As the number of COVID-19 cases diagnosed in the United States rises, hospitals are already managing the anticipated surges of contagious patients. Preparation has been challenged by rapidly changing guidelines, inconsistent directives, and a lack of testing capability. Many areas around the country are also raising concerns about resources, including a lack of PPE, ICU beds, and ventilators.
At Vituity, our leadership and front-line clinicians have responded quickly to this evolving threat. Our teams are caring for COVID-19 cases—including at the hospital where I practice outside Seattle where ICU volumes have begun to decrease. We have actively developed protocols for managing the disease while minimizing impact on hospital staff and patients.
As the epidemic unfolds, I will continue to update this post with the latest guidelines and best practices from public health authorities and our Vituity teams across the country. While each hospital’s response will be unique, our front-line providers have already stressed several common themes. I believe this information may be helpful to healthcare leaders caring for a growing increase in COVID-19 patients.
How should clinicians and staff respond when a patient with upper respiratory infection (URI) symptoms presents to the ED? What if an inpatient shows signs of COVID-19?
Isolation protocols, surge plans, and guidelines for staff PPE need to be clearly communicated. Having solid plans in place will help your teams to recognize potential red flags and respond quickly and effectively. If possible, test your systems using actors who portray patients with coronavirus symptoms or high-risk histories.
You also need to prepare your hospital for both an ICU and a sub-acute surge. If you haven’t already, cancel all elective procedures. PPE and ICU beds are needed for COVID-19 patients. In addition, many patients recovering from COVID-19 cannot be safely discharged back into the community. This is especially true for patients living in an adult family home or skilled nursing facility. These facilities may not be able to properly isolate the patient in the remaining weeks of quarantine, so hospitals should be prepared and equipped to board these patients – ideally in alternate locations such as hotels or other facilities arranged in conjunction with the local department of health.
Our medical directors on the front lines stress the importance of communication between the hospital leadership, the medical staff, and the local public health authorities. Because guidance about the epidemic changes rapidly, it’s helpful to designate a specific individual from leadership to act as your hospital’s interface between the bedside provider and public health authorities.
This is particularly important because public health guidelines around COVID-19 are changing rapidly, and each community is taking a slightly different approach to testing procedures, work exclusion, and self-quarantine. Your administrator point person should establish regular contact with the county public health department to monitor the emerging situation.
For example, at one hospital in Sacramento, CA, the director of quality tracks the latest developments, curates an online information library for medical staff, and holds twice-daily conference calls to update stakeholders.
To provide proper infection control, it’s important to screen each person who enters your hospital. To do this effectively, you may need to reduce the number of access points. Have a screener outside each door who can identify high-risk patients and initiate infection control procedures. Screeners should wear appropriate PPE and have supplies for patients. My hospital outside Seattle is asking all visitors to wear an “I’ve been screened” sticker.
In addition, many hospitals are now limiting visitors, except for pediatric and end-of-life patients.
Typically, EMTALA mandates an in-person MSE for every patient who comes to the ED, including patients with possible or confirmed COVID-19 infection.
On March 31, the Centers for Medicare and Medicaid Services (CMS) announced a series of blanket waivers for healthcare providers and facilities. These included a temporary easing of the EMTALA requirements, allowing ED providers to conduct their entire visits solely via telehealth in appropriate cases during the public health emergency. On April 9, the CMS issued new wave infection control guidance on April 9, protecting patients and healthcare workers from exposure to COVID-19.
The new guidelines allow providers to conduct MSEs—and indeed entire ED visits—via telehealth. This approach is most appropriate for patients who are not experiencing respiratory distress or other signs of serious illness. In addition, the CMS is permitting clinicians licensed in one state can now perform telehealth in all 50 states.
While HIPAA-compliant methods are always best, CMS has relaxed HIPAA requirements for telehealth platforms, meaning FaceTime or other consumer systems can be used. Telemedicine also allows you to utilize providers while they are on work restriction and can’t see patients face-to-face.
In addition to using telehealth, several of our hospitals are now directing patients with URI symptoms to mobile hospital tents outside the ED or creating designated drive-up areas where they can be evaluated in their vehicles. This greatly reduces the chance of spread to staff and other patients.
These waivers are retroactive to March 1, 2020, and expire when this Public Health Emergency (PHE) is officially ended.
It is currently unclear when the PHE will be declared over, and if that ending will happen uniformly or at different stages. What is certain is that telehealth will have a bigger role than ever in the future. Patient demand and advocacy work will continue to drive change in the use of telehealth in emergency and hospital medicine.
Begin planning now for the appropriate isolation measures for your hospitals to prevent patients and providers from getting sick. Suspected COVID-19 patients who require further medical care and evaluation should ideally be placed immediately in negative pressure rooms. But of course, each hospital only has so many. Now is the time to free up as many isolation rooms as possible and stock them with dedicated and disposable equipment. I personally donated my stethoscope to our negative pressure room after examining my hospital’s first suspected COVID-19 patient in a room we’d hastily jury-rigged.
The CDC previously recommended wearing gowns, gloves, and N-95 masks (which the website refers to as “respirators”) during all patient encounters where COVID-19 is suspected. Evidence from past epidemics (MERS and SARS) suggests that wearing a surgical mask, gloves, and gown may be equally effective for most patient encounters. However, an N-95 mask should always be used for all aerosolizing procedures (nebulization, oral-pharyngeal swabbing, intubation, etc.).
Follow the PPE recommendation of your hospital system. But at minimum, wear a mask and eye protection for every single patient encounter. Also, consider sterilization methods for PPE, as reuse is going to be essential due to constrained supply. Sterilization methods include heat, UV light, and hydrogen peroxide gas.
When you develop your guidelines, plan one step ahead and be clear about what would trigger a change in future PPE recommendations.
Several of our practices reported that their hospitals were locking up and rationing supplies such as surgical masks, hand sanitizer, and PPE. In one case, this became necessary when staff started taking supplies home for personal use. See the CDC’s strategies for optimizing the use of eye protection, isolation gowns, surgical masks, and N-95 respirators.
China’s experience shows that a respiratory epidemic can quickly create dangerous clinician shortages. Your hospital will not be able to function if too many of your doctors, advanced providers, nurses, and ancillary staff are ill or home on work restriction after a suspected exposure. It’s critical to ensure that everyone with patient contact follows infection control procedures, including wearing appropriate PPE. One medical director shared that his ED stations a “sitter” at each isolation room to check clinicians for PPE compliance before entering.
Hand hygiene is critical to maintain, both inside and outside the care setting. The CDC continues to recommend the use of alcohol-based hand rub (ABHR) as the primary method for hand hygiene in most clinical situations. Healthcare teams are advised to follow the recommended hand hygiene at all times.
It’s also important to promote social distancing among your hospital personnel. Administrators and clinical leaders can encourage this by shifting staff meetings to videoconferencing and canceling nonessential work travel.
As of this writing, many hospitals are reporting a major decrease in ED volumes, but acuity is higher. This has impact on staffing, and creates complicated messaging – how can we be cutting hours when we are in the midst of a pandemic? But the safest option for staff in the face of declining patient volumes is to keep as many health care workers at home and away from infected patients.
ICU and inpatient capacity are about ensuring sufficient staffing from other services and conducting the necessary cross-training. Nursing teams, advanced providers, anesthesiologists, and other ancillary staff need to be sufficiently trained and empowered to deliver long-term care when ICU teams are maxed out.
It’s also important to establish pragmatic work restriction guidelines. The CDC initially recommended quite aggressive work restrictions for staff with potential exposures. For example, they advised 14 days of work restriction for staff who were only wearing surgical masks and no eye protection who interacted with a masked COVID-19 patient.
This guidance is changing, with the CDC stating as of March 7: “Facilities could consider allowing asymptomatic HCP who have had an exposure to a COVID-19 patient to continue to work after . . . consultation with their occupational health program.” This recommendation has since been adopted by the state of California, which encourages exposed but asymptomatic providers to continue working while wearing surgical masks. Work restriction is always appropriate for providers who are symptomatic or have had a high-risk exposure (for example, were unprotected during an aerosolizing procedure).
The exact protocol for work restriction will vary by case and by hospital. Develop a clear approach that can be easily communicated to staff. As the epidemic spreads, also consider a check-in process where staff prior to each shift can confirm they aren’t suffering from respiratory symptoms and receive an “I’ve been screened” sticker.
As testing becomes more readily available, the use of serial testing for healthcare providers could reduce the uncertainty around work restrictions.
As testing capabilities expand, your facility will be challenged with multiple issues. In the initial phase, departments of health have been helping decide which patients to test, facilitating specimen transport and testing, and following up confirmed cases. While the bottleneck has been frustrating, it has supported a relatively clear testing and follow-up process.
As test kits become more available and patient demand for testing climbs, you will face a new set of challenges. It is unlikely your department of health will able to keep up with the demand. At this point, workflows might more closely resemble your current influenza or sexually transmitted disease testing workflow, where the burden falls more on the hospital or clinic.
This will prompt several new questions:
While expanded testing capacity is sorely needed, managing these logistics will be challenging.
While this pandemic threatens to strain our healthcare ecosystem, there’s also reason for hope. Just over a month ago, Washington state was the epicenter of the COVID-19 pandemic in the United States. We were home to the first U.S. case (Jan. 20) and the first death on American soil (Feb. 29). However, the expected surge in cases hasn’t materialized. In fact, it was reported in early April that the number of new cases dropped for four consecutive days, and data also indicates that new cases are a fraction of the number they were at the pandemic’s peak.
So when it comes to COVID-19, let’s allow ourselves to hope for the best while planning for the worst.