Pandemic Innovations That Will Outlast COVID

November 11, 2021

Editor’s note from The Hospitalist: Hospitalists told us about process changes that their teams have implemented during the COVID-19 pandemic.

Shyam Odeti, MD, SFHM

Ballad Health (Bristol, Tenn.) (Dr Odeti was a hospitalist at Ballad Health during the period he describes below. He is currently chief of hospital medicine at Carilion Clinic, Roanoke, Va.)

Ballad Health is a 21-hospital health system serving 1.2 million population in 21 counties of rural Appalachia (northeast Tennessee, southwest Virginia, western North Carolina, and Kentucky). We saw a significant spike in COVID-19 numbers beginning in October 2020. We were at a 7.9% test positivity rate and 89 COVID-19 hospitalizations on Oct. 1, which rapidly increased to over 18% positivity rate and over 250 hospitalizations by mid-November. This alarming trend created concerns about handling the future inpatient volumes in an already strained health system.

Dr Shyam Odeti

There were some unique challenges to this region that were contributing to the increased hospitalizations. A significant part of the population we serve in this region has low health literacy, low socioeconomic status, and problems with transportation. Telehealth in an outpatient setting was rudimentary in parts of this region.

Ballad Health developed Safe At Home to identify lower-acuity COVID-19 patients and transition them to the home setting safely. This in turn would prevent their readmissions or return visits to the ED by implementing comprehensive oversight to their disease course. We achieved this through a collaborative approach of the existing teams, case management, telenurse team, primary care providers, and hospitalist-led transitional care. We leveraged the newly implemented EHR Epic and telehealth under the leadership of Ballad Health's chief medical information officer, Dr Mark Wilkinson.

Among the patients diagnosed with COVID-19 in ED and urgent care, low acuity cases were identified and enrolled into Safe At Home. Patients were provided with a pulse oximeter, thermometer, and incentive spirometer. They received phone calls the next 2 days from the telenurse team for a comprehensive interview, followed by daily phone calls during the first week. If no concerns were raised initially, then calls were spaced to every 3 days after that for up to 2 weeks. Any complaints or alarming symptoms would trigger a telehealth visit with primary care physicians, transitional care clinics, or a hospitalist.

The Safe At Home program was highly successful – in the past 5 months, over 1,500 patients were enrolled and hundreds of admissions were likely avoided. As we feared, the positivity rate in our region went close to 35% and inpatient COVID-19 census was over 350, with ICU utilization over 92%. If not for our innovative solution, this pandemic could have easily paralyzed health care in our region. Our patients also felt safe, as they were monitored daily and had help one call away, 24/7.

This innovation has brought solutions through technological advancements and process improvement. Safe At Home was also instrumental in breaking down silos and developing a culture of collaboration and cohesiveness among the inpatient, outpatient, and virtual teams of the health system. Lessons learned from this initiative can be easily replicated in the management of several chronic diseases to provide safe and affordable care to our patients in the comfort of their homes.

Vasundara Singh, MBBS

Mount Sinai West (New York)

At the onset of the pandemic in New York, our medium-sized midtown hospital used personal protective equipment briskly. One reason identified was the failure to cohort COVID-19 patients on a single floor. The other more important cause was that medicine teams in our hospital have patients scattered throughout the hospital in a nongeographic model across four different floors. Within 2 weeks, administration and hospital medicine leadership developed a geographic model. We started cohorting all COVID-19 positive patients on separate floors from negative patients. A geographic physician team model was also developed, which allowed physicians and nurses to don and doff at the entry and exit of each COVID-19 unit.

After the pandemic surge, hospital medicine and internal medicine residency program leadership made the collective decision to continue the geographic model for inpatient care. Care providers enjoyed working in a unit-based model, and noted increases in efficiency while rounding. Each of our four medicine floors has 36-40 beds, with variable occupancy. We restructured our resident teams and physician assistant teams by geography. Our outgoing chief residents led the change in May, designing a resident schedule to accommodate for a resident on each team to be available to admit and provide coverage until 8 p.m. each evening on their respective floors. The hospital medicine leadership put together a committee comprising representation of all stakeholders in this large transition of systems: attending hospitalists, physician assistants, chief residents, nurse managers, bed assignment, and administration. Since the transition and resumption of normal inpatient activity, we have encountered and addressed multiple concerns. Some notable hurdles in this transition included the high throughput on our telemetry team, movement of patients by bed board or nursing without involving the physicians in the decision, and variable nursing staffing that impacts teaching team caps because of geographic model.

This transition is very much still a work in progress, yet some benefits are already obvious. It has made bedside rounding more appealing and uncomplicated. Physicians in training learn very well at the bedside by role modeling. Greater acceptance of bedside rounding also affords the opportunity to teach physical exam skills, a dying art amongst newer generations of doctors. Another large gain is being able to involve nursing in bedside rounds, discussions, and decision-making. Finally, coordination with ancillary staff including social work and case management has become seamless as a result of having an entire floor to ourselves.

In summary, the silver lining of this pernicious pandemic at our hospital has been a transition to a geographic model for inpatient care. This is considered to be the gold standard for inpatient care across multiple health systems, and we hope to continue to refine this geographic model of care. Next steps would involve developing capabilities with flex acuity beds on each unit so that no matter what the patients need they can stay in one place.

Marina Farah, MD, MHA

Sound Physicians (Tacoma, Wash.)

With hospital programs in over 40 states, Sound Physicians has played an important role in the COVID-19 pandemic, treating approximately 6% of all COVID hospitalizations nationwide. To meet the needs of the crisis, Sound relied on innovation to expand coverage and improve outcomes at facilities across the country. Of one particular note, Sound Telemedicine partnered with the University of Maryland Medical System to open the state's first COVID-only hospital. In March 2020, the UMMS needed to care for an emerging cohort of COVID-19 patients while maintaining high-quality care and minimizing exposure for non-COVID patients.

Dr Marina Farah

Sound collaborated with UMMS to rapidly reopen the University of Maryland Laurel Medical Center for COVID-only care, staffing the hospital with Sound's telehospitalists. A model based on daily rounding delivered 100% by telemedicine providers and flexible staffing available 24/7 would let the program scale up or down to meet volume demands. Onsite physician support would be limited to one admitting doctor and a nocturnist. The COVID-only facility allowed a small group of doctors, nurses, and technicians to focus exclusively on an emerging disease, honing critical skills for treating COVID-19 patients.

Immediate benefits yielded big results. UMLMC's capacity allowed UMMS to funnel COVID patients into fewer of their regional hospitals, limiting the risk of exposure. Rapid deployment got UMMS ahead of the surge, taking stress off other hospitals in the system and 24/7 telehospitalist coverage proved to be a successful long-term staffing strategy for UMLMC. Long-term benefits were recognized too. Sound's staffing model and clinical processes significantly improved quality of care. Mortality rates dropped from 18% to 9% during the initial 60 days of the program. Vaccinations shifted COVID-19 needs, however, due to improvements in care and the flexibility offered, telemedicine remains an integral part of the UMMS's long-term strategy

Emory Healthcare division of hospital medicine (Atlanta)

(Comments compiled by James Kim, MD, assistant professor in the division of hospital medicine) Ingrid Pinzon, MD, FACP Emory Johns Creek (Ga.) Hospital

When COVID-19 started, one of the things called to my attention was the disparity in education for the Hispanic population. Unfortunately, COVID showed how in our hospitals there is a lack of instructions and education in Spanish.

Dr Ingrid Pinzon

We started educating our Hispanic community with Facebook lives via the Latin American Association. I was also invited to the different Spanish news stations (Telemundo and Univision). I also educated this community through food drives, where I taught about the use of face masks, social distancing, and hand hygiene.

Reena Hemrajani, MD

Grady Memorial Hospital

At Grady, we transitioned our weekly educational conferences into virtual events, and this has increased our attendance, as more off-service people are likely to attend when they can log on remotely. This has also allowed us to record these sessions for later viewing by those were unable to make it in real time.

Yelena Burklin, MD, FHM

Emory University Hospital Midtown

In our Midtown group, we have started a few initiatives that we will continue post COVID. Hybrid didactic lectures have had great success with excellent attendance when our didactic sessions (lunch and learns, journal clubs, core lectures for step-down unit refresher series) have been conducted virtually.

Dr Yelena Burklin

During the pandemic's height, when all resources were dedicated to COVID-19 patient care, there was a particular need to cognitively separate from “all things COVID” and provide additional topics to learn about, such as review of the management of different types of shock, chronic obstructive pulmonary disorder, sepsis, liver cirrhosis, etc. Attendance to these non–COVID-19 sessions was just as high.

We had a number of stressful and near-death experiences that tested our resilience, professional integrity, and overall wellness. These reflections prompted us to invite psychiatrists to one of the in-person–only sessions so that an informal conversation could be afforded in a safe space. Those hospitalists who felt the need to discuss their issues further received additional support and instructions from a subspecialist.

Ray Dantes, MD

Emory University Hospital Midtown

Post COVID, we will certainly utilize a hybrid approach to the didactic sessions when patient sensitive information is not being discussed. We will also preserve the continuity in addressing wellness and resilience, particularly, when our Midtown hospitalists had to work a lot of extra hours to cover the growing need at the time of pandemic, and need to emotionally decompress post pandemic. We are also taking infection control more seriously, and not coming to work with upper respiratory infections.

Rajasree Roy, MD

Emory Saint Joseph's Hospital

At ESJH, we initiated a telemedicine pilot for our hospitalist team in order to sustain our service given census surge and physician illness.

Sara Millwee, DNP, APRN, FNP-BC

Emory chief of advanced practice providers

To help reduce exposure to COVID, our advanced practice providers (APPs) admitted patients from the ED (as they did pre-COVID) to the hospital medicine service, but the physicians administratively signed the note/orders. Emory Healthcare bylaws specify that patients are seen by a physician within 24 hours of admission. During the pandemic, at the time of admission, the APP discussed plan of care with the physician, but the patient was only seen by the APP upon initial evaluation/admission, as opposed to the physician and APP pre-COVID. This improved productivity, and facilitated communication and collaboration between APPs and physicians. This also fostered an environment where APPs were practicing at the top of their licenses and improved job satisfaction.

Additionally, across the hospital medicine division, several APPs were utilized from other divisions to assist with admissions and cross cover. As the volume was at incredibly high levels, this improved the workload and burden of the hospital medicine providers. The displaced APPs were utilized at several facilities and worked under the guidance and supervision of hospital medicine providers. Moving forward, this has prompted leadership to look at utilizing APPs from other divisions as “PRN” providers as well.

This article originally appeared on The Hospitalist, an official publication of the Society of Hospital Medicine.


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