. Miller says, “like using telehealth as e-PPE to let clinicians engage with patients without the risk of infection. We won’t need those when everyone is vaccinated.” He believes, however, that telehealth models that extend cross-coverage among hospitals or facilitate rounding at outlying sites “will stick around.”

Dr. Miller also doesn’t believe that one major patient innovation will revert back post-pandemic: insisting that patients come to facilities—either the hospital or the ED— for their care. “Patients will expect care in place, and we’ll have to meet them where they are at,” he says. That development could pose a real problem for hospitalists and emergency doctors who have a sole practice site “baked into their very name.”

The problem may be compounded if, post-pandemic, the patient mix in hospitals is both higher acuity and lower volume. “It will take us a while to figure out the right mix of resources to manage that population,” says Dr. Miller. His prediction: “Groups that continue to live only in the hospital doing fee-for-service medicine will really struggle.”

Instead, he believes physicians will need, once again, to think about managing patient episodes that last between 30 and 90 days. For some hospitalists, that might mean overseeing patients in infusion centers, post-acute facilities, or preop clearance or hospital at home programs. It also means that hospitalists should quickly get up to speed with the technology they are going to need.

“Say it’s 2022 and a post-discharge patient needs to be followed,” says Dr. Miller. “Maybe a hospitalist is the best provider to do that, but it’s a primary care physician who has the expertise and the technological infrastructure to manage that patient.” Hospitalists and ED doctors, he believes, need to make sure that primary care doctors don’t get too far out ahead of them in adopting telehealth.

They may also, he adds, need to change “how we think of ourselves as acute care and emergency physicians.”

Published in the May/June 2021 issue of Today’s Hospitalist

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