Although most of my time is spent building MediOrbis, the multi – specialty telemedicine and telehealth company I co – founded, I recently spent two weeks providing in – person ICU staffing in a number of different hospitals which provided me valuable insight into the current inpatient COVID 19 reality. The following reflects thoughts and impressions borne from that experience, set against the backdrop of my deep involvement with the world of remote or tele medicine.
Telemedicine was borne out of a desire to improve access, efficiency, and cost of medical care worldwide. By reimagining clinical medicine – distilling, isolating and utilizing the key components of physician contributions to patient care – telemedicine has been able to bring specialist access, previously unimaginable, to patient populations across the globe, without compromising the high standards of clinical expertise and performance.
Telemedicine over-emphasizes the patient history and ancillary testing, while de-emphasizing the physical examination and the positive transference of an in – person encounter, trends that had been making headway in clinical medicine for years. I trained with some of the top minds in clinical medicine in a variety of ICUs and witnessed world renowned physicians performing at the highest level without ever touching a patient.
Most importantly, however, telemedicine strives for efficiency, constantly struggling with the question of how to best utilize a rare commodity, physician expertise, in a “resource poor” world. By removing the physician from the bedside, the argument goes, physicians can be more effective in providing more care at a high level to a larger cohort of patients. An intensivist can monitor multiple units and hospitals simultaneously from one centralized location; a cardiologist can staff consults and be “on call” should emergencies arise in different states, thereby streamlining the staffing process and greatly improving access to highly trained specialty staff.
Telemedicine is willing to tolerate a small decrement in performance for a massive improvement in access and availability. In other words, it is a strategy of care which optimizes functionality of the entirety of a system, at the potential expense of the individual encounters.
Hospitals facing overwhelming numbers and acuity of COVID 19 patients must similarly make choices in their care strategies to improve the clinical value and utility of care givers to the overall system, while changing and sacrificing components of care that have otherwise been considered sacrosanct but that don’t stand up to rigorous necessity evaluation. Workflows, staffing protocols, infection control measures and organization standards should all be re – examined considering the following realities of COVID 19:
- COVID 19 is highly infectious and passed relatively easily between individuals.
- Hospitals, particularly those with the highest volume COVID 19 patients, are often already short staffed, and eroding staff further due to COVID 19 exposure can be crippling.
- Despite global interest and investment, there is a shortage of protective measures and personal protective equipment (PPE). There are a finite number of N95 masks, positive pressure protective hoods, face shields and negative pressure rooms in the inpatient setting.
- COVID 19 patients have high acuity, tenuous respiratory statuses and require significant amounts of bedside time and attention.
Hence the perfect storm poised to disrupt traditional inpatient practice – a highly contagious virus, spreading (relatively) easily among providers who are already short – staffed and not fully and comfortably protected, while simultaneously causing high acuity illness with high intensity clinical bedside requirements. At times like this the healthcare system must take a page from the telemedicine playbook, take a step back, distill down the most important components to the patient’s care, and provide an innovative model of medical care delivery to ensure the best overall result to the system, protecting healthcare workers and bringing the best overall possible clinical outcomes to patients.
Some suggestions from my own experience, that of my colleagues and friends, and those published in the available literature include:
- Institute strict management protocols for COVID 19 related patients. Examples include proning parameters, weaning protocols and sedation algorithms. By having policies automated and instituted by seasoned staff, physicians can focus on more challenging or unique management situations, rather than making the same recommendations repeatedly over multiple similar COVID 19 patients. Clinicians are already working against the clock and these measures can streamline patient care and provide efficiency to the system.
- Provide intubation and procedure teams. Procedures for COVID 19 patients, particularly intubations and other airway interventions, pose the highest risk of viral exposure. Prior to each procedure, providers must garb themselves in multiple layers of PPE and positive pressure airway masks for protection. The preparation alone can take up to 10-15 minutes, independent of the time for the procedure itself. Busy intensivists should not face a dilemma of providing efficient care versus providing it in a safe manner. Having a team geared for procedures with maximal protective equipment ensures a streamlined, safe, and efficient approach to intervening on these high intensity patients. The most worrisome moments for me in the unit were those with difficult airways where I was certain to be exposed to high volume of COVID 19 laden particulates from my patients. This would protect caregivers while providing the necessary airway interventions for patients.
- Bring as much equipment out of the patient room as possible. It is an ordeal every time a nurse, physician or RT enters a COVID 19 patient’s room, as gowning up and placing multiple face shields and protective measures is time intensive. By bringing IV poles, ventilators and mobile computers into the hallways and outside of patient’s rooms, providers can easily access these crucial components of ICU care without sacrificing their own protection. Although a departure from traditional ICU management and organization, and is an additional risk exposure (What if tubing becomes dislodged? Is there a higher risk of infection? Etc.), it is a fantastic way to optimize efficiency, save PPE and improve staff availability.
- Perform physical examinations and assessments only when necessary. Every physician has memories of saving a patient’s life or arriving at a correct diagnosis because of a finding on physical examination. In the ICU as well, examination of patients is generally considered essential for optimal patient care. However, because of the great risk of infection to clinicians who are exposed to COVID 19 particulate matter, this important component should be avoided unless absolutely necessary. Providers should avail themselves of the wealth of ancillary patient data and diagnostic services to take excellent care of their patients, in lieu of the direct physical contact traditionally provided to these patients.
- Have more providers for shorter times. Traditional clinical shifts are long, typically 8 – 12 hours. With the shift in patient acuity due to COVID 19, caregivers are providing a much more concentrated volume of care during their shifts. As such, the workload of an 8 – 12 hour shift is more typical of a 16 – 24 hour one. Allowing providers to work shorter shifts will improve their coping ability, decrease burnout, and elevate the emotional environment in which they practice.
We are entering unprecedented times in clinical medicine. COVID 19 is testing our mettle, ingenuity, malleability, and cohesiveness as a unit. We must be up to the challenge and develop strategies for this new reality. We will confront this new reality by taking lessons from telemedicine and integrating and reimagining how we care for patients. Healthcare systems must focus on core systemic values and provide the highest overall value system for all patients, allowing us to re – working our perspectives and streamline processes, thereby making clinical work efficient and protective to patients and caregivers alike. One of my mentors, Dr. Atul Mehta, used to chide us that “perfection is the enemy of good.” We must realize that implementation of new workflows, and integration of telemedicine and remote care, are key components to optimizing the care system during COVID times. We need not be shackled by traditional dogmas! By buckling down, reaching deep into our physical and emotional reserves, thinking outside the box and tapping into our innate ingenuity, our system will thrive in this new milieu and emerge stronger and grittier than ever!