WHEN THE COVID PANDEMIC was in its early stages in mid-March, the hospitalist group at Baptist St. Anthony’s Hospital in Amarillo, Texas, talked about allowing hospitalists to do some work from home. To limit their exposure to the virus, the program would let hospitalists pre-round from home, then round on patients in the hospital and return home to finish their documentation.
But the idea never really took off, and hospitalists for the most part have worked all their shifts—including the hours they spent on documentation—in the hospital. Sheryl L. Williams, MD, a hospitalist who is the hospital’s medical director of quality, says that working from home didn’t pan out for several reasons. For one, as the PPE supply stabilized, clinicians felt they were adequately protected in the hospital. But another key reason: Many hospitalists felt it was important for them to be in the hospital and on the wards.
“To really be leaders in hospital care, which is what hospitalists are supposed to be, you need to be there with the patients,” Dr. Williams says. “You also need to be there with the nursing staff, and you can’t lead from behind a wall. Hospitalists need to be out there, and they need to be seen.”
“You can’t lead from behind a wall. Hospitalists need to be seen.”
~ Sheryl L. Williams, MD
Baptist St. Anthony’s Hospital
The experience of the hospitalists in Amarillo illustrates the dilemma that hospital physicians around the country find themselves in. While they’re trying to protect their patients, themselves and their families from covid, hospitalists have a responsibility not only to care for patients, but to serve as the leaders of their care teams and hospitals. Even in the midst of a pandemic, hospitalists feel a need to be present.
That has left them with this challenge: how to minimize their exposure to the virus without reducing their roles in patient care.
Ways to limit exposure
While primary care physicians may stay in their outpatient offices and specialists can consult via phone, hospitalists typically need to be onsite.
When the pandemic was still relatively new, Rajat Prakash, MD, a hospitalist who works for a multispecialty group in Port Huron, Mich., was so nervous about becoming infected that he didn’t see his daughters for nearly a month. While he made changes to his personal life because of the virus, he never dreamed of not seeing patients. “There were times where I had to talk myself down,” he says, “but this is my duty.”
But Dr. Prakash did make some changes to his physical exams to try to keep the virus from spreading. For one, he sees his non-covid patients first and then moves onto the patients he describes as “full-blown covid.” On the day they are admitted, he gives those patients a full heart and lung exam. But after that, Dr. Prakash says he relies on sources other than a physical exam for that information to limit his exposure.
For subsequent visits, for example, he might talk to patients from the doorway of their room. “I don’t always listen to the heart and lungs on the second day,” Dr. Prakash says. “I take that information from the nursing documentation.”
He is still able to get a good sense of the patient from being in the room, he explains, “but I am not physically doing their direct physical exam after the first day. I make observations about the patient sitting up and looking comfortable and smiling, and I look at the pupils and the position of their limbs. I can document three systems just by standing in the room and doing that. To document three more systems—the heart and lungs and the belly, for example—I look at the nursing exam.”
Social distancing at the bedside
If any covid patients have symptoms that need additional examination, Dr. Prakash makes sure they wear a mask. He also asks patients to turn their heads away from him during the exam.
“I don’t always listen to the heart and lungs on the second day.”
~ Rajat Prakash, MD
And while social distancing at the bedside may not be ideal, Dr. Prakash says he is able to make it work. Even from several feet away, “you can get information about the symptoms they have, if they had a bowel movement or how much they’ve actually eaten. Simple things like that really matter in terms of the clinical picture.”
At St. Peter’s Hospital in Albany, N.Y., the hospitalist group developed a policy that doesn’t require them to do a heart and lung exam on covid patients as long as there is an oxygen saturation level available and one other person—maybe someone from respiratory—has already done a thorough lung and cardiac exam that day. “Not everybody who sees a patient has to do that exam,” says Thea Dalfino, MD, chief of hospital medicine. “We’re really trying to limit exposure.”
While the hospitalists want to reduce transmission risk, they make sure to alternate doing physical exams with the nurses. That’s in part to show that they’re not trying to dump all the high-risk activities on the nursing department. “Every other day, we’ll alternate who does the physical exam,” says Nadine Kalavazoff, MD, a hospitalist at St. Peter’s. “It helps minimize who’s going to touch the patient, and it shares the workload.”
Dr. Kalavazoff says it’s critical for hospitalists to maintain a presence on the wards. “Trying to be safe is super important,” she notes, “but I try to be on the unit as much as possible. In the morning, I’ll go and see everybody and spend 10 or 15 minutes with each patient.”
Even with tasks that don’t require a physical presence with patients (think documentation), hospitalists have found value in staying onsite.
“It’s a different perspective. How can I minimize things?”
~ Nadine Kalavazoff, MD
St. Peter’s Hospital
Early in the pandemic, Dr. Dalfino says her group talked about letting hospitalists leave the hospital “to get out of a potentially contaminated environment” and to write up their notes at home. While some people took advantage of this in the first days when anxiety was high, the group quickly returned to having the hospitalists do their documentation in the hospital.
“We had one provider who was staying at home to review all the charts before coming in to see patients,” Dr. Dalfino says, “but he wouldn’t get in until an hour after the shift started.” The problem: If a patient was crashing or really needed attention, “we need somebody there, and we don’t have backup in the morning.” Backup clinicians do arrive at 2 p.m., “so if you’re done at the end of the day and want to go home and your patient crashes, we have people there who can handle that. We don’t have that at 7:30 in the morning.”
An office for one
In Port Huron, Dr. Prakash handles his documentation from his hospital, although he’s made some modifications to limit his odds of getting infected. He has access to an office in the hospital that he has cleaned daily by a cleaning service. Because he is the only one using it, he believes it’s OK.
He also says the processes in place in the hospital help make him more efficient, which reduces the chances of spreading the virus. “Our hospital is pretty good with verbal orders,” he explains. “If something is important, the nurses will accept verbal orders. When the ER calls, I can actually tell them what medicines to put in the system.”
And with consults, Dr. Prakash can put an order for a consult into the system and that’s it. “We don’t have to call the consultant and tell them we have a consult,” he explains. “They’ll take it from there. We have cut out a lot of fat from the system in terms of processes.”
“We’re ordering medications less frequently and going into patients’ rooms less often for things like finger sticks.”
~ Thea Dalfino, MD
St. Peter’s Hospital
Dr. Williams from Amarillo notes that keeping documentation in the hospital during a pandemic has produced some unanticipated challenges. Her group had been facing a shortage of computers for documentation even before covid. But that shortage, combined with the realization that packing the 10 or so physicians from one shift into a conference room to do documentation was risky, led to a change.
“We got some extra space on a different floor of the hospital that doesn’t have patients on it so that people can spread out,” Dr. Williams says. “People can go up to this other floor and do their dictation so we’re not all sitting on top of each other.”
Hospitalists are using other strategies to tamp down the risk of transmission. Dr. Williams says her hospital has made a concerted effort to minimize labs. “If you don’t need it, you shouldn’t be drawing it,” she explains. “That should hold true whether we’re dealing with covid or not, but we’re really trying to minimize the number of times someone has to walk into the room and burn PPE.”
In the ICU, Dr. Williams adds, where ventilators need constant adjustment, many of the IV pumps and the ventilator monitors are placed outside of patient rooms. “They can be adjusted without having to change PPE and go in and out of the room several times,” she says.
The hospitalists at St. Peter’s in Albany have made changes with pharmacy. “We’re ordering medications less frequently and going into patients’ rooms less often for things like finger sticks,” Dr. Dalfino says. “We’re trying to limit everyone’s exposure as much as we can.”
Dr. Kalavazoff from St. Peter’s says she tries to scrutinize these types of decisions. “Do I really need that finger stick four times a day? Or can we get by with twice or even once a day?” she asks. “Is it going to dramatically impact this patient’s care?” In some ways, she adds, the pandemic helps bring out physicians’ clinical intuition, forcing them to prioritize what’s really important and what’s unnecessary. “It’s a different perspective. How can I minimize things?”
Dr. Dalfino mentions another accommodation being made because of covid: The pace of care has slowed down. While hospitalists at St. Peter’s typically see 15 patients per 10-hour shift, that has been dropped to 13 patients per shift.
“Because of PPE and everything we have to do with covid patients,” Dr. Dalfino notes, “and the fact that we need to call family members outside of the hospital, we’ve cut back.”
Pride and rewards
While caring for hospitalized patients in the midst of a pandemic can be grueling work, there are rewards. Dr. Williams says that although the hospitalists in her group already admit for most of the primary care physicians in Amarillo, she has seen demand for her services rise even more.
“Some physicians who still came to the hospital have said they don’t want to come anymore,” Dr. Williams explains. “They want us to take care of all their patients.”
She is also proud of the way hospitalists have risen to the challenge. “We are bearing the brunt of this,” she says, “but we’re well-equipped to do that because we keep current on information. We have covid grand rounds every week. We have meetings with pharmacy once a week looking at new therapies and treatment options.”
She is quick to add that while hospitalists are on the front lines, their contribution goes beyond just patient care.”
We should be very proud,” says Dr. Williams, “that we have the ability to be so nimble in the way we treat patients. We have taken the lead in managing these patients, staying up-to-date with the literature and working with pharmacists and intensivists. We’re working to come up with the best strategy to take care of these patients quickly, efficiently and with compassion.”
Edward Doyle is Editor of Today’s Hospitalist.Published in the August 2020 issue of Today’s Hospitalist