Best practices to support your patients, providers, and hospital performance in unprecedented times   

Whether your hospital is inundated with COVID-19 patients or struggling with volume downturn or both—this pandemic challenges you to innovate. It transformed emergency rooms, intensive care units, and hospitalist programs overnight. It sparked adaptation in every aspect of operations and clinical care—from safety and staffing to workflow and patient treatment. As the pandemic evolves, patient volume, clinician and staff burn out, and patient and provider safety remain top concerns. In this post, we share key best practices our quality leaders and Southern-California-based ICU medical directors are applying to provide outstanding patient care and physician leadership during COVID-19 that can be applied to thrive far beyond the pandemic.

 

Knowledge Share Nimbly  

At the outset of the pandemic, we acted quickly to establish a COVID-19 committee made up of the emergency department and intensive care unit medical directors. The weekly (at first, then bi-weekly) virtual meeting of the minds enables our clinical leaders to share experiences and insights related to safety and treatment protocols as well as operational management strategies. Our intensivists went a step further and arranged a daily chat with one another because changes were happening quickly, and they wanted to be in close contact.

“One of the biggest challenges we faced was the uncertainty of treatment protocols and lack of sufficient evidence backing certain treatments. Poor medical evidence circulates around social media and influences many providers and it is difficult to remain scientific.” Said Dr. Zafia Anklesaria, ICU Medical Director at California Hospital Medical Center in Down L.A.

The medical directors not only rapidly implemented treatment suggestions from the Society of Critical Care Medicine and the CDC but also shared insights from the front lines. The regular collaborative discussions helped accelerate the implementation of safe and efficient operational workflows, surge plans, and PPE, and ventilator resource allocation.

“VEP was very supportive of its providers from an early time with regards to ensuring that we were provided proper PPE,” said Dr. Anklesaria.

Through our COVID-19 committee, we ensured that each of our emergency departments and ICUs had adequate supplies such as monitors, ventilators and PPE, disinfection protocols, containment and isolation protocols, and visitor policies. We also sent our hospitals intubation boxes to decrease the risk of spreading the virus during this critical procedure.

“VEP leadership created a channel so we could communicate on a regular basis and collaborate. It’s very helpful to touch base with other directors facing similar challenges.” Dr. Rajan Garg, MD, ICU Director at Hollywood Presbyterian Medical Center, also located in L.A.

 

Support Clinicians by Checking In 1:1

Patient engagement and quality leadership is always a priority because it has a tremendous impact on patient care quality. That is even more true in times of stress.

“Our teams are working extra shifts to support colleagues and patients, they are seeing colleagues get sick, and they are taking great personal risk,” said VEP Vice President of Inpatient Services, Harneet Singh Bath, MD, MBA, FACP.

The overtime, personal risk, discomfort of constant PPE, mental fatigue of navigating a novel disease,  longer length of stay, higher mortality rates, and income uncertainty all add up to a heavy physical and emotional toll on all team members. Acknowledging the challenges and doing what we can as leaders to support the team’s mental wellbeing goes a long way to alleviate extreme burnout and improve team culture.

To support our leaders and teams through these challenges, we are prioritizing facetime (albeit virtual) to offer support to our clinical and hospital administration leaders. We are regularly checking in to assess capacity issues, mortality rates, team morale, and staffing levels, among other challenges presented by COVID-19.

“I can’t stress enough how impressive it is to see that our nursing, physician, and administrative teams are all in actively involved and engaged in their departments with extraordinary amounts of face time,” said Jamie Quinlan, DNP, RN, Senior Director of Nursing and Performance Improvement.

The reality is, many of our providers are facing more risk, higher censuses, more strapped staffing resources, and higher patient mortality rates than they have in their entire careers.

It feels like working during wartime… we face extreme uncertainty, limited resources, and fear of the known and the unknown.” Said Dr. Anklesaria, “But it definitely fosters a team working spirit as we were all in it together.”

We are encouraging our leaders to acknowledge how unique these challenges are with their teams and ensuring they have the resources they need to support their teams and patients.

“I am making it a priority to keep in touch with my team members 1:1 and I am taking on extra shifts to ensure I am there as a back-up in particularly stressful situations.” Dr. Garg.

 

Be Flexible, Thorough, and Creative with Staffing Plans  

Though we still face unprecedented uncertainty when it comes to staffing and clinical hours, we are vigilant about regularly adjusting schedules based on volume and continuing to ensure the health, safety, and well-being of our providers and patients. We are also getting creative to leverage interdisciplinary resources to cover patient care needs.

“Our ICUs have been functioning at double and often triple capacity, making our providers burn out very easily. We have adapted by getting emergency credentialing for additional critical care providers as well as VEP emergency room providers and having an additional physician on-site to help manage the additional volume of patients.” Dr. Anklesaria

The key is ensuring you have a staffing plan for volume downturns and surges as well as potential staffing shortages due to clinicians getting sick.

“We’ve never had this many back-up plans,” said Dr. Garg.

In many cases, covering patient surpluses requires tapping into interdisciplinary resources such as anesthesiology and training advanced practice clinicians (APCs) on tasks that are not part of their typical job description.

We have more NPs working the night shift as back up and we are training them on intubations and central lines. We are collaborating with anesthesiologists as a backup resource as well.” Sameer Bajaj, MD ICU Director at Glendale Memorial Hospital.

The pandemic has been a catalyst to think creatively about the best patient pathways along the entire continuum of care and forced leaders to think outside of their typical departmental paradigms. For example, virtual care through telemedicine has been one crucial way our hospitals have supplemented staff and resources to navigate COVID. Our providers have provided onsite consultations with ED patients to reduce the extensive use of limited PPE resources and increase efficiency. This new approach has opened the door to the possibility of ER providers having broader contact with ER patients virtually.

 

Adapt Processes to Improve Patient Experience in New Normal

 

COVID Considerations for ICU Emergency Department Processes

COVID has impacted patient experience in a variety of ways. Though COVID-19 has reduced volumes at many hospitals, throughput numbers are not going down because there is an increase in patient acuity. In some cases, more sick patients that require ICU care and are staying in the ER. That in itself extends stay. Patients are already more fearful because of the current climate, and any additional waiting period increases that fear.

“We are having discussions working with hospital leadership so that everyone has a discharge plan early in the day to get moved in a timely manner.” Said Quinlan. “We’re also emphasizing more frequent communication, more rounding, more reassurance that they have done the right thing for coming to the ED.”

Another major pandemic-related patient dissatisfier is the fact that no family is allowed to accompany patients in the ED. This has a ripple effect in which families feel in the dark and patients feel scared and alone. Our quality leaders are working with providers to provide educational resources to change that.

What we’ve found works is taking time to talk to the patient and educate them on the measures the hospital is taking to ensure they are safe. Little bits of added kindness (“Thank you for coming in”) and detailed communication (“This is how we can keep your family updated”) throughout their visit from the initial greeting to results updates, goes a long way to improve the patient experience.

Additionally, we find that getting creative with keeping the patient’s family involved can drastically increase patient and family satisfaction. For example, one unique way to involve family is to get permission from the patient to have a family member on speakerphone during results updates.

 

COVID Considerations for Hospitalist Processes  

As volumes rise at many hospitals, hospitalist departments are scaling to accommodate COVID patients, potential COVID patients under investigation, and non-COVID patients. We created a separate COVID floor within our hospitalist programs to maximize efficiency for our providers and nursing staff. By separating COVID patients as much as possible from the typical workflow, we are not only maximizing patient and provider safety but also increasing efficiency as PPE precautions are more involved when entering a COVID floor. Rounds are also strategically scheduled so that providers are not repeatedly gowning up and removing PPE more than necessary to provide outstanding care. Another way hospitalist programs are maximizing efficiency and safety is installing longer IV tubings so the pump can remain outside the patient room and nurses can maintain IVs without entering patient rooms.

Our hospitalists are also adjusting patient communication in the time of COVID. Because patients often do not have family members with them due to COVID regulations and are often not able to communicate well after being intubated or placed on a ventilator, palliative care, and advanced care discussions for COVID-positive patients who are also terminally ill need to happen sooner.

 

Do Not Acquire Tunnel Vision

COVID seems to be all we read, talk, and worry about lately. Our Vice President of Provider Development Gary Tamkin, MD FACEP reminds us to be aware of anchoring bias, which is the tendency to rely too heavily on one piece of information or idea when making decisions, and cognitive biases, which are systematic errors in thinking that influence decision making and judgement which can lead to missed or inaccurate diagnoses as well as lawsuits.

“While you should protect yourself against COVID with appropriate PPE for every patient encounter, the chief complaint is not a good predicator of an ultimate COVID diagnosis. Don’t overlook the non-COVID- related diagnosis.” Said Dr. Tamkin

Emergency department visits are down 40% across the country, and that includes emergent medical conditions like 911 calls, STEMIs, Stroke Alerts, and even Traumas. Community-acquired pneumonia, appendicitis, and heme-onc related emergencies were not replaced by COVID-19. That is why we encourage our provider teams to keep their differential broad, keep open minds, and address all potential serious diagnoses, including the “non-COVID,” early inpatient presentations to reduce risk to the hospital and improve quality of care.

 

Conclusion

The principles that always make our programs successful are the pillars of our COVID-19 adaptations: collaborate and share knowledge, ensure providers are supported and fulfilled, create creative and innovative staffing plans that maximize resource use, prioritize patient experience, and keep an open mind. COVID is challenging us in new ways, but the fundamentals that drive efficiency, quality, and provider and patient satisfaction remain the same. This pandemic is an incredible catalyst to adapt and innovate to do even better in each of these fundamental areas to better serve patients well into the future.

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