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iResident: Virtual care on hospital medicine teaching services during a pandemic
At the start of each shift on his clinical service with rotating internal medicine residents, Benji Mathews, MD, SFHM, now adds a few components to his usual preparation. First, visiting the Minnesota Department of Health and various organizational websites to review the latest COVID-19 updates and guidelines. Next comes checking to see where he needs to pick up the surgical mask and eye protection that he will need to wear through the day. Last, he evaluates which of his patients are in telemedicine-equipped rooms; this last change has fast become a crucial part of working with his resident learners during a pandemic.
During the COVID-19 pandemic, residents and residency programs find themselves in a unique situation. Balancing the educational needs of a training program with the safety of trainees is a challenging task, specifically when taking care of patients who are COVID-19 positive or patients under investigation (PUI). One increasingly available tool that can help protect trainees while continuing to prioritize patient care and medical education is the use of telemedicine for virtual rounding. For our internal medicine residents through the University of Minnesota Internal Medicine Residency program rotating at Regions Hospital in Saint Paul, Minn., we have used video visits to continue our mandate as both health care and education professionals.
Virtual care decision tree
Virtual care can mitigate exposure risk, minimize use of personal protective equipment (PPE), and improve communications with patients and their families. To guide our teaching teams on the optimal situations for telemedicine, we needed to select those patients who would be most appropriate for a virtual visit.
For example, patients with advanced dementia, or intubated in the intensive care unit, would have less utility from a real-time video encounter. Further, we implemented a simple decision tree (Figure 1). First, the team needs to decide whether the patient needs an immediate in-person assessment; for instance, for critically ill patients or those who need end-of-life care discussions, telemedicine would not be an appropriate modality. Next, the decision is made on whether a patient requires an in-person exam at that time. The idea of forgoing the in-person physical exam may run counterintuitive to the core training medical providers undergo, but in certain circumstances telemedicine can still provide the appropriate level of care a patient requires.
Virtual rounding with residents: Pros and cons
Through the course of this pandemic, there have many questions raised regarding how to handle inpatient teaching services: Should resident teams be assigned COVID-19 positives or PUIs? How do you optimize assessing and learning from patients’ conditions that require human touch? Should all members of the teaching team be donning PPE and entering the patient room?
Internal medicine residents in our hospital have been assigned COVID-19 positive and PUI patients. With proper PPE, and donning and doffing practices, residents may continue to learn from this important training opportunity while also optimizing care for patients supplemented by telemedicine. This pandemic has flattened the hierarchy; often residents are teaching their attendings much of the latest literature and best practices around COVID-19. Residents also benefit by joining the organization’s daily virtual interprofessional COVID-19 huddle where they partner with infectious disease, critical care, pharmacy, and other experts to collaborate in the care of these patients.
There have been counterarguments made for residents joining the front lines with COVID-19 patients. Some have conditions that limit them from seeing this subgroup of patients, such as their immune status or other issues. For these residents, we do not assign COVID-19–positive patients. However, they may continue to support in virtually updating COVID-19 patients and their families. A second argument has been the use of PPE. We have implemented telemedicine to limit the total number of exposures and have a protocol for the fewest number of providers possible to see any at-risk or confirmed COVID-19 patient. For example, a resident who sees a COVID-19 patient in person may also be simultaneously virtually supervised by the attending.
Webside manner
The physical exam is only one of several operational considerations when delivering virtual care, whether with a teaching or nonteaching service. One important aspect is the “webside manner” of the provider, the virtual analogue to bedside manner.
Inherent parts of in-person encounters, such as eye contact and allowing for patients to finish their sentences, have added nuances with virtual care. For instance, providers must adjust to looking into the web camera to make eye contact, even though the patient’s face may be on the screen below. Additionally, for patients who are hard of hearing or unfamiliar with video calling, providers must be cognizant of projecting well over an Internet connection and timing responses to avoid overlapping conversation.
Similarly, there are nuances to the virtual physical exam, some specific to care in the COVID-19 era. In our previous virtual care practice, a bedside facilitator assisted in using tools such a digital stethoscope. In contrast, our current practice aims to refine the observational skills of our learners in conjunction with chart review, vital signs, and actively incorporating the patient in the physical exam. This does not mean asking them to auscultate themselves, but is more toward allowing patients to participate in focused evaluations, such as assessing abdominal tenderness or working through range of motion. Remote guidance for virtual exams also extends itself to teaching teams; for example, in our practice, we have been able to conduct bedside ultrasound teaching with in-person team members and a virtual facilitator.
Maskless connections: ‘Face-to-face’ visits with patients
As many hospitalists have witnessed, COVID-19 is so isolating for patients and their families. Patients have limited visitors, and their care team members are aiming to minimize exposures. Those who are entering the rooms wear masks and face shields that limit connecting with patients in a truly “face-to-face” manner. Telemedicine provides a face-to-face encounter that arguably improves upon portions of the traditional in-person encounter during this pandemic, with providers wearing PPE. For medical learners, gaining the interpersonal skills essential for health care professionals has been skewed with pandemic-related limitations; telemedicine can provide a tool to adapt to this unique era and augment this important educational piece.
Limitations, equity, and technological considerations
Realistically, the virtual exam during COVID-19 does have its limitations. An important part of virtual care and teaching services is instilling the appropriate times for use of telemedicine. If a patient has a clinical change (such as increase in FiO2 requirements) or other clinical need, there should be no hesitation for learners to conduct in-person assessments with appropriate PPE.
Nonexam indications are just as important – for example, if a patient requires extensive goals of care counseling, we recommend this not be done virtually. Other indications may vary between organizations; in our practice, we suggest at least one in-person assessment on the initial and discharge hospital days. Regardless of the specific indications, a successful virtual inpatient teaching service must be predicated on outlining the appropriate uses of telemedicine.
In the United States, there are already health care disparities for people of color and non–English speakers. If there is not a careful consideration for these marginalized groups, their health disparities could be further exacerbated – not just around COVID-19, but also for other inpatient conditions where telemedicine is being used. Groups whose equity must be thoughtfully managed include those who do not speak English and those who do not have access to smartphones or the Internet. Our HealthPartners organization has implemented the integration of interpreters for virtual three-way connections with patients and their clinicians to help mitigate this for non–English speakers. Additionally, utilizing easy-to-use tablets and telemedicine-capable carts has helped patients overcome technology barriers.
Last, the members of the teaching team must know the essential technical aspects of the technology they are using. Robust information technology (IT) support is also needed, but no matter how simple the equipment may be, staff and trainees must know how to both operate it and handle basic troubleshooting (such as audio or video disconnections). This also dovetails with the important element of on-boarding other members of the care team. In our practice, nursing staff, chaplains, interpreters, and dietitians also use virtual care as part of their workflow. However, even if it is used only by the teaching team, orienting other care team members will limit technical problems such as equipment being turned off or moved out of position.
Prior to the COVID-19 pandemic, telemedicine adoption was limited because of lack of awareness, barriers in training, understanding, and narrow beliefs regarding the innovation. The COVID-19 pandemic has resulted in a remarkable increase in the provision of telemedicine services in the inpatient hospital medicine services. Importantly, it is, and should be, a developing part of the education and training for health care learners. This pandemic has underscored the need for providing telemedicine services that will likely long outlast this crisis, and to support our health care learners in being effective “iResidents” on our care teams.
Takeaways
- The future of graduate medical education involves virtual care.
The COVID-19 pandemic response has demonstrated that virtual care plays an instrumental part in patient care, and its effects will not dissipate when the pandemic is done. The curriculum for health care trainees should incorporate telemedicine competencies so that they may more effectively leverage this technology for improving care delivery.
- Selection of telemedicine patients must be stratified.
In order to obtain the highest utility for medical learners on telemedicine, there needs to be a clear decision process for which patients can be seen virtually. This involves both clinical criteria, such as avoiding virtual care for end-of-life discussions, and patient criteria, such as those who are hard of hearing.
- Virtual communication requires new communication skills.
Seeing patients via telemedicine mandates a different skill set than in-person communication. Learners must improve their “webside manner” in order to build the patient-provider relationship. Instilling these tools can pay dividends in settings where telemedicine has high yield, such as maskless communication during a pandemic.
- Health disparities could be further exacerbated by telemedicine and should not be overlooked.
Equity in access to health care applies to telemedicine as it does to many other elements. There are multiple groups that can suffer from disparities, such as patients who need interpreters, or those who have lower technological literacy and access to digital devices. Creating awareness of these pitfalls in virtual care can help medical learners recognize and support in creative solutions for these factors.
Dr. Mathews is chief, hospital medicine, at Regions Hospital, HealthPartners, St. Paul, Minn. Dr. Doshi is telemedicine director, hospital medicine, HealthPartners.
At the start of each shift on his clinical service with rotating internal medicine residents, Benji Mathews, MD, SFHM, now adds a few components to his usual preparation. First, visiting the Minnesota Department of Health and various organizational websites to review the latest COVID-19 updates and guidelines. Next comes checking to see where he needs to pick up the surgical mask and eye protection that he will need to wear through the day. Last, he evaluates which of his patients are in telemedicine-equipped rooms; this last change has fast become a crucial part of working with his resident learners during a pandemic.
During the COVID-19 pandemic, residents and residency programs find themselves in a unique situation. Balancing the educational needs of a training program with the safety of trainees is a challenging task, specifically when taking care of patients who are COVID-19 positive or patients under investigation (PUI). One increasingly available tool that can help protect trainees while continuing to prioritize patient care and medical education is the use of telemedicine for virtual rounding. For our internal medicine residents through the University of Minnesota Internal Medicine Residency program rotating at Regions Hospital in Saint Paul, Minn., we have used video visits to continue our mandate as both health care and education professionals.
Virtual care decision tree
Virtual care can mitigate exposure risk, minimize use of personal protective equipment (PPE), and improve communications with patients and their families. To guide our teaching teams on the optimal situations for telemedicine, we needed to select those patients who would be most appropriate for a virtual visit.
For example, patients with advanced dementia, or intubated in the intensive care unit, would have less utility from a real-time video encounter. Further, we implemented a simple decision tree (Figure 1). First, the team needs to decide whether the patient needs an immediate in-person assessment; for instance, for critically ill patients or those who need end-of-life care discussions, telemedicine would not be an appropriate modality. Next, the decision is made on whether a patient requires an in-person exam at that time. The idea of forgoing the in-person physical exam may run counterintuitive to the core training medical providers undergo, but in certain circumstances telemedicine can still provide the appropriate level of care a patient requires.
Virtual rounding with residents: Pros and cons
Through the course of this pandemic, there have many questions raised regarding how to handle inpatient teaching services: Should resident teams be assigned COVID-19 positives or PUIs? How do you optimize assessing and learning from patients’ conditions that require human touch? Should all members of the teaching team be donning PPE and entering the patient room?
Internal medicine residents in our hospital have been assigned COVID-19 positive and PUI patients. With proper PPE, and donning and doffing practices, residents may continue to learn from this important training opportunity while also optimizing care for patients supplemented by telemedicine. This pandemic has flattened the hierarchy; often residents are teaching their attendings much of the latest literature and best practices around COVID-19. Residents also benefit by joining the organization’s daily virtual interprofessional COVID-19 huddle where they partner with infectious disease, critical care, pharmacy, and other experts to collaborate in the care of these patients.
There have been counterarguments made for residents joining the front lines with COVID-19 patients. Some have conditions that limit them from seeing this subgroup of patients, such as their immune status or other issues. For these residents, we do not assign COVID-19–positive patients. However, they may continue to support in virtually updating COVID-19 patients and their families. A second argument has been the use of PPE. We have implemented telemedicine to limit the total number of exposures and have a protocol for the fewest number of providers possible to see any at-risk or confirmed COVID-19 patient. For example, a resident who sees a COVID-19 patient in person may also be simultaneously virtually supervised by the attending.
Webside manner
The physical exam is only one of several operational considerations when delivering virtual care, whether with a teaching or nonteaching service. One important aspect is the “webside manner” of the provider, the virtual analogue to bedside manner.
Inherent parts of in-person encounters, such as eye contact and allowing for patients to finish their sentences, have added nuances with virtual care. For instance, providers must adjust to looking into the web camera to make eye contact, even though the patient’s face may be on the screen below. Additionally, for patients who are hard of hearing or unfamiliar with video calling, providers must be cognizant of projecting well over an Internet connection and timing responses to avoid overlapping conversation.
Similarly, there are nuances to the virtual physical exam, some specific to care in the COVID-19 era. In our previous virtual care practice, a bedside facilitator assisted in using tools such a digital stethoscope. In contrast, our current practice aims to refine the observational skills of our learners in conjunction with chart review, vital signs, and actively incorporating the patient in the physical exam. This does not mean asking them to auscultate themselves, but is more toward allowing patients to participate in focused evaluations, such as assessing abdominal tenderness or working through range of motion. Remote guidance for virtual exams also extends itself to teaching teams; for example, in our practice, we have been able to conduct bedside ultrasound teaching with in-person team members and a virtual facilitator.
Maskless connections: ‘Face-to-face’ visits with patients
As many hospitalists have witnessed, COVID-19 is so isolating for patients and their families. Patients have limited visitors, and their care team members are aiming to minimize exposures. Those who are entering the rooms wear masks and face shields that limit connecting with patients in a truly “face-to-face” manner. Telemedicine provides a face-to-face encounter that arguably improves upon portions of the traditional in-person encounter during this pandemic, with providers wearing PPE. For medical learners, gaining the interpersonal skills essential for health care professionals has been skewed with pandemic-related limitations; telemedicine can provide a tool to adapt to this unique era and augment this important educational piece.
Limitations, equity, and technological considerations
Realistically, the virtual exam during COVID-19 does have its limitations. An important part of virtual care and teaching services is instilling the appropriate times for use of telemedicine. If a patient has a clinical change (such as increase in FiO2 requirements) or other clinical need, there should be no hesitation for learners to conduct in-person assessments with appropriate PPE.
Nonexam indications are just as important – for example, if a patient requires extensive goals of care counseling, we recommend this not be done virtually. Other indications may vary between organizations; in our practice, we suggest at least one in-person assessment on the initial and discharge hospital days. Regardless of the specific indications, a successful virtual inpatient teaching service must be predicated on outlining the appropriate uses of telemedicine.
In the United States, there are already health care disparities for people of color and non–English speakers. If there is not a careful consideration for these marginalized groups, their health disparities could be further exacerbated – not just around COVID-19, but also for other inpatient conditions where telemedicine is being used. Groups whose equity must be thoughtfully managed include those who do not speak English and those who do not have access to smartphones or the Internet. Our HealthPartners organization has implemented the integration of interpreters for virtual three-way connections with patients and their clinicians to help mitigate this for non–English speakers. Additionally, utilizing easy-to-use tablets and telemedicine-capable carts has helped patients overcome technology barriers.
Last, the members of the teaching team must know the essential technical aspects of the technology they are using. Robust information technology (IT) support is also needed, but no matter how simple the equipment may be, staff and trainees must know how to both operate it and handle basic troubleshooting (such as audio or video disconnections). This also dovetails with the important element of on-boarding other members of the care team. In our practice, nursing staff, chaplains, interpreters, and dietitians also use virtual care as part of their workflow. However, even if it is used only by the teaching team, orienting other care team members will limit technical problems such as equipment being turned off or moved out of position.
Prior to the COVID-19 pandemic, telemedicine adoption was limited because of lack of awareness, barriers in training, understanding, and narrow beliefs regarding the innovation. The COVID-19 pandemic has resulted in a remarkable increase in the provision of telemedicine services in the inpatient hospital medicine services. Importantly, it is, and should be, a developing part of the education and training for health care learners. This pandemic has underscored the need for providing telemedicine services that will likely long outlast this crisis, and to support our health care learners in being effective “iResidents” on our care teams.
Takeaways
- The future of graduate medical education involves virtual care.
The COVID-19 pandemic response has demonstrated that virtual care plays an instrumental part in patient care, and its effects will not dissipate when the pandemic is done. The curriculum for health care trainees should incorporate telemedicine competencies so that they may more effectively leverage this technology for improving care delivery.
- Selection of telemedicine patients must be stratified.
In order to obtain the highest utility for medical learners on telemedicine, there needs to be a clear decision process for which patients can be seen virtually. This involves both clinical criteria, such as avoiding virtual care for end-of-life discussions, and patient criteria, such as those who are hard of hearing.
- Virtual communication requires new communication skills.
Seeing patients via telemedicine mandates a different skill set than in-person communication. Learners must improve their “webside manner” in order to build the patient-provider relationship. Instilling these tools can pay dividends in settings where telemedicine has high yield, such as maskless communication during a pandemic.
- Health disparities could be further exacerbated by telemedicine and should not be overlooked.
Equity in access to health care applies to telemedicine as it does to many other elements. There are multiple groups that can suffer from disparities, such as patients who need interpreters, or those who have lower technological literacy and access to digital devices. Creating awareness of these pitfalls in virtual care can help medical learners recognize and support in creative solutions for these factors.
Dr. Mathews is chief, hospital medicine, at Regions Hospital, HealthPartners, St. Paul, Minn. Dr. Doshi is telemedicine director, hospital medicine, HealthPartners.
At the start of each shift on his clinical service with rotating internal medicine residents, Benji Mathews, MD, SFHM, now adds a few components to his usual preparation. First, visiting the Minnesota Department of Health and various organizational websites to review the latest COVID-19 updates and guidelines. Next comes checking to see where he needs to pick up the surgical mask and eye protection that he will need to wear through the day. Last, he evaluates which of his patients are in telemedicine-equipped rooms; this last change has fast become a crucial part of working with his resident learners during a pandemic.
During the COVID-19 pandemic, residents and residency programs find themselves in a unique situation. Balancing the educational needs of a training program with the safety of trainees is a challenging task, specifically when taking care of patients who are COVID-19 positive or patients under investigation (PUI). One increasingly available tool that can help protect trainees while continuing to prioritize patient care and medical education is the use of telemedicine for virtual rounding. For our internal medicine residents through the University of Minnesota Internal Medicine Residency program rotating at Regions Hospital in Saint Paul, Minn., we have used video visits to continue our mandate as both health care and education professionals.
Virtual care decision tree
Virtual care can mitigate exposure risk, minimize use of personal protective equipment (PPE), and improve communications with patients and their families. To guide our teaching teams on the optimal situations for telemedicine, we needed to select those patients who would be most appropriate for a virtual visit.
For example, patients with advanced dementia, or intubated in the intensive care unit, would have less utility from a real-time video encounter. Further, we implemented a simple decision tree (Figure 1). First, the team needs to decide whether the patient needs an immediate in-person assessment; for instance, for critically ill patients or those who need end-of-life care discussions, telemedicine would not be an appropriate modality. Next, the decision is made on whether a patient requires an in-person exam at that time. The idea of forgoing the in-person physical exam may run counterintuitive to the core training medical providers undergo, but in certain circumstances telemedicine can still provide the appropriate level of care a patient requires.
Virtual rounding with residents: Pros and cons
Through the course of this pandemic, there have many questions raised regarding how to handle inpatient teaching services: Should resident teams be assigned COVID-19 positives or PUIs? How do you optimize assessing and learning from patients’ conditions that require human touch? Should all members of the teaching team be donning PPE and entering the patient room?
Internal medicine residents in our hospital have been assigned COVID-19 positive and PUI patients. With proper PPE, and donning and doffing practices, residents may continue to learn from this important training opportunity while also optimizing care for patients supplemented by telemedicine. This pandemic has flattened the hierarchy; often residents are teaching their attendings much of the latest literature and best practices around COVID-19. Residents also benefit by joining the organization’s daily virtual interprofessional COVID-19 huddle where they partner with infectious disease, critical care, pharmacy, and other experts to collaborate in the care of these patients.
There have been counterarguments made for residents joining the front lines with COVID-19 patients. Some have conditions that limit them from seeing this subgroup of patients, such as their immune status or other issues. For these residents, we do not assign COVID-19–positive patients. However, they may continue to support in virtually updating COVID-19 patients and their families. A second argument has been the use of PPE. We have implemented telemedicine to limit the total number of exposures and have a protocol for the fewest number of providers possible to see any at-risk or confirmed COVID-19 patient. For example, a resident who sees a COVID-19 patient in person may also be simultaneously virtually supervised by the attending.
Webside manner
The physical exam is only one of several operational considerations when delivering virtual care, whether with a teaching or nonteaching service. One important aspect is the “webside manner” of the provider, the virtual analogue to bedside manner.
Inherent parts of in-person encounters, such as eye contact and allowing for patients to finish their sentences, have added nuances with virtual care. For instance, providers must adjust to looking into the web camera to make eye contact, even though the patient’s face may be on the screen below. Additionally, for patients who are hard of hearing or unfamiliar with video calling, providers must be cognizant of projecting well over an Internet connection and timing responses to avoid overlapping conversation.
Similarly, there are nuances to the virtual physical exam, some specific to care in the COVID-19 era. In our previous virtual care practice, a bedside facilitator assisted in using tools such a digital stethoscope. In contrast, our current practice aims to refine the observational skills of our learners in conjunction with chart review, vital signs, and actively incorporating the patient in the physical exam. This does not mean asking them to auscultate themselves, but is more toward allowing patients to participate in focused evaluations, such as assessing abdominal tenderness or working through range of motion. Remote guidance for virtual exams also extends itself to teaching teams; for example, in our practice, we have been able to conduct bedside ultrasound teaching with in-person team members and a virtual facilitator.
Maskless connections: ‘Face-to-face’ visits with patients
As many hospitalists have witnessed, COVID-19 is so isolating for patients and their families. Patients have limited visitors, and their care team members are aiming to minimize exposures. Those who are entering the rooms wear masks and face shields that limit connecting with patients in a truly “face-to-face” manner. Telemedicine provides a face-to-face encounter that arguably improves upon portions of the traditional in-person encounter during this pandemic, with providers wearing PPE. For medical learners, gaining the interpersonal skills essential for health care professionals has been skewed with pandemic-related limitations; telemedicine can provide a tool to adapt to this unique era and augment this important educational piece.
Limitations, equity, and technological considerations
Realistically, the virtual exam during COVID-19 does have its limitations. An important part of virtual care and teaching services is instilling the appropriate times for use of telemedicine. If a patient has a clinical change (such as increase in FiO2 requirements) or other clinical need, there should be no hesitation for learners to conduct in-person assessments with appropriate PPE.
Nonexam indications are just as important – for example, if a patient requires extensive goals of care counseling, we recommend this not be done virtually. Other indications may vary between organizations; in our practice, we suggest at least one in-person assessment on the initial and discharge hospital days. Regardless of the specific indications, a successful virtual inpatient teaching service must be predicated on outlining the appropriate uses of telemedicine.
In the United States, there are already health care disparities for people of color and non–English speakers. If there is not a careful consideration for these marginalized groups, their health disparities could be further exacerbated – not just around COVID-19, but also for other inpatient conditions where telemedicine is being used. Groups whose equity must be thoughtfully managed include those who do not speak English and those who do not have access to smartphones or the Internet. Our HealthPartners organization has implemented the integration of interpreters for virtual three-way connections with patients and their clinicians to help mitigate this for non–English speakers. Additionally, utilizing easy-to-use tablets and telemedicine-capable carts has helped patients overcome technology barriers.
Last, the members of the teaching team must know the essential technical aspects of the technology they are using. Robust information technology (IT) support is also needed, but no matter how simple the equipment may be, staff and trainees must know how to both operate it and handle basic troubleshooting (such as audio or video disconnections). This also dovetails with the important element of on-boarding other members of the care team. In our practice, nursing staff, chaplains, interpreters, and dietitians also use virtual care as part of their workflow. However, even if it is used only by the teaching team, orienting other care team members will limit technical problems such as equipment being turned off or moved out of position.
Prior to the COVID-19 pandemic, telemedicine adoption was limited because of lack of awareness, barriers in training, understanding, and narrow beliefs regarding the innovation. The COVID-19 pandemic has resulted in a remarkable increase in the provision of telemedicine services in the inpatient hospital medicine services. Importantly, it is, and should be, a developing part of the education and training for health care learners. This pandemic has underscored the need for providing telemedicine services that will likely long outlast this crisis, and to support our health care learners in being effective “iResidents” on our care teams.
Takeaways
- The future of graduate medical education involves virtual care.
The COVID-19 pandemic response has demonstrated that virtual care plays an instrumental part in patient care, and its effects will not dissipate when the pandemic is done. The curriculum for health care trainees should incorporate telemedicine competencies so that they may more effectively leverage this technology for improving care delivery.
- Selection of telemedicine patients must be stratified.
In order to obtain the highest utility for medical learners on telemedicine, there needs to be a clear decision process for which patients can be seen virtually. This involves both clinical criteria, such as avoiding virtual care for end-of-life discussions, and patient criteria, such as those who are hard of hearing.
- Virtual communication requires new communication skills.
Seeing patients via telemedicine mandates a different skill set than in-person communication. Learners must improve their “webside manner” in order to build the patient-provider relationship. Instilling these tools can pay dividends in settings where telemedicine has high yield, such as maskless communication during a pandemic.
- Health disparities could be further exacerbated by telemedicine and should not be overlooked.
Equity in access to health care applies to telemedicine as it does to many other elements. There are multiple groups that can suffer from disparities, such as patients who need interpreters, or those who have lower technological literacy and access to digital devices. Creating awareness of these pitfalls in virtual care can help medical learners recognize and support in creative solutions for these factors.
Dr. Mathews is chief, hospital medicine, at Regions Hospital, HealthPartners, St. Paul, Minn. Dr. Doshi is telemedicine director, hospital medicine, HealthPartners.
Chloroquine linked to serious psychiatric side effects
Chloroquine may be associated with serious psychiatric side effects, even in patients with no family or personal history of psychiatric disorders, a new review suggests.
In a letter to the editor published online July 28 in The Journal of Clinical Psychiatry, the authors summarize data from several studies published as far back as 1993 and as recently as May 2020.
“In addition to previously reported side effects, chloroquine could also induce psychiatric side effects which are polymorphic and can persist even after stopping the drug,” lead author Florence Gressier, MD, PhD, CESP, Inserm, department of psychiatry, Le Kremlin Bicêtre, France, said in an interview.
“In COVID-19 patients who may still be [undergoing treatment] with chloroquine, close psychiatric assessment and monitoring should be performed,” she said.
Heated controversy
Following findings of a small French study that suggested efficacy in lowering the viral load in patients with COVID-19, President Donald Trump expressed optimism regarding the role of hydroxychloroquine in treating COVID-19, calling it a “game changer”.
Other studies, however, have called into question both the efficacy and the safety of hydroxychloroquine in treating COVID-19. On June 15, the Food and Drug Administration revoked the emergency use authorization it had given in March to chloroquine and hydroxychloroquine for the treatment of COVID-19.
Nevertheless, hydroxychloroquine continues to be prescribed for COVID-19. For example, an article that appeared in Click2Houston on June 15 quoted the chief medical officer of Houston’s United Memorial Center as saying he plans to continue prescribing hydroxychloroquine for patients with COVID-19 until he finds a better alternative.
As discussed in a Medscape expert commentary, a group of physicians who held a “white coat summit” in front of the U.S. Supreme Court building promoted the use of hydroxychloroquine for the treatment of COVID-19. The video of their summit was retweeted by President Trump and garnered millions of views before it was taken down by Twitter, Facebook, and YouTube.
Sudden onset
For the new review, “we wanted to alert the public and practitioners on the potentially psychiatric risks induced by chloroquine, as it could be taken as self-medication or potentially still prescribed,” Dr. Gressier said.
“We think the format of the letter to the editor allows information to be provided in a concise and clear manner,” she added.
According to the FDA’s Adverse Event Reporting System database, 12% of reported adverse events (520 of 4,336) following the use of chloroquine that occurred between the fourth quarter of 2012 and the fourth quarter of 2019 were neuropsychiatric. These events included amnesia, delirium, hallucinations, depression, and loss of consciousness, the authors write.
The researchers acknowledged that the incidence of psychiatric adverse effects associated with the use of chloroquine is “unclear in the absence of high-quality, randomized placebo-controlled trials of its safety.” Nevertheless, they pointed out that there have been reports of insomnia and depression when the drug was used as prophylaxis against malaria .
Moreover, some case series or case reports describe symptoms such as depression, anxiety, agitation, violent outburst, suicidal ideation, and psychosis in patients who have been treated with chloroquine for malaria, lupus erythematosus, and rheumatoid arthritis .
“In contrast to many other psychoses, chloroquine psychosis may be more affective and include prominent visual hallucinations, symptoms of derealization, and disorders of thought, with preserved insight,” the authors wrote.
They noted that the frequency of symptoms does not appear to be connected to the cumulative dose or the duration of treatment, and the onset of psychosis or other adverse effects is usually “sudden.”
In addition, they warn that the drug’s psychiatric effects may go unnoticed, especially because COVID-19 itself has been associated with neuropsychiatric symptoms, making it hard to distinguish between symptoms caused by the illness and those caused by the drug.
Although the psychiatric symptoms typically occur early after treatment initiation, some “subtle” symptoms might persist after stopping the drug, possibly owing to its “extremely long” half-life, the authors stated.
Dr. Gressier noted that practicing clinicians should look up reports about self-medication with chloroquine “and warn their patients about the risk induced by chloroquine.”
Safe but ‘not benign’
Nilanjana Bose, MD, MBA, a rheumatologist at the Rheumatology Center of Houston, said she uses hydroxychloroquine “all the time” in clinical practice to treat patients with rheumatic conditions.
“I cannot comment on whether it [hydroxychloroquine or chloroquine] is a potential prophylactic or treatment for COVID-19, but I can say that, from a safety point of view, as a rheumatologist who uses hydroxychloroquine at a dose of 400 mg/day, I do not think we need to worry about serious [psychiatric] side effects,” Dr. Bose said in an interview.
Because clinicians are trying all types of possible treatments for COVID-19, “if this medication has possible efficacy, it is a great medicine from a rheumatologic perspective and is safe,” she added.
Nevertheless, the drug is “not benign, and regular side effects will be there, and of course, higher doses will cause more side effects,” said Dr. Bose, who was not involved in authoring the letter.
She counsels patients about potential psychiatric side effects of hydroxychloroquine because some of her patients have complained about irritability, worsening anxiety and depression, and difficulty sleeping.
Be wary
James “Jimmy” Potash, MD, MPH, Henry Phipps Professor of Psychiatry and Behavioral Sciences, Johns Hopkins Medicine, Baltimore, said in an interview that the “take-home message of this letter is that serious psychiatric effects, psychotic illness in particular,” can occur in individuals who take chloroquine and hydroxychloroquine.
In addition, “these are potentially very concerning side effects that psychiatrists should be aware of,” noted Dr. Potash, department director and psychiatrist-in-chief at Johns Hopkins.
He said that one of his patients who had been “completely psychiatrically healthy” took chloroquine prophylactically prior to traveling overseas. After she began taking the drug, she had an episode of mania that resolved once she discontinued the medication and received treatment for the mania.
“If you add potential psychiatric side effects to the other side effects that can result from these medications, that adds up to a pretty important reason to be wary of taking them, particularly for the indication of COVID-19, where the level of evidence that it helps in any way is still quite weak,” Dr. Potash said.
In an interview, Remington Nevin, MD, MPH, DrPH, executive director at the Quinism Foundation, White River Junction, Vt., a nonprofit organization that supports and promotes education and research on disorders caused by poisoning by quinoline drugs; and faculty associate in the department of mental health at Johns Hopkins Bloomberg School of Public Health, said that the authors of the letter “are to be commended for their efforts in raising awareness of the potentially lasting and disabling psychiatric effects of chloroquine and hydroxychloroquine, which, as with similar effects from other synthetic quinoline antimalarials, have occasionally been overlooked or misattributed to other conditions.”
He added: “I have proposed that the chronic neuropsychiatric effects of this class of drug are best considered not as side effects but as signs and symptoms of a disorder known as chronic quinoline encephalopathy caused by poisoning of the central nervous system.”
Dr. Gressier and the other letter authors, Dr. Bose, and Dr. Potash have reported no relevant financial relationships. Dr. Nevin has been retained as a consultant and expert witness in legal cases involving claims of adverse effects from quinoline antimalarial drugs.
A version of this article originally appeared on Medscape.com.
Chloroquine may be associated with serious psychiatric side effects, even in patients with no family or personal history of psychiatric disorders, a new review suggests.
In a letter to the editor published online July 28 in The Journal of Clinical Psychiatry, the authors summarize data from several studies published as far back as 1993 and as recently as May 2020.
“In addition to previously reported side effects, chloroquine could also induce psychiatric side effects which are polymorphic and can persist even after stopping the drug,” lead author Florence Gressier, MD, PhD, CESP, Inserm, department of psychiatry, Le Kremlin Bicêtre, France, said in an interview.
“In COVID-19 patients who may still be [undergoing treatment] with chloroquine, close psychiatric assessment and monitoring should be performed,” she said.
Heated controversy
Following findings of a small French study that suggested efficacy in lowering the viral load in patients with COVID-19, President Donald Trump expressed optimism regarding the role of hydroxychloroquine in treating COVID-19, calling it a “game changer”.
Other studies, however, have called into question both the efficacy and the safety of hydroxychloroquine in treating COVID-19. On June 15, the Food and Drug Administration revoked the emergency use authorization it had given in March to chloroquine and hydroxychloroquine for the treatment of COVID-19.
Nevertheless, hydroxychloroquine continues to be prescribed for COVID-19. For example, an article that appeared in Click2Houston on June 15 quoted the chief medical officer of Houston’s United Memorial Center as saying he plans to continue prescribing hydroxychloroquine for patients with COVID-19 until he finds a better alternative.
As discussed in a Medscape expert commentary, a group of physicians who held a “white coat summit” in front of the U.S. Supreme Court building promoted the use of hydroxychloroquine for the treatment of COVID-19. The video of their summit was retweeted by President Trump and garnered millions of views before it was taken down by Twitter, Facebook, and YouTube.
Sudden onset
For the new review, “we wanted to alert the public and practitioners on the potentially psychiatric risks induced by chloroquine, as it could be taken as self-medication or potentially still prescribed,” Dr. Gressier said.
“We think the format of the letter to the editor allows information to be provided in a concise and clear manner,” she added.
According to the FDA’s Adverse Event Reporting System database, 12% of reported adverse events (520 of 4,336) following the use of chloroquine that occurred between the fourth quarter of 2012 and the fourth quarter of 2019 were neuropsychiatric. These events included amnesia, delirium, hallucinations, depression, and loss of consciousness, the authors write.
The researchers acknowledged that the incidence of psychiatric adverse effects associated with the use of chloroquine is “unclear in the absence of high-quality, randomized placebo-controlled trials of its safety.” Nevertheless, they pointed out that there have been reports of insomnia and depression when the drug was used as prophylaxis against malaria .
Moreover, some case series or case reports describe symptoms such as depression, anxiety, agitation, violent outburst, suicidal ideation, and psychosis in patients who have been treated with chloroquine for malaria, lupus erythematosus, and rheumatoid arthritis .
“In contrast to many other psychoses, chloroquine psychosis may be more affective and include prominent visual hallucinations, symptoms of derealization, and disorders of thought, with preserved insight,” the authors wrote.
They noted that the frequency of symptoms does not appear to be connected to the cumulative dose or the duration of treatment, and the onset of psychosis or other adverse effects is usually “sudden.”
In addition, they warn that the drug’s psychiatric effects may go unnoticed, especially because COVID-19 itself has been associated with neuropsychiatric symptoms, making it hard to distinguish between symptoms caused by the illness and those caused by the drug.
Although the psychiatric symptoms typically occur early after treatment initiation, some “subtle” symptoms might persist after stopping the drug, possibly owing to its “extremely long” half-life, the authors stated.
Dr. Gressier noted that practicing clinicians should look up reports about self-medication with chloroquine “and warn their patients about the risk induced by chloroquine.”
Safe but ‘not benign’
Nilanjana Bose, MD, MBA, a rheumatologist at the Rheumatology Center of Houston, said she uses hydroxychloroquine “all the time” in clinical practice to treat patients with rheumatic conditions.
“I cannot comment on whether it [hydroxychloroquine or chloroquine] is a potential prophylactic or treatment for COVID-19, but I can say that, from a safety point of view, as a rheumatologist who uses hydroxychloroquine at a dose of 400 mg/day, I do not think we need to worry about serious [psychiatric] side effects,” Dr. Bose said in an interview.
Because clinicians are trying all types of possible treatments for COVID-19, “if this medication has possible efficacy, it is a great medicine from a rheumatologic perspective and is safe,” she added.
Nevertheless, the drug is “not benign, and regular side effects will be there, and of course, higher doses will cause more side effects,” said Dr. Bose, who was not involved in authoring the letter.
She counsels patients about potential psychiatric side effects of hydroxychloroquine because some of her patients have complained about irritability, worsening anxiety and depression, and difficulty sleeping.
Be wary
James “Jimmy” Potash, MD, MPH, Henry Phipps Professor of Psychiatry and Behavioral Sciences, Johns Hopkins Medicine, Baltimore, said in an interview that the “take-home message of this letter is that serious psychiatric effects, psychotic illness in particular,” can occur in individuals who take chloroquine and hydroxychloroquine.
In addition, “these are potentially very concerning side effects that psychiatrists should be aware of,” noted Dr. Potash, department director and psychiatrist-in-chief at Johns Hopkins.
He said that one of his patients who had been “completely psychiatrically healthy” took chloroquine prophylactically prior to traveling overseas. After she began taking the drug, she had an episode of mania that resolved once she discontinued the medication and received treatment for the mania.
“If you add potential psychiatric side effects to the other side effects that can result from these medications, that adds up to a pretty important reason to be wary of taking them, particularly for the indication of COVID-19, where the level of evidence that it helps in any way is still quite weak,” Dr. Potash said.
In an interview, Remington Nevin, MD, MPH, DrPH, executive director at the Quinism Foundation, White River Junction, Vt., a nonprofit organization that supports and promotes education and research on disorders caused by poisoning by quinoline drugs; and faculty associate in the department of mental health at Johns Hopkins Bloomberg School of Public Health, said that the authors of the letter “are to be commended for their efforts in raising awareness of the potentially lasting and disabling psychiatric effects of chloroquine and hydroxychloroquine, which, as with similar effects from other synthetic quinoline antimalarials, have occasionally been overlooked or misattributed to other conditions.”
He added: “I have proposed that the chronic neuropsychiatric effects of this class of drug are best considered not as side effects but as signs and symptoms of a disorder known as chronic quinoline encephalopathy caused by poisoning of the central nervous system.”
Dr. Gressier and the other letter authors, Dr. Bose, and Dr. Potash have reported no relevant financial relationships. Dr. Nevin has been retained as a consultant and expert witness in legal cases involving claims of adverse effects from quinoline antimalarial drugs.
A version of this article originally appeared on Medscape.com.
Chloroquine may be associated with serious psychiatric side effects, even in patients with no family or personal history of psychiatric disorders, a new review suggests.
In a letter to the editor published online July 28 in The Journal of Clinical Psychiatry, the authors summarize data from several studies published as far back as 1993 and as recently as May 2020.
“In addition to previously reported side effects, chloroquine could also induce psychiatric side effects which are polymorphic and can persist even after stopping the drug,” lead author Florence Gressier, MD, PhD, CESP, Inserm, department of psychiatry, Le Kremlin Bicêtre, France, said in an interview.
“In COVID-19 patients who may still be [undergoing treatment] with chloroquine, close psychiatric assessment and monitoring should be performed,” she said.
Heated controversy
Following findings of a small French study that suggested efficacy in lowering the viral load in patients with COVID-19, President Donald Trump expressed optimism regarding the role of hydroxychloroquine in treating COVID-19, calling it a “game changer”.
Other studies, however, have called into question both the efficacy and the safety of hydroxychloroquine in treating COVID-19. On June 15, the Food and Drug Administration revoked the emergency use authorization it had given in March to chloroquine and hydroxychloroquine for the treatment of COVID-19.
Nevertheless, hydroxychloroquine continues to be prescribed for COVID-19. For example, an article that appeared in Click2Houston on June 15 quoted the chief medical officer of Houston’s United Memorial Center as saying he plans to continue prescribing hydroxychloroquine for patients with COVID-19 until he finds a better alternative.
As discussed in a Medscape expert commentary, a group of physicians who held a “white coat summit” in front of the U.S. Supreme Court building promoted the use of hydroxychloroquine for the treatment of COVID-19. The video of their summit was retweeted by President Trump and garnered millions of views before it was taken down by Twitter, Facebook, and YouTube.
Sudden onset
For the new review, “we wanted to alert the public and practitioners on the potentially psychiatric risks induced by chloroquine, as it could be taken as self-medication or potentially still prescribed,” Dr. Gressier said.
“We think the format of the letter to the editor allows information to be provided in a concise and clear manner,” she added.
According to the FDA’s Adverse Event Reporting System database, 12% of reported adverse events (520 of 4,336) following the use of chloroquine that occurred between the fourth quarter of 2012 and the fourth quarter of 2019 were neuropsychiatric. These events included amnesia, delirium, hallucinations, depression, and loss of consciousness, the authors write.
The researchers acknowledged that the incidence of psychiatric adverse effects associated with the use of chloroquine is “unclear in the absence of high-quality, randomized placebo-controlled trials of its safety.” Nevertheless, they pointed out that there have been reports of insomnia and depression when the drug was used as prophylaxis against malaria .
Moreover, some case series or case reports describe symptoms such as depression, anxiety, agitation, violent outburst, suicidal ideation, and psychosis in patients who have been treated with chloroquine for malaria, lupus erythematosus, and rheumatoid arthritis .
“In contrast to many other psychoses, chloroquine psychosis may be more affective and include prominent visual hallucinations, symptoms of derealization, and disorders of thought, with preserved insight,” the authors wrote.
They noted that the frequency of symptoms does not appear to be connected to the cumulative dose or the duration of treatment, and the onset of psychosis or other adverse effects is usually “sudden.”
In addition, they warn that the drug’s psychiatric effects may go unnoticed, especially because COVID-19 itself has been associated with neuropsychiatric symptoms, making it hard to distinguish between symptoms caused by the illness and those caused by the drug.
Although the psychiatric symptoms typically occur early after treatment initiation, some “subtle” symptoms might persist after stopping the drug, possibly owing to its “extremely long” half-life, the authors stated.
Dr. Gressier noted that practicing clinicians should look up reports about self-medication with chloroquine “and warn their patients about the risk induced by chloroquine.”
Safe but ‘not benign’
Nilanjana Bose, MD, MBA, a rheumatologist at the Rheumatology Center of Houston, said she uses hydroxychloroquine “all the time” in clinical practice to treat patients with rheumatic conditions.
“I cannot comment on whether it [hydroxychloroquine or chloroquine] is a potential prophylactic or treatment for COVID-19, but I can say that, from a safety point of view, as a rheumatologist who uses hydroxychloroquine at a dose of 400 mg/day, I do not think we need to worry about serious [psychiatric] side effects,” Dr. Bose said in an interview.
Because clinicians are trying all types of possible treatments for COVID-19, “if this medication has possible efficacy, it is a great medicine from a rheumatologic perspective and is safe,” she added.
Nevertheless, the drug is “not benign, and regular side effects will be there, and of course, higher doses will cause more side effects,” said Dr. Bose, who was not involved in authoring the letter.
She counsels patients about potential psychiatric side effects of hydroxychloroquine because some of her patients have complained about irritability, worsening anxiety and depression, and difficulty sleeping.
Be wary
James “Jimmy” Potash, MD, MPH, Henry Phipps Professor of Psychiatry and Behavioral Sciences, Johns Hopkins Medicine, Baltimore, said in an interview that the “take-home message of this letter is that serious psychiatric effects, psychotic illness in particular,” can occur in individuals who take chloroquine and hydroxychloroquine.
In addition, “these are potentially very concerning side effects that psychiatrists should be aware of,” noted Dr. Potash, department director and psychiatrist-in-chief at Johns Hopkins.
He said that one of his patients who had been “completely psychiatrically healthy” took chloroquine prophylactically prior to traveling overseas. After she began taking the drug, she had an episode of mania that resolved once she discontinued the medication and received treatment for the mania.
“If you add potential psychiatric side effects to the other side effects that can result from these medications, that adds up to a pretty important reason to be wary of taking them, particularly for the indication of COVID-19, where the level of evidence that it helps in any way is still quite weak,” Dr. Potash said.
In an interview, Remington Nevin, MD, MPH, DrPH, executive director at the Quinism Foundation, White River Junction, Vt., a nonprofit organization that supports and promotes education and research on disorders caused by poisoning by quinoline drugs; and faculty associate in the department of mental health at Johns Hopkins Bloomberg School of Public Health, said that the authors of the letter “are to be commended for their efforts in raising awareness of the potentially lasting and disabling psychiatric effects of chloroquine and hydroxychloroquine, which, as with similar effects from other synthetic quinoline antimalarials, have occasionally been overlooked or misattributed to other conditions.”
He added: “I have proposed that the chronic neuropsychiatric effects of this class of drug are best considered not as side effects but as signs and symptoms of a disorder known as chronic quinoline encephalopathy caused by poisoning of the central nervous system.”
Dr. Gressier and the other letter authors, Dr. Bose, and Dr. Potash have reported no relevant financial relationships. Dr. Nevin has been retained as a consultant and expert witness in legal cases involving claims of adverse effects from quinoline antimalarial drugs.
A version of this article originally appeared on Medscape.com.
Pandemic hampers reopening of joint replacement gold mine
Dr. Ira Weintraub, a recently retired orthopedic surgeon who now works at a medical billing consultancy, saw a hip replacement bill for over $400,000 earlier this year.
“The patient stayed in the hospital 17 days, which is only 17 times normal. The bill got paid,” mused Weintraub, chief medical officer of Portland, Oregon-based WellRithms, which helps self-funded employers and workers’ compensation insurers make sense of large, complex medical bills and ensure they pay the fair amount.
Charges like that go a long way toward explaining why hospitals are eager to restore joint replacements to pre-COVID levels as quickly as possible – an eagerness tempered only by safety concerns amid a resurgence of the coronavirus in some regions of the country. Revenue losses at hospitals and outpatient surgery centers may have exceeded $5 billion from canceled knee and hip replacements alone during a roughly two-month hiatus on elective procedures earlier this year.
The cost of joint replacement surgery varies widely – though, on average, it is in the tens, not hundreds, of thousands of dollars. Still, given the high and rapidly growing volume, it’s easy to see why joint replacement operations have become a vital chunk of revenue at most U.S. hospitals.
The rate of knee and hip replacements more than doubled from 2000 to 2015, according to inpatient discharge data from the Agency for Healthcare Research and Quality. And that growth is likely to continue: Knee replacements are expected to triple between now and 2040, with hip replacements not far behind, according to projections published last year in the Journal of Rheumatology.
Joint procedures are usually not emergencies, and they were among the first to be scrubbed or delayed when hospitals froze elective surgeries in March – and again in July in some areas plagued by renewed COVID outbreaks.
“Without orthopedic volumes returning to something near their pre-pandemic levels, it will make it difficult for health systems to get back to anywhere near break-even from a bottom-line perspective,” said Stephen Thome, a principal in health care consulting at Grant Thornton, an advisory, audit and tax firm.
It’s impossible to know exactly how much knee and hip replacements are worth to hospitals, because no definitive data on total volume or price exists.
But using published estimates of volume, extrapolating average commercial payments from published Medicare rates based on a study, and making an educated guess of patient coinsurance, Thome helped KHN arrive at an annual market value for American hospitals and surgery centers of between $15.5 billion and $21.5 billion for knee replacements alone.
That suggests a revenue loss of $1.3 billion to $1.8 billion per month for the period the surgeries were shut down. These figures include ambulatory surgery centers not owned by hospitals, which also suspended most operations in late March, all of April and into May.
If you add hip replacements, which account for about half the volume of knees and are paid at similar rates, the total annual value rises to a range of $23 billion to $32 billion, with monthly revenue losses from $1.9 billion to $2.7 billion.
The American Hospital Association projects total revenue lost at U.S. hospitals will reach $323 billion by year’s end, not counting additional losses from surgeries canceled during the current coronavirus spike. That amount is partially offset by $69 billion in federal relief dollars hospitals have received so far, according to the association. The California Hospital Association puts the net revenue loss for hospitals in that state at about $10.5 billion, said spokesperson Jan Emerson-Shea.
Hospitals resumed joint replacement surgeries in early to mid-May, with the timing and ramp-up speed varying by region and hospital. Some hospitals restored volume quickly; others took a more cautious route and continue to lose revenue. Still others have had to shut down again.
At the NYU Langone Orthopedic Hospital in New York City, “people are starting to come in and you see the operating rooms full again,” said Dr. Claudette Lajam, chief orthopedic safety officer.
At St. Jude Medical Center in Fullerton, California, where the coronavirus is raging, inpatient joint replacements resumed in the second or third week of May – cautiously at first, but volume is “very close to pre-pandemic levels at this point,” said Dr. Kevin Khajavi, chairman of the hospital’s orthopedic surgery department. However, “we are constantly monitoring the situation to determine if we have to scale back once again,” he said.
In large swaths of Texas, elective surgeries were once again suspended in July because of the COVID-19 resurgence. The same is true at many hospitals in Florida, Alabama, South Carolina and Nevada.
The Mayo Clinic in Phoenix suspended nonemergency joint replacement surgeries in early July. It resumed outpatient replacement procedures the week of July 27, but still has not resumed nonemergency inpatient procedures, said Dr. Mark Spangehl, an orthopedic surgeon there. In terms of medical urgency, joint replacements are “at the bottom of the totem pole,” Spangehl said.
In terms of cash flow, however, joint replacements are decidedly not at the bottom of the totem pole. They have become a cash cow as the number of patients undergoing them has skyrocketed in recent decades.
The volume is being driven by an aging population, an epidemic of obesity and a significant rise in the number of younger people replacing joints worn out by years of sports and exercise.
It’s also being driven by the cash. Once only done in hospitals, the operations are now increasingly performed at ambulatory surgery centers – especially on younger, healthier patients who don’t require hospitalization.
The surgery centers are often physician-owned, but private equity groups such as Bain Capital and KKR & Co. have taken an interest in them, drawn by their high growth potential, robust financial returns and ability to offer competitive prices.
“[G]enerally the savings should be very good – but I do see a lot of outlier surgery centers where they are charging exorbitant amounts of money – $100,000 wouldn’t be too much,” said WellRithm’s Weintraub, who co-owned such a surgery center in Portland.
Fear of catching the coronavirus in a hospital is reinforcing the outpatient trend. Matthew Davis, a 58-year-old resident of Washington, was scheduled for a hip replacement on March 30 but got cold feet because of COVID-19, and canceled just before all elective surgeries were halted. When it came time to reschedule in June, he overcame his reservations in large part because the surgeon planned to perform the procedure at a free-standing surgery center.
“That was key to me – avoiding an overnight hospital stay to minimize my exposure,” Davis said. “These joint replacements are almost industrial-scale. They are cranking out joint replacements 9 to 5. I went in at 6:30 a.m. and I was walking out the door at 11:30.”
Acutely aware of the financial benefits, hospitals and surgery clinics have been marketing joint replacements for years, competing for coveted rankings and running ads that show healthy aging people, all smiles, engaged in vigorous activity.
However, a 2014 study concluded that one-third of knee replacements were not warranted, mainly because the symptoms of the patients were not severe enough to justify the procedures.
“The whole marketing of health care is so manipulative to the consuming public,” said Lisa McGiffert, a longtime consumer advocate and co-founder of the Patient Safety Action Network. “People might be encouraged to get a knee replacement, when in reality something less invasive could have improved their condition.”
McGiffert recounted a conversation with an orthopedic surgeon in Washington state who told her about a patient who requested a knee replacement, even though he had not tried any lower-impact treatments to fix the problem. “I asked the surgeon, ‘You didn’t do it, did you?’ And he said, ‘Of course I did. He would just have gone to somebody else.’ ”
This Kaiser Health News story first published on California Healthline, a service of the California Health Care Foundation.
Dr. Ira Weintraub, a recently retired orthopedic surgeon who now works at a medical billing consultancy, saw a hip replacement bill for over $400,000 earlier this year.
“The patient stayed in the hospital 17 days, which is only 17 times normal. The bill got paid,” mused Weintraub, chief medical officer of Portland, Oregon-based WellRithms, which helps self-funded employers and workers’ compensation insurers make sense of large, complex medical bills and ensure they pay the fair amount.
Charges like that go a long way toward explaining why hospitals are eager to restore joint replacements to pre-COVID levels as quickly as possible – an eagerness tempered only by safety concerns amid a resurgence of the coronavirus in some regions of the country. Revenue losses at hospitals and outpatient surgery centers may have exceeded $5 billion from canceled knee and hip replacements alone during a roughly two-month hiatus on elective procedures earlier this year.
The cost of joint replacement surgery varies widely – though, on average, it is in the tens, not hundreds, of thousands of dollars. Still, given the high and rapidly growing volume, it’s easy to see why joint replacement operations have become a vital chunk of revenue at most U.S. hospitals.
The rate of knee and hip replacements more than doubled from 2000 to 2015, according to inpatient discharge data from the Agency for Healthcare Research and Quality. And that growth is likely to continue: Knee replacements are expected to triple between now and 2040, with hip replacements not far behind, according to projections published last year in the Journal of Rheumatology.
Joint procedures are usually not emergencies, and they were among the first to be scrubbed or delayed when hospitals froze elective surgeries in March – and again in July in some areas plagued by renewed COVID outbreaks.
“Without orthopedic volumes returning to something near their pre-pandemic levels, it will make it difficult for health systems to get back to anywhere near break-even from a bottom-line perspective,” said Stephen Thome, a principal in health care consulting at Grant Thornton, an advisory, audit and tax firm.
It’s impossible to know exactly how much knee and hip replacements are worth to hospitals, because no definitive data on total volume or price exists.
But using published estimates of volume, extrapolating average commercial payments from published Medicare rates based on a study, and making an educated guess of patient coinsurance, Thome helped KHN arrive at an annual market value for American hospitals and surgery centers of between $15.5 billion and $21.5 billion for knee replacements alone.
That suggests a revenue loss of $1.3 billion to $1.8 billion per month for the period the surgeries were shut down. These figures include ambulatory surgery centers not owned by hospitals, which also suspended most operations in late March, all of April and into May.
If you add hip replacements, which account for about half the volume of knees and are paid at similar rates, the total annual value rises to a range of $23 billion to $32 billion, with monthly revenue losses from $1.9 billion to $2.7 billion.
The American Hospital Association projects total revenue lost at U.S. hospitals will reach $323 billion by year’s end, not counting additional losses from surgeries canceled during the current coronavirus spike. That amount is partially offset by $69 billion in federal relief dollars hospitals have received so far, according to the association. The California Hospital Association puts the net revenue loss for hospitals in that state at about $10.5 billion, said spokesperson Jan Emerson-Shea.
Hospitals resumed joint replacement surgeries in early to mid-May, with the timing and ramp-up speed varying by region and hospital. Some hospitals restored volume quickly; others took a more cautious route and continue to lose revenue. Still others have had to shut down again.
At the NYU Langone Orthopedic Hospital in New York City, “people are starting to come in and you see the operating rooms full again,” said Dr. Claudette Lajam, chief orthopedic safety officer.
At St. Jude Medical Center in Fullerton, California, where the coronavirus is raging, inpatient joint replacements resumed in the second or third week of May – cautiously at first, but volume is “very close to pre-pandemic levels at this point,” said Dr. Kevin Khajavi, chairman of the hospital’s orthopedic surgery department. However, “we are constantly monitoring the situation to determine if we have to scale back once again,” he said.
In large swaths of Texas, elective surgeries were once again suspended in July because of the COVID-19 resurgence. The same is true at many hospitals in Florida, Alabama, South Carolina and Nevada.
The Mayo Clinic in Phoenix suspended nonemergency joint replacement surgeries in early July. It resumed outpatient replacement procedures the week of July 27, but still has not resumed nonemergency inpatient procedures, said Dr. Mark Spangehl, an orthopedic surgeon there. In terms of medical urgency, joint replacements are “at the bottom of the totem pole,” Spangehl said.
In terms of cash flow, however, joint replacements are decidedly not at the bottom of the totem pole. They have become a cash cow as the number of patients undergoing them has skyrocketed in recent decades.
The volume is being driven by an aging population, an epidemic of obesity and a significant rise in the number of younger people replacing joints worn out by years of sports and exercise.
It’s also being driven by the cash. Once only done in hospitals, the operations are now increasingly performed at ambulatory surgery centers – especially on younger, healthier patients who don’t require hospitalization.
The surgery centers are often physician-owned, but private equity groups such as Bain Capital and KKR & Co. have taken an interest in them, drawn by their high growth potential, robust financial returns and ability to offer competitive prices.
“[G]enerally the savings should be very good – but I do see a lot of outlier surgery centers where they are charging exorbitant amounts of money – $100,000 wouldn’t be too much,” said WellRithm’s Weintraub, who co-owned such a surgery center in Portland.
Fear of catching the coronavirus in a hospital is reinforcing the outpatient trend. Matthew Davis, a 58-year-old resident of Washington, was scheduled for a hip replacement on March 30 but got cold feet because of COVID-19, and canceled just before all elective surgeries were halted. When it came time to reschedule in June, he overcame his reservations in large part because the surgeon planned to perform the procedure at a free-standing surgery center.
“That was key to me – avoiding an overnight hospital stay to minimize my exposure,” Davis said. “These joint replacements are almost industrial-scale. They are cranking out joint replacements 9 to 5. I went in at 6:30 a.m. and I was walking out the door at 11:30.”
Acutely aware of the financial benefits, hospitals and surgery clinics have been marketing joint replacements for years, competing for coveted rankings and running ads that show healthy aging people, all smiles, engaged in vigorous activity.
However, a 2014 study concluded that one-third of knee replacements were not warranted, mainly because the symptoms of the patients were not severe enough to justify the procedures.
“The whole marketing of health care is so manipulative to the consuming public,” said Lisa McGiffert, a longtime consumer advocate and co-founder of the Patient Safety Action Network. “People might be encouraged to get a knee replacement, when in reality something less invasive could have improved their condition.”
McGiffert recounted a conversation with an orthopedic surgeon in Washington state who told her about a patient who requested a knee replacement, even though he had not tried any lower-impact treatments to fix the problem. “I asked the surgeon, ‘You didn’t do it, did you?’ And he said, ‘Of course I did. He would just have gone to somebody else.’ ”
This Kaiser Health News story first published on California Healthline, a service of the California Health Care Foundation.
Dr. Ira Weintraub, a recently retired orthopedic surgeon who now works at a medical billing consultancy, saw a hip replacement bill for over $400,000 earlier this year.
“The patient stayed in the hospital 17 days, which is only 17 times normal. The bill got paid,” mused Weintraub, chief medical officer of Portland, Oregon-based WellRithms, which helps self-funded employers and workers’ compensation insurers make sense of large, complex medical bills and ensure they pay the fair amount.
Charges like that go a long way toward explaining why hospitals are eager to restore joint replacements to pre-COVID levels as quickly as possible – an eagerness tempered only by safety concerns amid a resurgence of the coronavirus in some regions of the country. Revenue losses at hospitals and outpatient surgery centers may have exceeded $5 billion from canceled knee and hip replacements alone during a roughly two-month hiatus on elective procedures earlier this year.
The cost of joint replacement surgery varies widely – though, on average, it is in the tens, not hundreds, of thousands of dollars. Still, given the high and rapidly growing volume, it’s easy to see why joint replacement operations have become a vital chunk of revenue at most U.S. hospitals.
The rate of knee and hip replacements more than doubled from 2000 to 2015, according to inpatient discharge data from the Agency for Healthcare Research and Quality. And that growth is likely to continue: Knee replacements are expected to triple between now and 2040, with hip replacements not far behind, according to projections published last year in the Journal of Rheumatology.
Joint procedures are usually not emergencies, and they were among the first to be scrubbed or delayed when hospitals froze elective surgeries in March – and again in July in some areas plagued by renewed COVID outbreaks.
“Without orthopedic volumes returning to something near their pre-pandemic levels, it will make it difficult for health systems to get back to anywhere near break-even from a bottom-line perspective,” said Stephen Thome, a principal in health care consulting at Grant Thornton, an advisory, audit and tax firm.
It’s impossible to know exactly how much knee and hip replacements are worth to hospitals, because no definitive data on total volume or price exists.
But using published estimates of volume, extrapolating average commercial payments from published Medicare rates based on a study, and making an educated guess of patient coinsurance, Thome helped KHN arrive at an annual market value for American hospitals and surgery centers of between $15.5 billion and $21.5 billion for knee replacements alone.
That suggests a revenue loss of $1.3 billion to $1.8 billion per month for the period the surgeries were shut down. These figures include ambulatory surgery centers not owned by hospitals, which also suspended most operations in late March, all of April and into May.
If you add hip replacements, which account for about half the volume of knees and are paid at similar rates, the total annual value rises to a range of $23 billion to $32 billion, with monthly revenue losses from $1.9 billion to $2.7 billion.
The American Hospital Association projects total revenue lost at U.S. hospitals will reach $323 billion by year’s end, not counting additional losses from surgeries canceled during the current coronavirus spike. That amount is partially offset by $69 billion in federal relief dollars hospitals have received so far, according to the association. The California Hospital Association puts the net revenue loss for hospitals in that state at about $10.5 billion, said spokesperson Jan Emerson-Shea.
Hospitals resumed joint replacement surgeries in early to mid-May, with the timing and ramp-up speed varying by region and hospital. Some hospitals restored volume quickly; others took a more cautious route and continue to lose revenue. Still others have had to shut down again.
At the NYU Langone Orthopedic Hospital in New York City, “people are starting to come in and you see the operating rooms full again,” said Dr. Claudette Lajam, chief orthopedic safety officer.
At St. Jude Medical Center in Fullerton, California, where the coronavirus is raging, inpatient joint replacements resumed in the second or third week of May – cautiously at first, but volume is “very close to pre-pandemic levels at this point,” said Dr. Kevin Khajavi, chairman of the hospital’s orthopedic surgery department. However, “we are constantly monitoring the situation to determine if we have to scale back once again,” he said.
In large swaths of Texas, elective surgeries were once again suspended in July because of the COVID-19 resurgence. The same is true at many hospitals in Florida, Alabama, South Carolina and Nevada.
The Mayo Clinic in Phoenix suspended nonemergency joint replacement surgeries in early July. It resumed outpatient replacement procedures the week of July 27, but still has not resumed nonemergency inpatient procedures, said Dr. Mark Spangehl, an orthopedic surgeon there. In terms of medical urgency, joint replacements are “at the bottom of the totem pole,” Spangehl said.
In terms of cash flow, however, joint replacements are decidedly not at the bottom of the totem pole. They have become a cash cow as the number of patients undergoing them has skyrocketed in recent decades.
The volume is being driven by an aging population, an epidemic of obesity and a significant rise in the number of younger people replacing joints worn out by years of sports and exercise.
It’s also being driven by the cash. Once only done in hospitals, the operations are now increasingly performed at ambulatory surgery centers – especially on younger, healthier patients who don’t require hospitalization.
The surgery centers are often physician-owned, but private equity groups such as Bain Capital and KKR & Co. have taken an interest in them, drawn by their high growth potential, robust financial returns and ability to offer competitive prices.
“[G]enerally the savings should be very good – but I do see a lot of outlier surgery centers where they are charging exorbitant amounts of money – $100,000 wouldn’t be too much,” said WellRithm’s Weintraub, who co-owned such a surgery center in Portland.
Fear of catching the coronavirus in a hospital is reinforcing the outpatient trend. Matthew Davis, a 58-year-old resident of Washington, was scheduled for a hip replacement on March 30 but got cold feet because of COVID-19, and canceled just before all elective surgeries were halted. When it came time to reschedule in June, he overcame his reservations in large part because the surgeon planned to perform the procedure at a free-standing surgery center.
“That was key to me – avoiding an overnight hospital stay to minimize my exposure,” Davis said. “These joint replacements are almost industrial-scale. They are cranking out joint replacements 9 to 5. I went in at 6:30 a.m. and I was walking out the door at 11:30.”
Acutely aware of the financial benefits, hospitals and surgery clinics have been marketing joint replacements for years, competing for coveted rankings and running ads that show healthy aging people, all smiles, engaged in vigorous activity.
However, a 2014 study concluded that one-third of knee replacements were not warranted, mainly because the symptoms of the patients were not severe enough to justify the procedures.
“The whole marketing of health care is so manipulative to the consuming public,” said Lisa McGiffert, a longtime consumer advocate and co-founder of the Patient Safety Action Network. “People might be encouraged to get a knee replacement, when in reality something less invasive could have improved their condition.”
McGiffert recounted a conversation with an orthopedic surgeon in Washington state who told her about a patient who requested a knee replacement, even though he had not tried any lower-impact treatments to fix the problem. “I asked the surgeon, ‘You didn’t do it, did you?’ And he said, ‘Of course I did. He would just have gone to somebody else.’ ”
This Kaiser Health News story first published on California Healthline, a service of the California Health Care Foundation.
Taming a terrible illness
Darth Vader is, to me, one of the most intimidating villains in movie history. I was 11 when Star Wars came out. I even cleaned my room so my mother would take me to see it.
When Darth Vader first walked on screen, it was striking. A tall, imposing figure in black, with harsh mechanical respirations. There was no question of who the bad guy was. As the movie progressed his darkness became more frightening until, in the first lightsaber battle any of us had seen, he cut down the benevolent Obi-Wan Kenobi.
Last year my family went to Disneyland. While browsing the park’s stores we saw numerous Darth Vader items ... with him now available as a teddy bear, and on T-shirts riding carousels and the Dumbo ride.
From terrifying villain to cutesy toy in 43 years.* Quite the fall from glory.
Diseases are often (and hopefully) like that. Syphilis, once the most common, feared, and incurable neurologic disease is now, for most, just a nuisance. The butt of jokes and sexual innuendos, rendered harmless by Alexander Fleming’s discoveries.
Bit by bit we see other diseases tamed. Multiple sclerosis, though still serious, becomes better controlled every year as new agents come out. The cure for Parkinson’s disease remains elusive, but agents to control the symptoms and improve quality of life are available. Even HIV, the most feared disease of the 80s and 90s, has been beaten back from a terrible death sentence to one where patients lead normal lives with antiviral therapy.
Today we face a new enemy, the COVID-19 pandemic. So far we have no definite treatments, nor shortage of ideas. Many companies are racing to develop a vaccine, and will likely, at some point, find one, but what and when are still in the future. too.
Alzheimer’s disease, for all practical purposes, remains untreatable and rightfully feared. Perhaps the only ones more terrifying are those we’ve reduced to just three letters: ALS (amyotrophic lateral sclerosis) and GBM (glioblastoma multiforme). Both have terrible courses and, in spite of years of research, nothing even close to an effective treatment.
I hope that changes, and soon, for all those affected by these (and many other) terrible disorders.
Like the Darth Vader teddy bear, I’ll be happy to see them become shells of their former selves, with the dread they bring now reduced to the lesser trepidation seen when facing a serious, but treatable, illness.
*Correction, 8/11/20: An earlier version of this column misstated the number of years since Star Wars debuted.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Darth Vader is, to me, one of the most intimidating villains in movie history. I was 11 when Star Wars came out. I even cleaned my room so my mother would take me to see it.
When Darth Vader first walked on screen, it was striking. A tall, imposing figure in black, with harsh mechanical respirations. There was no question of who the bad guy was. As the movie progressed his darkness became more frightening until, in the first lightsaber battle any of us had seen, he cut down the benevolent Obi-Wan Kenobi.
Last year my family went to Disneyland. While browsing the park’s stores we saw numerous Darth Vader items ... with him now available as a teddy bear, and on T-shirts riding carousels and the Dumbo ride.
From terrifying villain to cutesy toy in 43 years.* Quite the fall from glory.
Diseases are often (and hopefully) like that. Syphilis, once the most common, feared, and incurable neurologic disease is now, for most, just a nuisance. The butt of jokes and sexual innuendos, rendered harmless by Alexander Fleming’s discoveries.
Bit by bit we see other diseases tamed. Multiple sclerosis, though still serious, becomes better controlled every year as new agents come out. The cure for Parkinson’s disease remains elusive, but agents to control the symptoms and improve quality of life are available. Even HIV, the most feared disease of the 80s and 90s, has been beaten back from a terrible death sentence to one where patients lead normal lives with antiviral therapy.
Today we face a new enemy, the COVID-19 pandemic. So far we have no definite treatments, nor shortage of ideas. Many companies are racing to develop a vaccine, and will likely, at some point, find one, but what and when are still in the future. too.
Alzheimer’s disease, for all practical purposes, remains untreatable and rightfully feared. Perhaps the only ones more terrifying are those we’ve reduced to just three letters: ALS (amyotrophic lateral sclerosis) and GBM (glioblastoma multiforme). Both have terrible courses and, in spite of years of research, nothing even close to an effective treatment.
I hope that changes, and soon, for all those affected by these (and many other) terrible disorders.
Like the Darth Vader teddy bear, I’ll be happy to see them become shells of their former selves, with the dread they bring now reduced to the lesser trepidation seen when facing a serious, but treatable, illness.
*Correction, 8/11/20: An earlier version of this column misstated the number of years since Star Wars debuted.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Darth Vader is, to me, one of the most intimidating villains in movie history. I was 11 when Star Wars came out. I even cleaned my room so my mother would take me to see it.
When Darth Vader first walked on screen, it was striking. A tall, imposing figure in black, with harsh mechanical respirations. There was no question of who the bad guy was. As the movie progressed his darkness became more frightening until, in the first lightsaber battle any of us had seen, he cut down the benevolent Obi-Wan Kenobi.
Last year my family went to Disneyland. While browsing the park’s stores we saw numerous Darth Vader items ... with him now available as a teddy bear, and on T-shirts riding carousels and the Dumbo ride.
From terrifying villain to cutesy toy in 43 years.* Quite the fall from glory.
Diseases are often (and hopefully) like that. Syphilis, once the most common, feared, and incurable neurologic disease is now, for most, just a nuisance. The butt of jokes and sexual innuendos, rendered harmless by Alexander Fleming’s discoveries.
Bit by bit we see other diseases tamed. Multiple sclerosis, though still serious, becomes better controlled every year as new agents come out. The cure for Parkinson’s disease remains elusive, but agents to control the symptoms and improve quality of life are available. Even HIV, the most feared disease of the 80s and 90s, has been beaten back from a terrible death sentence to one where patients lead normal lives with antiviral therapy.
Today we face a new enemy, the COVID-19 pandemic. So far we have no definite treatments, nor shortage of ideas. Many companies are racing to develop a vaccine, and will likely, at some point, find one, but what and when are still in the future. too.
Alzheimer’s disease, for all practical purposes, remains untreatable and rightfully feared. Perhaps the only ones more terrifying are those we’ve reduced to just three letters: ALS (amyotrophic lateral sclerosis) and GBM (glioblastoma multiforme). Both have terrible courses and, in spite of years of research, nothing even close to an effective treatment.
I hope that changes, and soon, for all those affected by these (and many other) terrible disorders.
Like the Darth Vader teddy bear, I’ll be happy to see them become shells of their former selves, with the dread they bring now reduced to the lesser trepidation seen when facing a serious, but treatable, illness.
*Correction, 8/11/20: An earlier version of this column misstated the number of years since Star Wars debuted.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Studies gauge role of schools, kids in spread of COVID-19
When officials closed U.S. schools in March to limit the spread of COVID-19, they may have prevented more than 1 million cases over a 26-day period, a new estimate published online July 29 in JAMA suggests.
But school closures also left blind spots in understanding how children and schools affect disease transmission.
“School closures early in pandemic responses thwarted larger-scale investigations of schools as a source of community transmission,” researchers noted in a separate study, published online July 30 in JAMA Pediatrics, that examined levels of viral RNA in children and adults with COVID-19.
“Our analyses suggest children younger than 5 years with mild to moderate COVID-19 have high amounts of SARS-CoV-2 viral RNA in their nasopharynx, compared with older children and adults,” reported Taylor Heald-Sargent, MD, PhD, and colleagues. “Thus, young children can potentially be important drivers of SARS-CoV-2 spread in the general population, as has been demonstrated with respiratory syncytial virus, where children with high viral loads are more likely to transmit.”
Although the study “was not designed to prove that younger children spread COVID-19 as much as adults,” it is a possibility, Dr. Heald-Sargent, a pediatric infectious diseases specialist at Ann and Robert H. Lurie Children’s Hospital and assistant professor of pediatrics at Northwestern University, Chicago, said in a related news release. “We need to take that into account in efforts to reduce transmission as we continue to learn more about this virus.”.
The study included 145 patients with mild or moderate illness who were within 1 week of symptom onset. The researchers used reverse transcriptase–polymerase chain reaction (rt-PCR) on nasopharyngeal swabs collected at inpatient, outpatient, emergency department, or drive-through testing sites to measure SARS-CoV-2 levels. The investigators compared PCR amplification cycle threshold (CT) values for children younger than 5 years (n = 46), children aged 5-17 years (n = 51), and adults aged 18-65 years (n = 48); lower CT values indicate higher amounts of viral nucleic acid.
Median CT values for older children and adults were similar (about 11), whereas the median CT value for young children was significantly lower (6.5). The differences between young children and adults “approximate a 10-fold to 100-fold greater amount of SARS-CoV-2 in the upper respiratory tract of young children,” the researchers wrote.
“Behavioral habits of young children and close quarters in school and day care settings raise concern for SARS-CoV-2 amplification in this population as public health restrictions are eased,” they write.
Modeling the impact of school closures
In the JAMA study, Katherine A. Auger, MD, of Cincinnati Children’s Hospital Medical Center, and colleagues examined at the U.S. population level whether closing schools, as all 50 states did in March, was associated with relative decreases in COVID-19 incidence and mortality.
To isolate the effect of school closures, the researchers used an interrupted time series analysis and included other state-level nonpharmaceutical interventions and variables in their regression models.
“Per week, the incidence was estimated to have been 39% of what it would have been had schools remained open,” Dr. Auger and colleagues wrote. “Extrapolating the absolute differences of 423.9 cases and 12.6 deaths per 100,000 to 322.2 million residents nationally suggests that school closure may have been associated with approximately 1.37 million fewer cases of COVID-19 over a 26-day period and 40,600 fewer deaths over a 16-day period; however, these figures do not account for uncertainty in the model assumptions and the resulting estimates.”
Relative reductions in incidence and mortality were largest in states that closed schools when the incidence of COVID-19 was low, the authors found.
Decisions with high stakes
In an accompanying editorial, Julie M. Donohue, PhD, and Elizabeth Miller, MD, PhD, both affiliated with the University of Pittsburgh, emphasized that the results are estimates. “School closures were enacted in close proximity ... to other physical distancing measures, such as nonessential business closures and stay-at-home orders, making it difficult to disentangle the potential effect of each intervention.”
Although the findings “suggest a role for school closures in virus mitigation, school and health officials must balance this with academic, health, and economic consequences,” Dr. Donohue and Dr. Miller added. “Given the strong connection between education, income, and life expectancy, school closures could have long-term deleterious consequences for child health, likely reaching into adulthood.” Schools provide “meals and nutrition, health care including behavioral health supports, physical activity, social interaction, supports for students with special education needs and disabilities, and other vital resources for healthy development.”
In a viewpoint article also published in JAMA, authors involved in the creation of a National Academies of Sciences, Engineering, and Medicine reported on the reopening of schools recommend that districts “make every effort to prioritize reopening with an emphasis on providing in-person instruction for students in kindergarten through grade 5 as well as those students with special needs who might be best served by in-person instruction.
“To reopen safely, school districts are encouraged to ensure ventilation and air filtration, clean surfaces frequently, provide facilities for regular handwashing, and provide space for physical distancing,” write Kenne A. Dibner, PhD, of the NASEM in Washington, D.C., and coauthors.
Furthermore, districts “need to consider transparent communication of the reality that while measures can be implemented to lower the risk of transmitting COVID-19 when schools reopen, there is no way to eliminate that risk entirely. It is critical to share both the risks and benefits of different scenarios,” they wrote.
The JAMA modeling study received funding from the Agency for Healthcare Research and Quality and the National Institutes of Health. The NASEM report was funded by the Brady Education Foundation and the Spencer Foundation. The authors disclosed no relevant financial relationships.
A version of this story originally appeared on Medscape.com.
When officials closed U.S. schools in March to limit the spread of COVID-19, they may have prevented more than 1 million cases over a 26-day period, a new estimate published online July 29 in JAMA suggests.
But school closures also left blind spots in understanding how children and schools affect disease transmission.
“School closures early in pandemic responses thwarted larger-scale investigations of schools as a source of community transmission,” researchers noted in a separate study, published online July 30 in JAMA Pediatrics, that examined levels of viral RNA in children and adults with COVID-19.
“Our analyses suggest children younger than 5 years with mild to moderate COVID-19 have high amounts of SARS-CoV-2 viral RNA in their nasopharynx, compared with older children and adults,” reported Taylor Heald-Sargent, MD, PhD, and colleagues. “Thus, young children can potentially be important drivers of SARS-CoV-2 spread in the general population, as has been demonstrated with respiratory syncytial virus, where children with high viral loads are more likely to transmit.”
Although the study “was not designed to prove that younger children spread COVID-19 as much as adults,” it is a possibility, Dr. Heald-Sargent, a pediatric infectious diseases specialist at Ann and Robert H. Lurie Children’s Hospital and assistant professor of pediatrics at Northwestern University, Chicago, said in a related news release. “We need to take that into account in efforts to reduce transmission as we continue to learn more about this virus.”.
The study included 145 patients with mild or moderate illness who were within 1 week of symptom onset. The researchers used reverse transcriptase–polymerase chain reaction (rt-PCR) on nasopharyngeal swabs collected at inpatient, outpatient, emergency department, or drive-through testing sites to measure SARS-CoV-2 levels. The investigators compared PCR amplification cycle threshold (CT) values for children younger than 5 years (n = 46), children aged 5-17 years (n = 51), and adults aged 18-65 years (n = 48); lower CT values indicate higher amounts of viral nucleic acid.
Median CT values for older children and adults were similar (about 11), whereas the median CT value for young children was significantly lower (6.5). The differences between young children and adults “approximate a 10-fold to 100-fold greater amount of SARS-CoV-2 in the upper respiratory tract of young children,” the researchers wrote.
“Behavioral habits of young children and close quarters in school and day care settings raise concern for SARS-CoV-2 amplification in this population as public health restrictions are eased,” they write.
Modeling the impact of school closures
In the JAMA study, Katherine A. Auger, MD, of Cincinnati Children’s Hospital Medical Center, and colleagues examined at the U.S. population level whether closing schools, as all 50 states did in March, was associated with relative decreases in COVID-19 incidence and mortality.
To isolate the effect of school closures, the researchers used an interrupted time series analysis and included other state-level nonpharmaceutical interventions and variables in their regression models.
“Per week, the incidence was estimated to have been 39% of what it would have been had schools remained open,” Dr. Auger and colleagues wrote. “Extrapolating the absolute differences of 423.9 cases and 12.6 deaths per 100,000 to 322.2 million residents nationally suggests that school closure may have been associated with approximately 1.37 million fewer cases of COVID-19 over a 26-day period and 40,600 fewer deaths over a 16-day period; however, these figures do not account for uncertainty in the model assumptions and the resulting estimates.”
Relative reductions in incidence and mortality were largest in states that closed schools when the incidence of COVID-19 was low, the authors found.
Decisions with high stakes
In an accompanying editorial, Julie M. Donohue, PhD, and Elizabeth Miller, MD, PhD, both affiliated with the University of Pittsburgh, emphasized that the results are estimates. “School closures were enacted in close proximity ... to other physical distancing measures, such as nonessential business closures and stay-at-home orders, making it difficult to disentangle the potential effect of each intervention.”
Although the findings “suggest a role for school closures in virus mitigation, school and health officials must balance this with academic, health, and economic consequences,” Dr. Donohue and Dr. Miller added. “Given the strong connection between education, income, and life expectancy, school closures could have long-term deleterious consequences for child health, likely reaching into adulthood.” Schools provide “meals and nutrition, health care including behavioral health supports, physical activity, social interaction, supports for students with special education needs and disabilities, and other vital resources for healthy development.”
In a viewpoint article also published in JAMA, authors involved in the creation of a National Academies of Sciences, Engineering, and Medicine reported on the reopening of schools recommend that districts “make every effort to prioritize reopening with an emphasis on providing in-person instruction for students in kindergarten through grade 5 as well as those students with special needs who might be best served by in-person instruction.
“To reopen safely, school districts are encouraged to ensure ventilation and air filtration, clean surfaces frequently, provide facilities for regular handwashing, and provide space for physical distancing,” write Kenne A. Dibner, PhD, of the NASEM in Washington, D.C., and coauthors.
Furthermore, districts “need to consider transparent communication of the reality that while measures can be implemented to lower the risk of transmitting COVID-19 when schools reopen, there is no way to eliminate that risk entirely. It is critical to share both the risks and benefits of different scenarios,” they wrote.
The JAMA modeling study received funding from the Agency for Healthcare Research and Quality and the National Institutes of Health. The NASEM report was funded by the Brady Education Foundation and the Spencer Foundation. The authors disclosed no relevant financial relationships.
A version of this story originally appeared on Medscape.com.
When officials closed U.S. schools in March to limit the spread of COVID-19, they may have prevented more than 1 million cases over a 26-day period, a new estimate published online July 29 in JAMA suggests.
But school closures also left blind spots in understanding how children and schools affect disease transmission.
“School closures early in pandemic responses thwarted larger-scale investigations of schools as a source of community transmission,” researchers noted in a separate study, published online July 30 in JAMA Pediatrics, that examined levels of viral RNA in children and adults with COVID-19.
“Our analyses suggest children younger than 5 years with mild to moderate COVID-19 have high amounts of SARS-CoV-2 viral RNA in their nasopharynx, compared with older children and adults,” reported Taylor Heald-Sargent, MD, PhD, and colleagues. “Thus, young children can potentially be important drivers of SARS-CoV-2 spread in the general population, as has been demonstrated with respiratory syncytial virus, where children with high viral loads are more likely to transmit.”
Although the study “was not designed to prove that younger children spread COVID-19 as much as adults,” it is a possibility, Dr. Heald-Sargent, a pediatric infectious diseases specialist at Ann and Robert H. Lurie Children’s Hospital and assistant professor of pediatrics at Northwestern University, Chicago, said in a related news release. “We need to take that into account in efforts to reduce transmission as we continue to learn more about this virus.”.
The study included 145 patients with mild or moderate illness who were within 1 week of symptom onset. The researchers used reverse transcriptase–polymerase chain reaction (rt-PCR) on nasopharyngeal swabs collected at inpatient, outpatient, emergency department, or drive-through testing sites to measure SARS-CoV-2 levels. The investigators compared PCR amplification cycle threshold (CT) values for children younger than 5 years (n = 46), children aged 5-17 years (n = 51), and adults aged 18-65 years (n = 48); lower CT values indicate higher amounts of viral nucleic acid.
Median CT values for older children and adults were similar (about 11), whereas the median CT value for young children was significantly lower (6.5). The differences between young children and adults “approximate a 10-fold to 100-fold greater amount of SARS-CoV-2 in the upper respiratory tract of young children,” the researchers wrote.
“Behavioral habits of young children and close quarters in school and day care settings raise concern for SARS-CoV-2 amplification in this population as public health restrictions are eased,” they write.
Modeling the impact of school closures
In the JAMA study, Katherine A. Auger, MD, of Cincinnati Children’s Hospital Medical Center, and colleagues examined at the U.S. population level whether closing schools, as all 50 states did in March, was associated with relative decreases in COVID-19 incidence and mortality.
To isolate the effect of school closures, the researchers used an interrupted time series analysis and included other state-level nonpharmaceutical interventions and variables in their regression models.
“Per week, the incidence was estimated to have been 39% of what it would have been had schools remained open,” Dr. Auger and colleagues wrote. “Extrapolating the absolute differences of 423.9 cases and 12.6 deaths per 100,000 to 322.2 million residents nationally suggests that school closure may have been associated with approximately 1.37 million fewer cases of COVID-19 over a 26-day period and 40,600 fewer deaths over a 16-day period; however, these figures do not account for uncertainty in the model assumptions and the resulting estimates.”
Relative reductions in incidence and mortality were largest in states that closed schools when the incidence of COVID-19 was low, the authors found.
Decisions with high stakes
In an accompanying editorial, Julie M. Donohue, PhD, and Elizabeth Miller, MD, PhD, both affiliated with the University of Pittsburgh, emphasized that the results are estimates. “School closures were enacted in close proximity ... to other physical distancing measures, such as nonessential business closures and stay-at-home orders, making it difficult to disentangle the potential effect of each intervention.”
Although the findings “suggest a role for school closures in virus mitigation, school and health officials must balance this with academic, health, and economic consequences,” Dr. Donohue and Dr. Miller added. “Given the strong connection between education, income, and life expectancy, school closures could have long-term deleterious consequences for child health, likely reaching into adulthood.” Schools provide “meals and nutrition, health care including behavioral health supports, physical activity, social interaction, supports for students with special education needs and disabilities, and other vital resources for healthy development.”
In a viewpoint article also published in JAMA, authors involved in the creation of a National Academies of Sciences, Engineering, and Medicine reported on the reopening of schools recommend that districts “make every effort to prioritize reopening with an emphasis on providing in-person instruction for students in kindergarten through grade 5 as well as those students with special needs who might be best served by in-person instruction.
“To reopen safely, school districts are encouraged to ensure ventilation and air filtration, clean surfaces frequently, provide facilities for regular handwashing, and provide space for physical distancing,” write Kenne A. Dibner, PhD, of the NASEM in Washington, D.C., and coauthors.
Furthermore, districts “need to consider transparent communication of the reality that while measures can be implemented to lower the risk of transmitting COVID-19 when schools reopen, there is no way to eliminate that risk entirely. It is critical to share both the risks and benefits of different scenarios,” they wrote.
The JAMA modeling study received funding from the Agency for Healthcare Research and Quality and the National Institutes of Health. The NASEM report was funded by the Brady Education Foundation and the Spencer Foundation. The authors disclosed no relevant financial relationships.
A version of this story originally appeared on Medscape.com.
Telemedicine in primary care
How to effectively utilize this tool
By now it is well known that the COVID-19 pandemic has significantly disrupted primary care. Office visits and revenues have precipitously dropped as physicians and patients alike fear in-person visits may increase their risks of contracting the virus. However, telemedicine has emerged as a lifeline of sorts for many practices, enabling them to conduct visits and maintain contact with patients.
Telemedicine is likely to continue to serve as a tool for primary care providers to improve access to convenient, cost-effective, high-quality care after the pandemic. Another benefit of telemedicine is it can help maintain a portion of a practice’s revenue stream for physicians during uncertain times.
Indeed, the nation has seen recent progress toward telemedicine parity, which refers to the concept of reimbursing providers’ telehealth visits at the same rates as similar in-person visits.
A challenge to adopting telemedicine is that it calls for adjusting established workflows for in-person encounters. A practice cannot simply replicate in-person processes to work for telehealth. While both in-person and virtual visits require adherence to HIPAA, for example, how you actually protect patient privacy will call for different measures. Harking back to the early days of EMR implementation, one does not need to like the telemedicine platform or process, but come to terms with the fact that it is a tool that is here to stay to deliver patient care.
Treat your practice like a laboratory
Adoption may vary between practices depending on many factors, including clinicians’ comfort with technology, clinical tolerance and triage rules for nontouch encounters, state regulations, and more. Every provider group should begin experimenting with telemedicine in specific ways that make sense for them.
One physician may practice telemedicine full-time while the rest abstain, or perhaps the practice prefers to offer telemedicine services during specific hours on specific days. Don’t be afraid to start slowly when you’re trying something new – but do get started with telehealth. It will increasingly be a mainstream medium and more patients will come to expect it.
Train the entire team
Many primary care practices do not enjoy the resources of an information technology team, so all team members essentially need to learn the new skill of telemedicine usage, in addition to assisting patients. That can’t happen without staff buy-in, so it is essential that everyone from the office manager to medical assistants have the training they need to make the technology work. Juggling schedules for telehealth and in-office, activating an account through email, starting and joining a telehealth meeting, and preparing a patient for a visit are just a handful of basic tasks your staff should be trained to do to contribute to the successful integration of telehealth.
Educate and encourage patients to use telehealth
While unfamiliarity with technology may represent a roadblock for some patients, others resist telemedicine simply because no one has explained to them why it’s so important and the benefits it can hold for them. Education and communication are critical, including the sometimes painstaking work of slowly walking patients through the process of performing important functions on the telemedicine app. By providing them with some friendly coaching, patients won’t feel lost or abandoned during what for some may be an unfamiliar and frustrating process.
Manage more behavioral health
Different states and health plans incentivize primary practices for integrating behavioral health into their offerings. Rather than dismiss this addition to your own practice as too cumbersome to take on, I would recommend using telehealth to expand behavioral health care services.
If your practice is working toward a team-based, interdisciplinary approach to care delivery, behavioral health is a critical component. While other elements of this “whole person” health care may be better suited for an office visit, the vast majority of behavioral health services can be delivered virtually.
To decide if your patient may benefit from behavioral health care, the primary care provider (PCP) can conduct a screening via telehealth. Once the screening is complete, the PCP can discuss results and refer the patient to a mental health professional – all via telehealth. While patients may be reluctant to receive behavioral health treatment, perhaps because of stigma or inexperience, they may appreciate the telemedicine option as they can remain in the comfort and familiarity of their homes.
Collaborative Care is both an in-person and virtual model that allows PCP practices to offer behavioral health services in a cost effective way by utilizing a psychiatrist as a “consultant” to the practice as opposed to hiring a full-time psychiatrist. All services within the Collaborative Care Model can be offered via telehealth, and all major insurance providers reimburse primary care providers for delivering Collaborative Care.
When PCPs provide behavioral health treatment as an “extension” of the primary care service offerings, the stigma is reduced and more patients are willing to accept the care they need.
Many areas of the country suffer from a lack of access to behavioral health specialists. In rural counties, for example, the nearest therapist may be located over an hour away. By integrating behavioral telehealth services into your practice’s offerings, you can remove geographic and transportation obstacles to care for your patient population.
Doing this can lead to providing more culturally competent care. It’s important that you’re able to offer mental health services to your patients from a professional with a similar ethnic or racial background. Language barriers and cultural differences may limit a provider’s ability to treat a patient, particularly if the patient faces health disparities related to race or ethnicity. If your practice needs to look outside of your community to tap into a more diverse pool of providers to better meet your patients’ needs, telehealth makes it easier to do that.
Adopting telemedicine for consultative patient visits offers primary care a path toward restoring patient volume and hope for a postpandemic future.
Mark Stephan, MD, is chief medical officer at Equality Health, a whole-health delivery system. He practiced family medicine for 19 years, including hospital medicine and obstetrics in rural and urban settings. Dr. Stephan has no conflicts related to the content of this piece.
How to effectively utilize this tool
How to effectively utilize this tool
By now it is well known that the COVID-19 pandemic has significantly disrupted primary care. Office visits and revenues have precipitously dropped as physicians and patients alike fear in-person visits may increase their risks of contracting the virus. However, telemedicine has emerged as a lifeline of sorts for many practices, enabling them to conduct visits and maintain contact with patients.
Telemedicine is likely to continue to serve as a tool for primary care providers to improve access to convenient, cost-effective, high-quality care after the pandemic. Another benefit of telemedicine is it can help maintain a portion of a practice’s revenue stream for physicians during uncertain times.
Indeed, the nation has seen recent progress toward telemedicine parity, which refers to the concept of reimbursing providers’ telehealth visits at the same rates as similar in-person visits.
A challenge to adopting telemedicine is that it calls for adjusting established workflows for in-person encounters. A practice cannot simply replicate in-person processes to work for telehealth. While both in-person and virtual visits require adherence to HIPAA, for example, how you actually protect patient privacy will call for different measures. Harking back to the early days of EMR implementation, one does not need to like the telemedicine platform or process, but come to terms with the fact that it is a tool that is here to stay to deliver patient care.
Treat your practice like a laboratory
Adoption may vary between practices depending on many factors, including clinicians’ comfort with technology, clinical tolerance and triage rules for nontouch encounters, state regulations, and more. Every provider group should begin experimenting with telemedicine in specific ways that make sense for them.
One physician may practice telemedicine full-time while the rest abstain, or perhaps the practice prefers to offer telemedicine services during specific hours on specific days. Don’t be afraid to start slowly when you’re trying something new – but do get started with telehealth. It will increasingly be a mainstream medium and more patients will come to expect it.
Train the entire team
Many primary care practices do not enjoy the resources of an information technology team, so all team members essentially need to learn the new skill of telemedicine usage, in addition to assisting patients. That can’t happen without staff buy-in, so it is essential that everyone from the office manager to medical assistants have the training they need to make the technology work. Juggling schedules for telehealth and in-office, activating an account through email, starting and joining a telehealth meeting, and preparing a patient for a visit are just a handful of basic tasks your staff should be trained to do to contribute to the successful integration of telehealth.
Educate and encourage patients to use telehealth
While unfamiliarity with technology may represent a roadblock for some patients, others resist telemedicine simply because no one has explained to them why it’s so important and the benefits it can hold for them. Education and communication are critical, including the sometimes painstaking work of slowly walking patients through the process of performing important functions on the telemedicine app. By providing them with some friendly coaching, patients won’t feel lost or abandoned during what for some may be an unfamiliar and frustrating process.
Manage more behavioral health
Different states and health plans incentivize primary practices for integrating behavioral health into their offerings. Rather than dismiss this addition to your own practice as too cumbersome to take on, I would recommend using telehealth to expand behavioral health care services.
If your practice is working toward a team-based, interdisciplinary approach to care delivery, behavioral health is a critical component. While other elements of this “whole person” health care may be better suited for an office visit, the vast majority of behavioral health services can be delivered virtually.
To decide if your patient may benefit from behavioral health care, the primary care provider (PCP) can conduct a screening via telehealth. Once the screening is complete, the PCP can discuss results and refer the patient to a mental health professional – all via telehealth. While patients may be reluctant to receive behavioral health treatment, perhaps because of stigma or inexperience, they may appreciate the telemedicine option as they can remain in the comfort and familiarity of their homes.
Collaborative Care is both an in-person and virtual model that allows PCP practices to offer behavioral health services in a cost effective way by utilizing a psychiatrist as a “consultant” to the practice as opposed to hiring a full-time psychiatrist. All services within the Collaborative Care Model can be offered via telehealth, and all major insurance providers reimburse primary care providers for delivering Collaborative Care.
When PCPs provide behavioral health treatment as an “extension” of the primary care service offerings, the stigma is reduced and more patients are willing to accept the care they need.
Many areas of the country suffer from a lack of access to behavioral health specialists. In rural counties, for example, the nearest therapist may be located over an hour away. By integrating behavioral telehealth services into your practice’s offerings, you can remove geographic and transportation obstacles to care for your patient population.
Doing this can lead to providing more culturally competent care. It’s important that you’re able to offer mental health services to your patients from a professional with a similar ethnic or racial background. Language barriers and cultural differences may limit a provider’s ability to treat a patient, particularly if the patient faces health disparities related to race or ethnicity. If your practice needs to look outside of your community to tap into a more diverse pool of providers to better meet your patients’ needs, telehealth makes it easier to do that.
Adopting telemedicine for consultative patient visits offers primary care a path toward restoring patient volume and hope for a postpandemic future.
Mark Stephan, MD, is chief medical officer at Equality Health, a whole-health delivery system. He practiced family medicine for 19 years, including hospital medicine and obstetrics in rural and urban settings. Dr. Stephan has no conflicts related to the content of this piece.
By now it is well known that the COVID-19 pandemic has significantly disrupted primary care. Office visits and revenues have precipitously dropped as physicians and patients alike fear in-person visits may increase their risks of contracting the virus. However, telemedicine has emerged as a lifeline of sorts for many practices, enabling them to conduct visits and maintain contact with patients.
Telemedicine is likely to continue to serve as a tool for primary care providers to improve access to convenient, cost-effective, high-quality care after the pandemic. Another benefit of telemedicine is it can help maintain a portion of a practice’s revenue stream for physicians during uncertain times.
Indeed, the nation has seen recent progress toward telemedicine parity, which refers to the concept of reimbursing providers’ telehealth visits at the same rates as similar in-person visits.
A challenge to adopting telemedicine is that it calls for adjusting established workflows for in-person encounters. A practice cannot simply replicate in-person processes to work for telehealth. While both in-person and virtual visits require adherence to HIPAA, for example, how you actually protect patient privacy will call for different measures. Harking back to the early days of EMR implementation, one does not need to like the telemedicine platform or process, but come to terms with the fact that it is a tool that is here to stay to deliver patient care.
Treat your practice like a laboratory
Adoption may vary between practices depending on many factors, including clinicians’ comfort with technology, clinical tolerance and triage rules for nontouch encounters, state regulations, and more. Every provider group should begin experimenting with telemedicine in specific ways that make sense for them.
One physician may practice telemedicine full-time while the rest abstain, or perhaps the practice prefers to offer telemedicine services during specific hours on specific days. Don’t be afraid to start slowly when you’re trying something new – but do get started with telehealth. It will increasingly be a mainstream medium and more patients will come to expect it.
Train the entire team
Many primary care practices do not enjoy the resources of an information technology team, so all team members essentially need to learn the new skill of telemedicine usage, in addition to assisting patients. That can’t happen without staff buy-in, so it is essential that everyone from the office manager to medical assistants have the training they need to make the technology work. Juggling schedules for telehealth and in-office, activating an account through email, starting and joining a telehealth meeting, and preparing a patient for a visit are just a handful of basic tasks your staff should be trained to do to contribute to the successful integration of telehealth.
Educate and encourage patients to use telehealth
While unfamiliarity with technology may represent a roadblock for some patients, others resist telemedicine simply because no one has explained to them why it’s so important and the benefits it can hold for them. Education and communication are critical, including the sometimes painstaking work of slowly walking patients through the process of performing important functions on the telemedicine app. By providing them with some friendly coaching, patients won’t feel lost or abandoned during what for some may be an unfamiliar and frustrating process.
Manage more behavioral health
Different states and health plans incentivize primary practices for integrating behavioral health into their offerings. Rather than dismiss this addition to your own practice as too cumbersome to take on, I would recommend using telehealth to expand behavioral health care services.
If your practice is working toward a team-based, interdisciplinary approach to care delivery, behavioral health is a critical component. While other elements of this “whole person” health care may be better suited for an office visit, the vast majority of behavioral health services can be delivered virtually.
To decide if your patient may benefit from behavioral health care, the primary care provider (PCP) can conduct a screening via telehealth. Once the screening is complete, the PCP can discuss results and refer the patient to a mental health professional – all via telehealth. While patients may be reluctant to receive behavioral health treatment, perhaps because of stigma or inexperience, they may appreciate the telemedicine option as they can remain in the comfort and familiarity of their homes.
Collaborative Care is both an in-person and virtual model that allows PCP practices to offer behavioral health services in a cost effective way by utilizing a psychiatrist as a “consultant” to the practice as opposed to hiring a full-time psychiatrist. All services within the Collaborative Care Model can be offered via telehealth, and all major insurance providers reimburse primary care providers for delivering Collaborative Care.
When PCPs provide behavioral health treatment as an “extension” of the primary care service offerings, the stigma is reduced and more patients are willing to accept the care they need.
Many areas of the country suffer from a lack of access to behavioral health specialists. In rural counties, for example, the nearest therapist may be located over an hour away. By integrating behavioral telehealth services into your practice’s offerings, you can remove geographic and transportation obstacles to care for your patient population.
Doing this can lead to providing more culturally competent care. It’s important that you’re able to offer mental health services to your patients from a professional with a similar ethnic or racial background. Language barriers and cultural differences may limit a provider’s ability to treat a patient, particularly if the patient faces health disparities related to race or ethnicity. If your practice needs to look outside of your community to tap into a more diverse pool of providers to better meet your patients’ needs, telehealth makes it easier to do that.
Adopting telemedicine for consultative patient visits offers primary care a path toward restoring patient volume and hope for a postpandemic future.
Mark Stephan, MD, is chief medical officer at Equality Health, a whole-health delivery system. He practiced family medicine for 19 years, including hospital medicine and obstetrics in rural and urban settings. Dr. Stephan has no conflicts related to the content of this piece.
Shielding ‘had little effect on rates of COVID-19 in rheumatology patients’
Researchers from the Royal Wolverhampton (England) Hospitals National Health Service Trust say shielding – or taking extra steps to protect oneself against COVID-19 if at high risk – has had little effect on the incidence of COVID-19 in rheumatology patients.
In Annals of the Rheumatic Diseases, the team present data from a large rheumatology cohort in the United Kingdom between Feb. 1, 2020, and May 1, 2020. Patients’ health-related quality of life (HRQoL) was assessed on April 24, 2020, using the Short Form–12 to assess Physical Component Score (PCS) and Mental Component Score (MCS) on a 0-100 scale (0 being the lowest score).
Of 1,693 participants, at the time, there were 61 (3.6%) reported COVID-19 infections (eight had confirmatory swab results; three had clinical diagnoses with “false-negative” swab; 50 had clinical diagnosis but were not swabbed in line with U.K. policy at that time).
Seven of the 61 (11.5%) patients were hospitalized, two requiring intensive care. Of this group, 24 were shielding, a similar proportion to the non-COVID cohort (24/61 vs. 768/1,632; P = .24). There was no significant effect of treatment on self-reported COVID-19 incidence.
There were significantly lower MCSs in the infected group, compared with control participants (38.9 vs. 42.2; mean difference: −3.3; 95% CI, −5.2 to 1.4; P < .001). There was no difference in PCS (−0.4; 95% CI, −2.1 to 1.3).
In patients without COVID-19, the ‘shielding’ group had significantly lower MCS (−2.1; 95% CI, −2.9 to 1.4; P < .001) and PCS (−2.2; 95% CI, −3.8 to 2.5; P < .001) than those not shielding.
There were no differences in MCSs between patients on non–biologic disease-modifying antirheumatic drugs and biologic DMARDs (0.6; 95% CI, 0.1-2.4).
The findings suggest that overall strict social isolation had little effect on the incidence of COVID-19 infection. Patients who had suffered from the virus had reduced mental but not physical HRQoL scores.
There was an adverse effect on both MCS and PCS reported by patients undergoing shielding,n compared with those not. This has also been shown in previous work from India.
This article originally appeared on Univadis, part of the Medscape Professional Network.
Researchers from the Royal Wolverhampton (England) Hospitals National Health Service Trust say shielding – or taking extra steps to protect oneself against COVID-19 if at high risk – has had little effect on the incidence of COVID-19 in rheumatology patients.
In Annals of the Rheumatic Diseases, the team present data from a large rheumatology cohort in the United Kingdom between Feb. 1, 2020, and May 1, 2020. Patients’ health-related quality of life (HRQoL) was assessed on April 24, 2020, using the Short Form–12 to assess Physical Component Score (PCS) and Mental Component Score (MCS) on a 0-100 scale (0 being the lowest score).
Of 1,693 participants, at the time, there were 61 (3.6%) reported COVID-19 infections (eight had confirmatory swab results; three had clinical diagnoses with “false-negative” swab; 50 had clinical diagnosis but were not swabbed in line with U.K. policy at that time).
Seven of the 61 (11.5%) patients were hospitalized, two requiring intensive care. Of this group, 24 were shielding, a similar proportion to the non-COVID cohort (24/61 vs. 768/1,632; P = .24). There was no significant effect of treatment on self-reported COVID-19 incidence.
There were significantly lower MCSs in the infected group, compared with control participants (38.9 vs. 42.2; mean difference: −3.3; 95% CI, −5.2 to 1.4; P < .001). There was no difference in PCS (−0.4; 95% CI, −2.1 to 1.3).
In patients without COVID-19, the ‘shielding’ group had significantly lower MCS (−2.1; 95% CI, −2.9 to 1.4; P < .001) and PCS (−2.2; 95% CI, −3.8 to 2.5; P < .001) than those not shielding.
There were no differences in MCSs between patients on non–biologic disease-modifying antirheumatic drugs and biologic DMARDs (0.6; 95% CI, 0.1-2.4).
The findings suggest that overall strict social isolation had little effect on the incidence of COVID-19 infection. Patients who had suffered from the virus had reduced mental but not physical HRQoL scores.
There was an adverse effect on both MCS and PCS reported by patients undergoing shielding,n compared with those not. This has also been shown in previous work from India.
This article originally appeared on Univadis, part of the Medscape Professional Network.
Researchers from the Royal Wolverhampton (England) Hospitals National Health Service Trust say shielding – or taking extra steps to protect oneself against COVID-19 if at high risk – has had little effect on the incidence of COVID-19 in rheumatology patients.
In Annals of the Rheumatic Diseases, the team present data from a large rheumatology cohort in the United Kingdom between Feb. 1, 2020, and May 1, 2020. Patients’ health-related quality of life (HRQoL) was assessed on April 24, 2020, using the Short Form–12 to assess Physical Component Score (PCS) and Mental Component Score (MCS) on a 0-100 scale (0 being the lowest score).
Of 1,693 participants, at the time, there were 61 (3.6%) reported COVID-19 infections (eight had confirmatory swab results; three had clinical diagnoses with “false-negative” swab; 50 had clinical diagnosis but were not swabbed in line with U.K. policy at that time).
Seven of the 61 (11.5%) patients were hospitalized, two requiring intensive care. Of this group, 24 were shielding, a similar proportion to the non-COVID cohort (24/61 vs. 768/1,632; P = .24). There was no significant effect of treatment on self-reported COVID-19 incidence.
There were significantly lower MCSs in the infected group, compared with control participants (38.9 vs. 42.2; mean difference: −3.3; 95% CI, −5.2 to 1.4; P < .001). There was no difference in PCS (−0.4; 95% CI, −2.1 to 1.3).
In patients without COVID-19, the ‘shielding’ group had significantly lower MCS (−2.1; 95% CI, −2.9 to 1.4; P < .001) and PCS (−2.2; 95% CI, −3.8 to 2.5; P < .001) than those not shielding.
There were no differences in MCSs between patients on non–biologic disease-modifying antirheumatic drugs and biologic DMARDs (0.6; 95% CI, 0.1-2.4).
The findings suggest that overall strict social isolation had little effect on the incidence of COVID-19 infection. Patients who had suffered from the virus had reduced mental but not physical HRQoL scores.
There was an adverse effect on both MCS and PCS reported by patients undergoing shielding,n compared with those not. This has also been shown in previous work from India.
This article originally appeared on Univadis, part of the Medscape Professional Network.
Guidance covers glycemia in dexamethasone-treated COVID-19 patients
New guidance from the U.K. National Diabetes COVID-19 Response Group addresses glucose management in patients with COVID-19 who are receiving dexamethasone therapy.
Although there are already guidelines that address inpatient management of steroid-induced hyperglycemia, the authors of the new document wrote that this new expert opinion paper was needed “given the ‘triple insult’ of dexamethasone-induced–impaired glucose metabolism, COVID-19–induced insulin resistance, and COVID-19–impaired insulin production.”
RECOVERY trial spurs response
The document, which is the latest in a series from the Association of British Clinical Diabetologists, was published online Aug. 2 in Diabetic Medicine. The group is chaired by Gerry Rayman, MD, consultant physician at the diabetes centre and diabetes research unit, East Suffolk (England) and North East NHS Foundation Trust.
The guidance was developed in response to the recent “breakthrough” Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial, which showed that dexamethasone reduced deaths in patients with COVID-19 on ventilators or receiving oxygen therapy. The advice is not intended for critical care units but can be adapted for that use.
The dose used in RECOVERY – 6 mg daily for 10 days – is 400%-500% greater than the therapeutic glucocorticoid replacement dose. High glucocorticoid doses can exacerbate hyperglycemia in people with established diabetes, unmask undiagnosed diabetes, precipitate hyperglycemia or new-onset diabetes, and can also cause hyperglycemic hyperosmolar state (HHS), the authors explained.
They recommended a target glucose of 6.0-10.0 mmol/L (108-180 mg/dL), although they say up to 12 mmol/L (216 mg/dL) is “acceptable.” They then gave advice on frequency of monitoring for people with and without known diabetes, exclusion of diabetic ketoacidosis and HHS, correction of initial hyperglycemia and maintenance of glycemic control using subcutaneous insulin, and prevention of hypoglycemia at the end of dexamethasone therapy (day 10) with insulin down-titration, discharge, and follow-up.
The detailed insulin guidance covers dose escalation for both insulin-treated and insulin-naive patients. A table suggests increasing correction doses of rapid-acting insulin based on prior total daily dose or weight.
Use of once- or twice-daily NPH insulin is recommended for patients whose glucose has risen above 12 mmol/L, in some cases with the addition of a long-acting analog. A second chart gives dose adjustments for those insulins. Additional guidance addresses patients on insulin pumps.
Guidance useful for U.S. physicians
Francisco Pasquel, MD, assistant professor of medicine in the division of endocrinology at Emory University, Atlanta, said in an interview that he believes the guidance is “acceptable” for worldwide use, and that “it’s coherent and consistent with what we typically do.”
However, Dr. Pasquel, who founded COVID-in-Diabetes, an online repository of published guidance and shared experience – to which this new document has now been added – did take issue with one piece of advice. The guidance says that patients already taking premixed insulin formulations can continue using them while increasing the dose by 20%-40%. Given the risk of hypoglycemia associated with those formulations, Dr. Pasquel said he would switch those patients to NPH during the time that they’re on dexamethasone.
He also noted that the rapid-acting insulin dose range of 2-10 units provided in the first table, for correction of initial hyperglycemia, are more conservative than those used at his hospital, where correction doses of up to 14-16 units are sometimes necessary.
But Dr. Pasquel praised the group’s overall efforts since the pandemic began, noting that “they’re very organized and constantly updating their recommendations. They have a unified system in the [National Health Service], so it’s easier to standardize. They have a unique [electronic health record] which is far superior to what we do from a public health perspective.”
Dr. Rayman reported no relevant financial relationships. Dr. Pasquel reported receiving research funding from Dexcom, Merck, and the National Institutes of Health, and consulting for AstraZeneca, Eli Lilly, Merck, and Boehringer Ingelheim.
A version of this article originally appeared on Medscape.com.
New guidance from the U.K. National Diabetes COVID-19 Response Group addresses glucose management in patients with COVID-19 who are receiving dexamethasone therapy.
Although there are already guidelines that address inpatient management of steroid-induced hyperglycemia, the authors of the new document wrote that this new expert opinion paper was needed “given the ‘triple insult’ of dexamethasone-induced–impaired glucose metabolism, COVID-19–induced insulin resistance, and COVID-19–impaired insulin production.”
RECOVERY trial spurs response
The document, which is the latest in a series from the Association of British Clinical Diabetologists, was published online Aug. 2 in Diabetic Medicine. The group is chaired by Gerry Rayman, MD, consultant physician at the diabetes centre and diabetes research unit, East Suffolk (England) and North East NHS Foundation Trust.
The guidance was developed in response to the recent “breakthrough” Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial, which showed that dexamethasone reduced deaths in patients with COVID-19 on ventilators or receiving oxygen therapy. The advice is not intended for critical care units but can be adapted for that use.
The dose used in RECOVERY – 6 mg daily for 10 days – is 400%-500% greater than the therapeutic glucocorticoid replacement dose. High glucocorticoid doses can exacerbate hyperglycemia in people with established diabetes, unmask undiagnosed diabetes, precipitate hyperglycemia or new-onset diabetes, and can also cause hyperglycemic hyperosmolar state (HHS), the authors explained.
They recommended a target glucose of 6.0-10.0 mmol/L (108-180 mg/dL), although they say up to 12 mmol/L (216 mg/dL) is “acceptable.” They then gave advice on frequency of monitoring for people with and without known diabetes, exclusion of diabetic ketoacidosis and HHS, correction of initial hyperglycemia and maintenance of glycemic control using subcutaneous insulin, and prevention of hypoglycemia at the end of dexamethasone therapy (day 10) with insulin down-titration, discharge, and follow-up.
The detailed insulin guidance covers dose escalation for both insulin-treated and insulin-naive patients. A table suggests increasing correction doses of rapid-acting insulin based on prior total daily dose or weight.
Use of once- or twice-daily NPH insulin is recommended for patients whose glucose has risen above 12 mmol/L, in some cases with the addition of a long-acting analog. A second chart gives dose adjustments for those insulins. Additional guidance addresses patients on insulin pumps.
Guidance useful for U.S. physicians
Francisco Pasquel, MD, assistant professor of medicine in the division of endocrinology at Emory University, Atlanta, said in an interview that he believes the guidance is “acceptable” for worldwide use, and that “it’s coherent and consistent with what we typically do.”
However, Dr. Pasquel, who founded COVID-in-Diabetes, an online repository of published guidance and shared experience – to which this new document has now been added – did take issue with one piece of advice. The guidance says that patients already taking premixed insulin formulations can continue using them while increasing the dose by 20%-40%. Given the risk of hypoglycemia associated with those formulations, Dr. Pasquel said he would switch those patients to NPH during the time that they’re on dexamethasone.
He also noted that the rapid-acting insulin dose range of 2-10 units provided in the first table, for correction of initial hyperglycemia, are more conservative than those used at his hospital, where correction doses of up to 14-16 units are sometimes necessary.
But Dr. Pasquel praised the group’s overall efforts since the pandemic began, noting that “they’re very organized and constantly updating their recommendations. They have a unified system in the [National Health Service], so it’s easier to standardize. They have a unique [electronic health record] which is far superior to what we do from a public health perspective.”
Dr. Rayman reported no relevant financial relationships. Dr. Pasquel reported receiving research funding from Dexcom, Merck, and the National Institutes of Health, and consulting for AstraZeneca, Eli Lilly, Merck, and Boehringer Ingelheim.
A version of this article originally appeared on Medscape.com.
New guidance from the U.K. National Diabetes COVID-19 Response Group addresses glucose management in patients with COVID-19 who are receiving dexamethasone therapy.
Although there are already guidelines that address inpatient management of steroid-induced hyperglycemia, the authors of the new document wrote that this new expert opinion paper was needed “given the ‘triple insult’ of dexamethasone-induced–impaired glucose metabolism, COVID-19–induced insulin resistance, and COVID-19–impaired insulin production.”
RECOVERY trial spurs response
The document, which is the latest in a series from the Association of British Clinical Diabetologists, was published online Aug. 2 in Diabetic Medicine. The group is chaired by Gerry Rayman, MD, consultant physician at the diabetes centre and diabetes research unit, East Suffolk (England) and North East NHS Foundation Trust.
The guidance was developed in response to the recent “breakthrough” Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial, which showed that dexamethasone reduced deaths in patients with COVID-19 on ventilators or receiving oxygen therapy. The advice is not intended for critical care units but can be adapted for that use.
The dose used in RECOVERY – 6 mg daily for 10 days – is 400%-500% greater than the therapeutic glucocorticoid replacement dose. High glucocorticoid doses can exacerbate hyperglycemia in people with established diabetes, unmask undiagnosed diabetes, precipitate hyperglycemia or new-onset diabetes, and can also cause hyperglycemic hyperosmolar state (HHS), the authors explained.
They recommended a target glucose of 6.0-10.0 mmol/L (108-180 mg/dL), although they say up to 12 mmol/L (216 mg/dL) is “acceptable.” They then gave advice on frequency of monitoring for people with and without known diabetes, exclusion of diabetic ketoacidosis and HHS, correction of initial hyperglycemia and maintenance of glycemic control using subcutaneous insulin, and prevention of hypoglycemia at the end of dexamethasone therapy (day 10) with insulin down-titration, discharge, and follow-up.
The detailed insulin guidance covers dose escalation for both insulin-treated and insulin-naive patients. A table suggests increasing correction doses of rapid-acting insulin based on prior total daily dose or weight.
Use of once- or twice-daily NPH insulin is recommended for patients whose glucose has risen above 12 mmol/L, in some cases with the addition of a long-acting analog. A second chart gives dose adjustments for those insulins. Additional guidance addresses patients on insulin pumps.
Guidance useful for U.S. physicians
Francisco Pasquel, MD, assistant professor of medicine in the division of endocrinology at Emory University, Atlanta, said in an interview that he believes the guidance is “acceptable” for worldwide use, and that “it’s coherent and consistent with what we typically do.”
However, Dr. Pasquel, who founded COVID-in-Diabetes, an online repository of published guidance and shared experience – to which this new document has now been added – did take issue with one piece of advice. The guidance says that patients already taking premixed insulin formulations can continue using them while increasing the dose by 20%-40%. Given the risk of hypoglycemia associated with those formulations, Dr. Pasquel said he would switch those patients to NPH during the time that they’re on dexamethasone.
He also noted that the rapid-acting insulin dose range of 2-10 units provided in the first table, for correction of initial hyperglycemia, are more conservative than those used at his hospital, where correction doses of up to 14-16 units are sometimes necessary.
But Dr. Pasquel praised the group’s overall efforts since the pandemic began, noting that “they’re very organized and constantly updating their recommendations. They have a unified system in the [National Health Service], so it’s easier to standardize. They have a unique [electronic health record] which is far superior to what we do from a public health perspective.”
Dr. Rayman reported no relevant financial relationships. Dr. Pasquel reported receiving research funding from Dexcom, Merck, and the National Institutes of Health, and consulting for AstraZeneca, Eli Lilly, Merck, and Boehringer Ingelheim.
A version of this article originally appeared on Medscape.com.
Children’s doctors in the world of adults
Pediatric hospitalists venture into COVID-19 adult care
The memories I have from the few nights spent in the adult pop-up cardiac intensive care unit are pouring in as I sit down to tell this story. I am a pediatric hospitalist at Columbia University NewYork-Presbyterian Morgan Stanley Children’s Hospital. I usually take care of sick, hospitalized children. However, in these extraordinary times, I have joined an army of colleagues taking care of adult patients with COVID-19.
Almost all these patients had tracheostomies connected to ventilators, as well as acute-on-chronic cardiac issues. They were often delirious and unable to speak, and always alone. I was happy to help our adult colleagues, but I was also afraid. I was scared to make a mistake that could be detrimental to my patient, even though I knew well that ICU residents, fellows, and attendings were just a phone call away.
I felt like Alice in Wonderland, initially too small compared with her environment, and the next minute hunched, giant, and still clearly displaced. Except I was not dreaming or watching a movie. There was no white rabbit to chase. The situation was serious and emotionally challenging. I imagined that each patient was the dearest member of my family: my mother, my father, my aunt or uncle. I took pleasure in sharing smiles while asking the patients how they were feeling, and I touched their hands, even though much of my face was covered and there were gloves on my hands.
The year 2020 has been surreal. People have had to find their own way of pushing through the unknown and unexpected. For a start, I would never in a million years have imagined using phrases like pop-up ICU.1 I was signing an admission note for a 90-year-old lady with acute-on-chronic congestive heart failure and acute respiratory hypoxemic failure and there, at the bottom of the note, was my name, followed by an odd remark: “pediatric hospital medicine.” That is what happened in New York City in 2020: Many unexpected events took place.
This article represents a virtual conversation with three other pediatric hospitalists who, under different sets of circumstances, did the same thing: took care of adult patients. I hope that the answers to the questions I asked make you pause, reflect, and learn from the experiences described.
Would you describe the usual environment where you practice pediatric hospital medicine?
Julie Dunbar, MD: I am a full-time pediatric hospitalist at the Children’s Hospital at Montefiore, a tertiary care academic children’s hospital in the Bronx. A typical day on service involves staffing up to 14 patients, up to 21 years old, on a teaching service with residents and physician assistants. We normally staff the hospital in two shifts – day and evening – until 11:00 at night. We are situated at the heart of a medically underserved area, and our hospital system cares for about one-third of the total population of the Bronx.
L. Nell Hodo, MD: I work at Kravis Children’s Hospital at the Mount Sinai Hospital, in Manhattan at the juncture of the Upper East Side and Harlem. Our usual hospital medicine environment is the general ward/floor in a nested children’s hospital within an adult hospital. We have about 32 non-ICU beds, and the patients are managed by a combination of hospitalists, general pediatricians, and specialist attendings. All patients are on resident teams. We have a comanagement model in which the primary attending for surgical patients is always a pediatric attending (hospitalist or specialist).
Avital M. Fischer, MD: NewYork-Presbyterian Morgan Stanley Children’s Hospital is a quaternary care center – where children from the area receive subspecialty care – as well as, functionally, a community hospital for the Washington Heights area. Therefore, we always have an interesting mix of general pediatric inpatient medicine including patients with complex medical conditions, rare diseases, postoperative conditions, and undiagnosed illnesses on our wards. We are a children’s hospital, connected to a larger adult hospital system. Pediatric hospitalists cover two pediatric wards, team-staffed by residents, and a progressive care unit, staffed by nurse practitioners. There is usually evening coverage until 11 p.m.
How did this change when New York became the U.S. epicenter of the SARS-CoV-2 pandemic? Was the transition to taking care of adult patients gradual or sudden? Were you deployed to a different hospital or part of the hospital? How prepared did you feel?
Dr. Dunbar: We experienced the COVID-19 pandemic like much of the rest of New York City – it started as a slow and uncertain process, and then it hit us all at once. In initial conversations, like everyone else, we did not know exactly what was coming. We started with small changes like working from home on nonclinical days and canceling family-centered rounds to conserve personal protective equipment (PPE). In mid-March, we were still expecting that redeployment to adult floors was a highly unlikely scenario. We made work-from-home schedules and planned projects we would work on while social distancing. We planned journal clubs about emerging evidence on COVID-19. However, things happened fast, and many of these plans were scrapped.
On Saturday, March 28, we closed the main floor of the children’s hospital because so few pediatric patients were being admitted. Two days later, we admitted our first cohort of adult COVID-19 patients, all more than 30 years old. They were transferred en masse from an outside hospital emergency department that desperately needed our beds. They arrived all at once, and they all required respiratory support. At the last hospitalist division meeting before the adults arrived, we had time for only one priority set of information, and so we chose end-of-life care. We reviewed scripts for advance care planning and logistics of death certificates. As fast as things changed for us, they changed even faster for the patients. Most were relatively healthy people who rather suddenly found themselves isolated, on oxygen, dictating their final wishes to pediatricians in full protective gear. Many, many patients got better, and of course, several spent their last moments with us. One physician assistant, who works closely with the hospitalists, spent the last 5 hours of an elderly patient’s life holding her hand and helping her FaceTime with family.
For the most part, the patients came to us. We worked with our own colleagues and our own nurses, on our own territory. A few of my colleagues were briefly redeployed to a series of conference rooms that were used for several weeks as overflow space for more stable COVID-19 patients. Staffing by the pediatrics teams was so robust, with willing volunteers from every corner of the children’s hospital, that we were not needed for long.
During the early days, there was no clinical pathway to follow to care for COVID-19 patients – it didn’t exist for this novel and variable disease. We created a platform to share documents and resources in real time as they became available to us. We used group texts and emails to learn from our experiences and encourage one another. Importantly, no one was afraid to ask for help, and we relied on our adult colleagues when patients started to decompensate. Adult critical care came to our aid for all rapid responses for patients older than 30. Pediatric critical care, in their infinite flexibility, was responsible for anyone younger.
Dr. Hodo: We had a variety of changes. The first thing was the deployment of many of our attendings (hospital medicine, ICU, outpatient, and subspecialists) and residents to the adult side to work on medical COVID-19 units or in the many ICUs (some new “pop-up” units in former medical units, postanesthesia care units, and so on).2 On the adult floor we had “COVID teams,” which had an attending and two frontline providers; one of these three people was an internal medicine faculty member or resident. Residents from other specialties (emergency medicine, family medicine) were pulled off pediatric assignments in pediatric wards, PICUs, and EDs, so pediatric residents not originally assigned to inpatient rotations were sent to cover these core pediatric areas. The remaining pediatric faculty backfilled the pediatric services – so the remaining ICU docs did more shifts to cover ICU; the undeployed specialists took more inpatient service or clinic time, and so on. Outpatient pediatrics covered the inpatient pediatric service for the 3 weeks when most of the hospitalists were deployed.
We had one pediatric unit, which was a unit with equipment that made it capable of having ICU patients or floor patients, that was designated a COVID-19 unit. Most COVID-19 patients were there. Some were also in negative-pressure rooms on other floors or in the unit directly above the COVID-19 unit. Some adult patients came to the unit in the pediatric hospital but not as many as initially expected, and most were young adults in their 20s. So rather than adult patients coming to pediatrics, our experience was more that pediatricians went to the adult side.
The transition to adult care for physicians was variable in its suddenness. Most people had at least 48 hours’ notice, whereas some had as much as a week. Most of our department members deployed within the hospital complex of which we are a part, though a few went to other sites in the health system. Some were deployed into administrative or support roles in the system, rather than patient-facing roles. I felt, I would say, reasonably prepared. I trained in family medicine, though I have been exclusively in pediatrics for the past 7 years. I felt rusty, for sure, but perhaps not quite as out of my element as others. In preparation, I read a lot about COVID, reviewed some adult medicine topics provided by the medicine department, used the resources on the Pediatric Overflow Planning Contingency Response Network (POPCoRN), including an Advanced Cardiac Life Support review, and was able to shadow on a COVID-19 unit before I actually started – that was incredibly helpful. I also had the opportunity to speak about that shadowing experience in a department meeting, which I hope was helpful for others.
Dr. Fischer: Our whole focus for a relatively short time shifted to how to take care of adults within the children’s hospital. Although we had some time to prepare – the ICU was the first unit to take adults, so we knew they would come to the floor – it still felt quick. We took adult patients onto the general pediatrics floor from both the emergency department and the ICU. We took adults mostly with COVID-19, but we did have some young adults admitted for other reasons too. Those of us who were on service during this time collaborated closely, sharing what we learned and even joining one another on rounds to provide support. We basically would “teach it forward” as we learned. We also had adult providers available by phone for questions, and our pediatric subspecialists were readily available for consults and would reach out to their adult counterparts for support. Some of the hospitalists were reaching out to POPCoRN, and some were attending an ACLS crash course prior to getting on service.
What was hardest about this experience for you?
Dr. Dunbar: For me, one of the hardest aspects of dealing with COVID-19 was the unknown. In every aspect of professional life and clinical care, there were unanswered questions. What’s the best way to care for these patients? What prognoses can we give their loved ones? How can I help when it seems like there’s so little I can offer? Will we run out of PPE? As doctors, what behaviors most endanger our friends and family when we go home after work? When will things start to get better?
Dr. Hodo: For me, the week or two before being notified of the deployment was the worst and hardest time. The uncertainty about if I would be called or no, and to do what? And where? I was trying to read everything there was on management, what little was known about treatment, and so on. Once I received notification of a start date, that allowed me to focus on very clear endpoints and knowledge items (for example, reviewing ACLS algorithms) and to do things I knew would help me settle and be more effective (like shadowing).
Dr. Fischer: It was a lot of new. Not only were we taking care of a population that we hadn’t cared for since medical school (adults), but we were facing a disease process that was also new to everyone. We were learning on our feet, while at the same time providing guidance to our house staff.
What have you learned about yourself that you did not know before?
Dr. Dunbar: I was surprised to learn how much I liked caring for adult patients. The fear I felt immediately before they arrived dissipated fairly quickly after they arrived. The opportunity to address their chronic conditions while supporting them in an acute illness took me back to many of the fundamentals of medicine that I hadn’t thought much about since medical school. I liked that they could speak up to tell us how they were feeling, both physically and emotionally, so that we could address their needs and allow them to participate in their own care. Some of my favorite patients kept detailed histories of their own C-reactive protein values and oxygen levels to show they were active participants in their own recovery.
I was worried that these adult patients would be offended or scared to learn that they were being cared for by pediatricians, but at no point did anyone ask me why they were not assigned to an adult hospitalist. They saw us only as doctors and nurses, and they were grateful for our care. One 65-year-old U.S. Army veteran told me that his nurse had told him to take a shower and make his bed. “She treated me just like a 5-year-old kid. And I loved it!” he said.
Dr. Hodo: I don’t know that I was totally unaware of these things, but I will say that I had partially forgotten them: I really like adult medicine, and I love geriatrics. I like high-energy and high-stress situations … at least occasionally! I feel very comfortable discussing end-of-life decisions and death. I cope with personal stress by helping and supporting others – patients, team members, colleagues, neighbors. I risk not taking enough time for myself and have to remind myself to do so.
Dr. Fischer: I actually loved taking care of adults. It felt like there was a different kind of patient-doctor relationship to be had, and it was interesting to get to know people who had jobs and families of their own – essentially a different type of story than you typically hear taking care of children.
Were there any silver linings in this situation? How did you grow personally through this experience? What do we need to do better going forward as a profession and a community?
Dr. Dunbar: The part that I hope will stay with me is the memory of how we came together as clinicians to fight a common invisible enemy. The teamwork was unprecedented. Our day-to-day goals were simple and straightforward: do what needed to be done to help as many New Yorkers as possible. Our team made themselves available for last-minute meetings and shift changes without complaint. We practiced a type of medicine that prioritized patient comfort, flexibility, and compassionate care. We ordered methadone and insulin and antihypertensives – brand new experiences for us, but we figured it out. We worked through novel clinical problems together because there was no textbook to read.
Our colleagues from other specialties and different levels of experience stepped up to join us on overnight shifts, and we welcomed them. With the help of an ad hoc palliative care team, we improved how we listened to patients’ own self-directed needs. We reached across the aisle to our internal medicine and adult hospitalist colleagues to refresh our memories on chronic conditions, and they always answered the phone. I hope we always remember who we were during this crisis, because we were ourselves at our most generous.
Dr. Hodo: This was an unexpected but great opportunity to meet physicians, nurses, and staff in different departments and sections of the hospital from my own. I am hopeful that this experience will help us in the future with multidisciplinary work and breaking down silos that isolate specialties and units in the hospital.
I feel (and this is probably weird) invigorated by this experience. It feels good to have been able to help when I was needed. Even though there are a lot of things in adult hospital medicine I do not know, I know I did my best, asked for help when I needed it, and asked for feedback regularly from the medicine residents and nurses I worked with. I know I supported my team and my colleagues to the best of my ability through stressful and sometimes upsetting and emotionally draining times.
As a profession, we can continue to remember the value of the multidisciplinary team and the value of listening to, and making space for, different voices to be heard. We can reconsider the traditional, rigid hierarchy in medicine and medical education that can stifle creative thought and innovative ideas. We can remember that the people “at the top” of the pyramid can always learn something from those “at the bottom.” We can see the ways that department and discipline and specialty can help us but also sometimes hinder, and seek involvement in programs and discussions that unite and pool resources and skills. And, most of all, we can try, every day we are at work, to put the patients’ and families’ needs first – and when we leave work, to turn that around, and put ourselves and our loved ones in that prime position.
As a community, we also can work on thinking communally – that, after all, is the entire point of the wearing of masks in public and social distancing. It is as much about you as about me! We can try to hold on to some of this perspective of the greater good and appreciation for the work others do that makes our lives better and easier. It is not only health care workers who deserve a round of applause every day; it is every person who did something today that benefited someone else, be that giving extra space in a line, wearing a mask in a store, delivering food to an elder, teaching a class over Zoom, or simply minimizing time outside the house. It is every person who thought about the community at or near the same level of priority that they thought about themselves.
Dr. Fischer: It was a very challenging situation, but because our adult patients in the children’s hospital were relatively young with fewer comorbidities, we got to see people get well. I took care of one man with renal failure who we thought would be on dialysis for the rest of his life. By the end of my first week on service, he had begun to regain kidney function. It was amazing. I think most frontline providers caring for adults in this pandemic have had to face significant morbidity and mortality. I felt lucky that we were able to care for patients who generally got better.
I recently read the article published in the Journal of Pediatrics laying out how the Children’s Hospital at Montefiore adapted an entire pediatric floor to caring for adults.3 This example of recognition of need, quick preparation, and collaboration both within the children’s hospital and with the adult hospital was admirable. I also feel that at the beginning of this pandemic, there was a glimmer that the failure of our health care system to cover everyone and the repercussions of this failure would be drawn into sharp relief. I hope that this understanding of the importance of universal coverage persists beyond the pandemic.
Dr. Giordano is assistant professor of pediatrics at Columbia University and a pediatric hospitalist at NewYork-Presbyterian Morgan Stanley Children’s Hospital with an interest in surgical comanagement. She serves on the Society of Hospital Medicine’s Pediatric Special Interest Group Executive Committee and is the chair of the Education Subcommittee. She is also an advisory board member for the New York/Westchester SHM Chapter.
References
1. Kumaraiah D et al. Innovative ICU physician care models: Covid-19 pandemic at NewYork-Presbyterian. NEJM Catal. 2020 Apr 28. doi: 10.1056/CAT.20.0158.
2. Kim MK et al. A primer for clinician deployment to the medicine floors from an epicenter of Covid-19. NEJM Catal. 2020 May 4. doi: 10.1056/CAT.20.0180.
3. Philips K, et al. Rapid Implementation of an Adult COVID-19 Unit in a Children’s Hospital. J Pediatr. 2020. doi: 10.1016/j.jpeds.2020.04.060.
Pediatric hospitalists venture into COVID-19 adult care
Pediatric hospitalists venture into COVID-19 adult care
The memories I have from the few nights spent in the adult pop-up cardiac intensive care unit are pouring in as I sit down to tell this story. I am a pediatric hospitalist at Columbia University NewYork-Presbyterian Morgan Stanley Children’s Hospital. I usually take care of sick, hospitalized children. However, in these extraordinary times, I have joined an army of colleagues taking care of adult patients with COVID-19.
Almost all these patients had tracheostomies connected to ventilators, as well as acute-on-chronic cardiac issues. They were often delirious and unable to speak, and always alone. I was happy to help our adult colleagues, but I was also afraid. I was scared to make a mistake that could be detrimental to my patient, even though I knew well that ICU residents, fellows, and attendings were just a phone call away.
I felt like Alice in Wonderland, initially too small compared with her environment, and the next minute hunched, giant, and still clearly displaced. Except I was not dreaming or watching a movie. There was no white rabbit to chase. The situation was serious and emotionally challenging. I imagined that each patient was the dearest member of my family: my mother, my father, my aunt or uncle. I took pleasure in sharing smiles while asking the patients how they were feeling, and I touched their hands, even though much of my face was covered and there were gloves on my hands.
The year 2020 has been surreal. People have had to find their own way of pushing through the unknown and unexpected. For a start, I would never in a million years have imagined using phrases like pop-up ICU.1 I was signing an admission note for a 90-year-old lady with acute-on-chronic congestive heart failure and acute respiratory hypoxemic failure and there, at the bottom of the note, was my name, followed by an odd remark: “pediatric hospital medicine.” That is what happened in New York City in 2020: Many unexpected events took place.
This article represents a virtual conversation with three other pediatric hospitalists who, under different sets of circumstances, did the same thing: took care of adult patients. I hope that the answers to the questions I asked make you pause, reflect, and learn from the experiences described.
Would you describe the usual environment where you practice pediatric hospital medicine?
Julie Dunbar, MD: I am a full-time pediatric hospitalist at the Children’s Hospital at Montefiore, a tertiary care academic children’s hospital in the Bronx. A typical day on service involves staffing up to 14 patients, up to 21 years old, on a teaching service with residents and physician assistants. We normally staff the hospital in two shifts – day and evening – until 11:00 at night. We are situated at the heart of a medically underserved area, and our hospital system cares for about one-third of the total population of the Bronx.
L. Nell Hodo, MD: I work at Kravis Children’s Hospital at the Mount Sinai Hospital, in Manhattan at the juncture of the Upper East Side and Harlem. Our usual hospital medicine environment is the general ward/floor in a nested children’s hospital within an adult hospital. We have about 32 non-ICU beds, and the patients are managed by a combination of hospitalists, general pediatricians, and specialist attendings. All patients are on resident teams. We have a comanagement model in which the primary attending for surgical patients is always a pediatric attending (hospitalist or specialist).
Avital M. Fischer, MD: NewYork-Presbyterian Morgan Stanley Children’s Hospital is a quaternary care center – where children from the area receive subspecialty care – as well as, functionally, a community hospital for the Washington Heights area. Therefore, we always have an interesting mix of general pediatric inpatient medicine including patients with complex medical conditions, rare diseases, postoperative conditions, and undiagnosed illnesses on our wards. We are a children’s hospital, connected to a larger adult hospital system. Pediatric hospitalists cover two pediatric wards, team-staffed by residents, and a progressive care unit, staffed by nurse practitioners. There is usually evening coverage until 11 p.m.
How did this change when New York became the U.S. epicenter of the SARS-CoV-2 pandemic? Was the transition to taking care of adult patients gradual or sudden? Were you deployed to a different hospital or part of the hospital? How prepared did you feel?
Dr. Dunbar: We experienced the COVID-19 pandemic like much of the rest of New York City – it started as a slow and uncertain process, and then it hit us all at once. In initial conversations, like everyone else, we did not know exactly what was coming. We started with small changes like working from home on nonclinical days and canceling family-centered rounds to conserve personal protective equipment (PPE). In mid-March, we were still expecting that redeployment to adult floors was a highly unlikely scenario. We made work-from-home schedules and planned projects we would work on while social distancing. We planned journal clubs about emerging evidence on COVID-19. However, things happened fast, and many of these plans were scrapped.
On Saturday, March 28, we closed the main floor of the children’s hospital because so few pediatric patients were being admitted. Two days later, we admitted our first cohort of adult COVID-19 patients, all more than 30 years old. They were transferred en masse from an outside hospital emergency department that desperately needed our beds. They arrived all at once, and they all required respiratory support. At the last hospitalist division meeting before the adults arrived, we had time for only one priority set of information, and so we chose end-of-life care. We reviewed scripts for advance care planning and logistics of death certificates. As fast as things changed for us, they changed even faster for the patients. Most were relatively healthy people who rather suddenly found themselves isolated, on oxygen, dictating their final wishes to pediatricians in full protective gear. Many, many patients got better, and of course, several spent their last moments with us. One physician assistant, who works closely with the hospitalists, spent the last 5 hours of an elderly patient’s life holding her hand and helping her FaceTime with family.
For the most part, the patients came to us. We worked with our own colleagues and our own nurses, on our own territory. A few of my colleagues were briefly redeployed to a series of conference rooms that were used for several weeks as overflow space for more stable COVID-19 patients. Staffing by the pediatrics teams was so robust, with willing volunteers from every corner of the children’s hospital, that we were not needed for long.
During the early days, there was no clinical pathway to follow to care for COVID-19 patients – it didn’t exist for this novel and variable disease. We created a platform to share documents and resources in real time as they became available to us. We used group texts and emails to learn from our experiences and encourage one another. Importantly, no one was afraid to ask for help, and we relied on our adult colleagues when patients started to decompensate. Adult critical care came to our aid for all rapid responses for patients older than 30. Pediatric critical care, in their infinite flexibility, was responsible for anyone younger.
Dr. Hodo: We had a variety of changes. The first thing was the deployment of many of our attendings (hospital medicine, ICU, outpatient, and subspecialists) and residents to the adult side to work on medical COVID-19 units or in the many ICUs (some new “pop-up” units in former medical units, postanesthesia care units, and so on).2 On the adult floor we had “COVID teams,” which had an attending and two frontline providers; one of these three people was an internal medicine faculty member or resident. Residents from other specialties (emergency medicine, family medicine) were pulled off pediatric assignments in pediatric wards, PICUs, and EDs, so pediatric residents not originally assigned to inpatient rotations were sent to cover these core pediatric areas. The remaining pediatric faculty backfilled the pediatric services – so the remaining ICU docs did more shifts to cover ICU; the undeployed specialists took more inpatient service or clinic time, and so on. Outpatient pediatrics covered the inpatient pediatric service for the 3 weeks when most of the hospitalists were deployed.
We had one pediatric unit, which was a unit with equipment that made it capable of having ICU patients or floor patients, that was designated a COVID-19 unit. Most COVID-19 patients were there. Some were also in negative-pressure rooms on other floors or in the unit directly above the COVID-19 unit. Some adult patients came to the unit in the pediatric hospital but not as many as initially expected, and most were young adults in their 20s. So rather than adult patients coming to pediatrics, our experience was more that pediatricians went to the adult side.
The transition to adult care for physicians was variable in its suddenness. Most people had at least 48 hours’ notice, whereas some had as much as a week. Most of our department members deployed within the hospital complex of which we are a part, though a few went to other sites in the health system. Some were deployed into administrative or support roles in the system, rather than patient-facing roles. I felt, I would say, reasonably prepared. I trained in family medicine, though I have been exclusively in pediatrics for the past 7 years. I felt rusty, for sure, but perhaps not quite as out of my element as others. In preparation, I read a lot about COVID, reviewed some adult medicine topics provided by the medicine department, used the resources on the Pediatric Overflow Planning Contingency Response Network (POPCoRN), including an Advanced Cardiac Life Support review, and was able to shadow on a COVID-19 unit before I actually started – that was incredibly helpful. I also had the opportunity to speak about that shadowing experience in a department meeting, which I hope was helpful for others.
Dr. Fischer: Our whole focus for a relatively short time shifted to how to take care of adults within the children’s hospital. Although we had some time to prepare – the ICU was the first unit to take adults, so we knew they would come to the floor – it still felt quick. We took adult patients onto the general pediatrics floor from both the emergency department and the ICU. We took adults mostly with COVID-19, but we did have some young adults admitted for other reasons too. Those of us who were on service during this time collaborated closely, sharing what we learned and even joining one another on rounds to provide support. We basically would “teach it forward” as we learned. We also had adult providers available by phone for questions, and our pediatric subspecialists were readily available for consults and would reach out to their adult counterparts for support. Some of the hospitalists were reaching out to POPCoRN, and some were attending an ACLS crash course prior to getting on service.
What was hardest about this experience for you?
Dr. Dunbar: For me, one of the hardest aspects of dealing with COVID-19 was the unknown. In every aspect of professional life and clinical care, there were unanswered questions. What’s the best way to care for these patients? What prognoses can we give their loved ones? How can I help when it seems like there’s so little I can offer? Will we run out of PPE? As doctors, what behaviors most endanger our friends and family when we go home after work? When will things start to get better?
Dr. Hodo: For me, the week or two before being notified of the deployment was the worst and hardest time. The uncertainty about if I would be called or no, and to do what? And where? I was trying to read everything there was on management, what little was known about treatment, and so on. Once I received notification of a start date, that allowed me to focus on very clear endpoints and knowledge items (for example, reviewing ACLS algorithms) and to do things I knew would help me settle and be more effective (like shadowing).
Dr. Fischer: It was a lot of new. Not only were we taking care of a population that we hadn’t cared for since medical school (adults), but we were facing a disease process that was also new to everyone. We were learning on our feet, while at the same time providing guidance to our house staff.
What have you learned about yourself that you did not know before?
Dr. Dunbar: I was surprised to learn how much I liked caring for adult patients. The fear I felt immediately before they arrived dissipated fairly quickly after they arrived. The opportunity to address their chronic conditions while supporting them in an acute illness took me back to many of the fundamentals of medicine that I hadn’t thought much about since medical school. I liked that they could speak up to tell us how they were feeling, both physically and emotionally, so that we could address their needs and allow them to participate in their own care. Some of my favorite patients kept detailed histories of their own C-reactive protein values and oxygen levels to show they were active participants in their own recovery.
I was worried that these adult patients would be offended or scared to learn that they were being cared for by pediatricians, but at no point did anyone ask me why they were not assigned to an adult hospitalist. They saw us only as doctors and nurses, and they were grateful for our care. One 65-year-old U.S. Army veteran told me that his nurse had told him to take a shower and make his bed. “She treated me just like a 5-year-old kid. And I loved it!” he said.
Dr. Hodo: I don’t know that I was totally unaware of these things, but I will say that I had partially forgotten them: I really like adult medicine, and I love geriatrics. I like high-energy and high-stress situations … at least occasionally! I feel very comfortable discussing end-of-life decisions and death. I cope with personal stress by helping and supporting others – patients, team members, colleagues, neighbors. I risk not taking enough time for myself and have to remind myself to do so.
Dr. Fischer: I actually loved taking care of adults. It felt like there was a different kind of patient-doctor relationship to be had, and it was interesting to get to know people who had jobs and families of their own – essentially a different type of story than you typically hear taking care of children.
Were there any silver linings in this situation? How did you grow personally through this experience? What do we need to do better going forward as a profession and a community?
Dr. Dunbar: The part that I hope will stay with me is the memory of how we came together as clinicians to fight a common invisible enemy. The teamwork was unprecedented. Our day-to-day goals were simple and straightforward: do what needed to be done to help as many New Yorkers as possible. Our team made themselves available for last-minute meetings and shift changes without complaint. We practiced a type of medicine that prioritized patient comfort, flexibility, and compassionate care. We ordered methadone and insulin and antihypertensives – brand new experiences for us, but we figured it out. We worked through novel clinical problems together because there was no textbook to read.
Our colleagues from other specialties and different levels of experience stepped up to join us on overnight shifts, and we welcomed them. With the help of an ad hoc palliative care team, we improved how we listened to patients’ own self-directed needs. We reached across the aisle to our internal medicine and adult hospitalist colleagues to refresh our memories on chronic conditions, and they always answered the phone. I hope we always remember who we were during this crisis, because we were ourselves at our most generous.
Dr. Hodo: This was an unexpected but great opportunity to meet physicians, nurses, and staff in different departments and sections of the hospital from my own. I am hopeful that this experience will help us in the future with multidisciplinary work and breaking down silos that isolate specialties and units in the hospital.
I feel (and this is probably weird) invigorated by this experience. It feels good to have been able to help when I was needed. Even though there are a lot of things in adult hospital medicine I do not know, I know I did my best, asked for help when I needed it, and asked for feedback regularly from the medicine residents and nurses I worked with. I know I supported my team and my colleagues to the best of my ability through stressful and sometimes upsetting and emotionally draining times.
As a profession, we can continue to remember the value of the multidisciplinary team and the value of listening to, and making space for, different voices to be heard. We can reconsider the traditional, rigid hierarchy in medicine and medical education that can stifle creative thought and innovative ideas. We can remember that the people “at the top” of the pyramid can always learn something from those “at the bottom.” We can see the ways that department and discipline and specialty can help us but also sometimes hinder, and seek involvement in programs and discussions that unite and pool resources and skills. And, most of all, we can try, every day we are at work, to put the patients’ and families’ needs first – and when we leave work, to turn that around, and put ourselves and our loved ones in that prime position.
As a community, we also can work on thinking communally – that, after all, is the entire point of the wearing of masks in public and social distancing. It is as much about you as about me! We can try to hold on to some of this perspective of the greater good and appreciation for the work others do that makes our lives better and easier. It is not only health care workers who deserve a round of applause every day; it is every person who did something today that benefited someone else, be that giving extra space in a line, wearing a mask in a store, delivering food to an elder, teaching a class over Zoom, or simply minimizing time outside the house. It is every person who thought about the community at or near the same level of priority that they thought about themselves.
Dr. Fischer: It was a very challenging situation, but because our adult patients in the children’s hospital were relatively young with fewer comorbidities, we got to see people get well. I took care of one man with renal failure who we thought would be on dialysis for the rest of his life. By the end of my first week on service, he had begun to regain kidney function. It was amazing. I think most frontline providers caring for adults in this pandemic have had to face significant morbidity and mortality. I felt lucky that we were able to care for patients who generally got better.
I recently read the article published in the Journal of Pediatrics laying out how the Children’s Hospital at Montefiore adapted an entire pediatric floor to caring for adults.3 This example of recognition of need, quick preparation, and collaboration both within the children’s hospital and with the adult hospital was admirable. I also feel that at the beginning of this pandemic, there was a glimmer that the failure of our health care system to cover everyone and the repercussions of this failure would be drawn into sharp relief. I hope that this understanding of the importance of universal coverage persists beyond the pandemic.
Dr. Giordano is assistant professor of pediatrics at Columbia University and a pediatric hospitalist at NewYork-Presbyterian Morgan Stanley Children’s Hospital with an interest in surgical comanagement. She serves on the Society of Hospital Medicine’s Pediatric Special Interest Group Executive Committee and is the chair of the Education Subcommittee. She is also an advisory board member for the New York/Westchester SHM Chapter.
References
1. Kumaraiah D et al. Innovative ICU physician care models: Covid-19 pandemic at NewYork-Presbyterian. NEJM Catal. 2020 Apr 28. doi: 10.1056/CAT.20.0158.
2. Kim MK et al. A primer for clinician deployment to the medicine floors from an epicenter of Covid-19. NEJM Catal. 2020 May 4. doi: 10.1056/CAT.20.0180.
3. Philips K, et al. Rapid Implementation of an Adult COVID-19 Unit in a Children’s Hospital. J Pediatr. 2020. doi: 10.1016/j.jpeds.2020.04.060.
The memories I have from the few nights spent in the adult pop-up cardiac intensive care unit are pouring in as I sit down to tell this story. I am a pediatric hospitalist at Columbia University NewYork-Presbyterian Morgan Stanley Children’s Hospital. I usually take care of sick, hospitalized children. However, in these extraordinary times, I have joined an army of colleagues taking care of adult patients with COVID-19.
Almost all these patients had tracheostomies connected to ventilators, as well as acute-on-chronic cardiac issues. They were often delirious and unable to speak, and always alone. I was happy to help our adult colleagues, but I was also afraid. I was scared to make a mistake that could be detrimental to my patient, even though I knew well that ICU residents, fellows, and attendings were just a phone call away.
I felt like Alice in Wonderland, initially too small compared with her environment, and the next minute hunched, giant, and still clearly displaced. Except I was not dreaming or watching a movie. There was no white rabbit to chase. The situation was serious and emotionally challenging. I imagined that each patient was the dearest member of my family: my mother, my father, my aunt or uncle. I took pleasure in sharing smiles while asking the patients how they were feeling, and I touched their hands, even though much of my face was covered and there were gloves on my hands.
The year 2020 has been surreal. People have had to find their own way of pushing through the unknown and unexpected. For a start, I would never in a million years have imagined using phrases like pop-up ICU.1 I was signing an admission note for a 90-year-old lady with acute-on-chronic congestive heart failure and acute respiratory hypoxemic failure and there, at the bottom of the note, was my name, followed by an odd remark: “pediatric hospital medicine.” That is what happened in New York City in 2020: Many unexpected events took place.
This article represents a virtual conversation with three other pediatric hospitalists who, under different sets of circumstances, did the same thing: took care of adult patients. I hope that the answers to the questions I asked make you pause, reflect, and learn from the experiences described.
Would you describe the usual environment where you practice pediatric hospital medicine?
Julie Dunbar, MD: I am a full-time pediatric hospitalist at the Children’s Hospital at Montefiore, a tertiary care academic children’s hospital in the Bronx. A typical day on service involves staffing up to 14 patients, up to 21 years old, on a teaching service with residents and physician assistants. We normally staff the hospital in two shifts – day and evening – until 11:00 at night. We are situated at the heart of a medically underserved area, and our hospital system cares for about one-third of the total population of the Bronx.
L. Nell Hodo, MD: I work at Kravis Children’s Hospital at the Mount Sinai Hospital, in Manhattan at the juncture of the Upper East Side and Harlem. Our usual hospital medicine environment is the general ward/floor in a nested children’s hospital within an adult hospital. We have about 32 non-ICU beds, and the patients are managed by a combination of hospitalists, general pediatricians, and specialist attendings. All patients are on resident teams. We have a comanagement model in which the primary attending for surgical patients is always a pediatric attending (hospitalist or specialist).
Avital M. Fischer, MD: NewYork-Presbyterian Morgan Stanley Children’s Hospital is a quaternary care center – where children from the area receive subspecialty care – as well as, functionally, a community hospital for the Washington Heights area. Therefore, we always have an interesting mix of general pediatric inpatient medicine including patients with complex medical conditions, rare diseases, postoperative conditions, and undiagnosed illnesses on our wards. We are a children’s hospital, connected to a larger adult hospital system. Pediatric hospitalists cover two pediatric wards, team-staffed by residents, and a progressive care unit, staffed by nurse practitioners. There is usually evening coverage until 11 p.m.
How did this change when New York became the U.S. epicenter of the SARS-CoV-2 pandemic? Was the transition to taking care of adult patients gradual or sudden? Were you deployed to a different hospital or part of the hospital? How prepared did you feel?
Dr. Dunbar: We experienced the COVID-19 pandemic like much of the rest of New York City – it started as a slow and uncertain process, and then it hit us all at once. In initial conversations, like everyone else, we did not know exactly what was coming. We started with small changes like working from home on nonclinical days and canceling family-centered rounds to conserve personal protective equipment (PPE). In mid-March, we were still expecting that redeployment to adult floors was a highly unlikely scenario. We made work-from-home schedules and planned projects we would work on while social distancing. We planned journal clubs about emerging evidence on COVID-19. However, things happened fast, and many of these plans were scrapped.
On Saturday, March 28, we closed the main floor of the children’s hospital because so few pediatric patients were being admitted. Two days later, we admitted our first cohort of adult COVID-19 patients, all more than 30 years old. They were transferred en masse from an outside hospital emergency department that desperately needed our beds. They arrived all at once, and they all required respiratory support. At the last hospitalist division meeting before the adults arrived, we had time for only one priority set of information, and so we chose end-of-life care. We reviewed scripts for advance care planning and logistics of death certificates. As fast as things changed for us, they changed even faster for the patients. Most were relatively healthy people who rather suddenly found themselves isolated, on oxygen, dictating their final wishes to pediatricians in full protective gear. Many, many patients got better, and of course, several spent their last moments with us. One physician assistant, who works closely with the hospitalists, spent the last 5 hours of an elderly patient’s life holding her hand and helping her FaceTime with family.
For the most part, the patients came to us. We worked with our own colleagues and our own nurses, on our own territory. A few of my colleagues were briefly redeployed to a series of conference rooms that were used for several weeks as overflow space for more stable COVID-19 patients. Staffing by the pediatrics teams was so robust, with willing volunteers from every corner of the children’s hospital, that we were not needed for long.
During the early days, there was no clinical pathway to follow to care for COVID-19 patients – it didn’t exist for this novel and variable disease. We created a platform to share documents and resources in real time as they became available to us. We used group texts and emails to learn from our experiences and encourage one another. Importantly, no one was afraid to ask for help, and we relied on our adult colleagues when patients started to decompensate. Adult critical care came to our aid for all rapid responses for patients older than 30. Pediatric critical care, in their infinite flexibility, was responsible for anyone younger.
Dr. Hodo: We had a variety of changes. The first thing was the deployment of many of our attendings (hospital medicine, ICU, outpatient, and subspecialists) and residents to the adult side to work on medical COVID-19 units or in the many ICUs (some new “pop-up” units in former medical units, postanesthesia care units, and so on).2 On the adult floor we had “COVID teams,” which had an attending and two frontline providers; one of these three people was an internal medicine faculty member or resident. Residents from other specialties (emergency medicine, family medicine) were pulled off pediatric assignments in pediatric wards, PICUs, and EDs, so pediatric residents not originally assigned to inpatient rotations were sent to cover these core pediatric areas. The remaining pediatric faculty backfilled the pediatric services – so the remaining ICU docs did more shifts to cover ICU; the undeployed specialists took more inpatient service or clinic time, and so on. Outpatient pediatrics covered the inpatient pediatric service for the 3 weeks when most of the hospitalists were deployed.
We had one pediatric unit, which was a unit with equipment that made it capable of having ICU patients or floor patients, that was designated a COVID-19 unit. Most COVID-19 patients were there. Some were also in negative-pressure rooms on other floors or in the unit directly above the COVID-19 unit. Some adult patients came to the unit in the pediatric hospital but not as many as initially expected, and most were young adults in their 20s. So rather than adult patients coming to pediatrics, our experience was more that pediatricians went to the adult side.
The transition to adult care for physicians was variable in its suddenness. Most people had at least 48 hours’ notice, whereas some had as much as a week. Most of our department members deployed within the hospital complex of which we are a part, though a few went to other sites in the health system. Some were deployed into administrative or support roles in the system, rather than patient-facing roles. I felt, I would say, reasonably prepared. I trained in family medicine, though I have been exclusively in pediatrics for the past 7 years. I felt rusty, for sure, but perhaps not quite as out of my element as others. In preparation, I read a lot about COVID, reviewed some adult medicine topics provided by the medicine department, used the resources on the Pediatric Overflow Planning Contingency Response Network (POPCoRN), including an Advanced Cardiac Life Support review, and was able to shadow on a COVID-19 unit before I actually started – that was incredibly helpful. I also had the opportunity to speak about that shadowing experience in a department meeting, which I hope was helpful for others.
Dr. Fischer: Our whole focus for a relatively short time shifted to how to take care of adults within the children’s hospital. Although we had some time to prepare – the ICU was the first unit to take adults, so we knew they would come to the floor – it still felt quick. We took adult patients onto the general pediatrics floor from both the emergency department and the ICU. We took adults mostly with COVID-19, but we did have some young adults admitted for other reasons too. Those of us who were on service during this time collaborated closely, sharing what we learned and even joining one another on rounds to provide support. We basically would “teach it forward” as we learned. We also had adult providers available by phone for questions, and our pediatric subspecialists were readily available for consults and would reach out to their adult counterparts for support. Some of the hospitalists were reaching out to POPCoRN, and some were attending an ACLS crash course prior to getting on service.
What was hardest about this experience for you?
Dr. Dunbar: For me, one of the hardest aspects of dealing with COVID-19 was the unknown. In every aspect of professional life and clinical care, there were unanswered questions. What’s the best way to care for these patients? What prognoses can we give their loved ones? How can I help when it seems like there’s so little I can offer? Will we run out of PPE? As doctors, what behaviors most endanger our friends and family when we go home after work? When will things start to get better?
Dr. Hodo: For me, the week or two before being notified of the deployment was the worst and hardest time. The uncertainty about if I would be called or no, and to do what? And where? I was trying to read everything there was on management, what little was known about treatment, and so on. Once I received notification of a start date, that allowed me to focus on very clear endpoints and knowledge items (for example, reviewing ACLS algorithms) and to do things I knew would help me settle and be more effective (like shadowing).
Dr. Fischer: It was a lot of new. Not only were we taking care of a population that we hadn’t cared for since medical school (adults), but we were facing a disease process that was also new to everyone. We were learning on our feet, while at the same time providing guidance to our house staff.
What have you learned about yourself that you did not know before?
Dr. Dunbar: I was surprised to learn how much I liked caring for adult patients. The fear I felt immediately before they arrived dissipated fairly quickly after they arrived. The opportunity to address their chronic conditions while supporting them in an acute illness took me back to many of the fundamentals of medicine that I hadn’t thought much about since medical school. I liked that they could speak up to tell us how they were feeling, both physically and emotionally, so that we could address their needs and allow them to participate in their own care. Some of my favorite patients kept detailed histories of their own C-reactive protein values and oxygen levels to show they were active participants in their own recovery.
I was worried that these adult patients would be offended or scared to learn that they were being cared for by pediatricians, but at no point did anyone ask me why they were not assigned to an adult hospitalist. They saw us only as doctors and nurses, and they were grateful for our care. One 65-year-old U.S. Army veteran told me that his nurse had told him to take a shower and make his bed. “She treated me just like a 5-year-old kid. And I loved it!” he said.
Dr. Hodo: I don’t know that I was totally unaware of these things, but I will say that I had partially forgotten them: I really like adult medicine, and I love geriatrics. I like high-energy and high-stress situations … at least occasionally! I feel very comfortable discussing end-of-life decisions and death. I cope with personal stress by helping and supporting others – patients, team members, colleagues, neighbors. I risk not taking enough time for myself and have to remind myself to do so.
Dr. Fischer: I actually loved taking care of adults. It felt like there was a different kind of patient-doctor relationship to be had, and it was interesting to get to know people who had jobs and families of their own – essentially a different type of story than you typically hear taking care of children.
Were there any silver linings in this situation? How did you grow personally through this experience? What do we need to do better going forward as a profession and a community?
Dr. Dunbar: The part that I hope will stay with me is the memory of how we came together as clinicians to fight a common invisible enemy. The teamwork was unprecedented. Our day-to-day goals were simple and straightforward: do what needed to be done to help as many New Yorkers as possible. Our team made themselves available for last-minute meetings and shift changes without complaint. We practiced a type of medicine that prioritized patient comfort, flexibility, and compassionate care. We ordered methadone and insulin and antihypertensives – brand new experiences for us, but we figured it out. We worked through novel clinical problems together because there was no textbook to read.
Our colleagues from other specialties and different levels of experience stepped up to join us on overnight shifts, and we welcomed them. With the help of an ad hoc palliative care team, we improved how we listened to patients’ own self-directed needs. We reached across the aisle to our internal medicine and adult hospitalist colleagues to refresh our memories on chronic conditions, and they always answered the phone. I hope we always remember who we were during this crisis, because we were ourselves at our most generous.
Dr. Hodo: This was an unexpected but great opportunity to meet physicians, nurses, and staff in different departments and sections of the hospital from my own. I am hopeful that this experience will help us in the future with multidisciplinary work and breaking down silos that isolate specialties and units in the hospital.
I feel (and this is probably weird) invigorated by this experience. It feels good to have been able to help when I was needed. Even though there are a lot of things in adult hospital medicine I do not know, I know I did my best, asked for help when I needed it, and asked for feedback regularly from the medicine residents and nurses I worked with. I know I supported my team and my colleagues to the best of my ability through stressful and sometimes upsetting and emotionally draining times.
As a profession, we can continue to remember the value of the multidisciplinary team and the value of listening to, and making space for, different voices to be heard. We can reconsider the traditional, rigid hierarchy in medicine and medical education that can stifle creative thought and innovative ideas. We can remember that the people “at the top” of the pyramid can always learn something from those “at the bottom.” We can see the ways that department and discipline and specialty can help us but also sometimes hinder, and seek involvement in programs and discussions that unite and pool resources and skills. And, most of all, we can try, every day we are at work, to put the patients’ and families’ needs first – and when we leave work, to turn that around, and put ourselves and our loved ones in that prime position.
As a community, we also can work on thinking communally – that, after all, is the entire point of the wearing of masks in public and social distancing. It is as much about you as about me! We can try to hold on to some of this perspective of the greater good and appreciation for the work others do that makes our lives better and easier. It is not only health care workers who deserve a round of applause every day; it is every person who did something today that benefited someone else, be that giving extra space in a line, wearing a mask in a store, delivering food to an elder, teaching a class over Zoom, or simply minimizing time outside the house. It is every person who thought about the community at or near the same level of priority that they thought about themselves.
Dr. Fischer: It was a very challenging situation, but because our adult patients in the children’s hospital were relatively young with fewer comorbidities, we got to see people get well. I took care of one man with renal failure who we thought would be on dialysis for the rest of his life. By the end of my first week on service, he had begun to regain kidney function. It was amazing. I think most frontline providers caring for adults in this pandemic have had to face significant morbidity and mortality. I felt lucky that we were able to care for patients who generally got better.
I recently read the article published in the Journal of Pediatrics laying out how the Children’s Hospital at Montefiore adapted an entire pediatric floor to caring for adults.3 This example of recognition of need, quick preparation, and collaboration both within the children’s hospital and with the adult hospital was admirable. I also feel that at the beginning of this pandemic, there was a glimmer that the failure of our health care system to cover everyone and the repercussions of this failure would be drawn into sharp relief. I hope that this understanding of the importance of universal coverage persists beyond the pandemic.
Dr. Giordano is assistant professor of pediatrics at Columbia University and a pediatric hospitalist at NewYork-Presbyterian Morgan Stanley Children’s Hospital with an interest in surgical comanagement. She serves on the Society of Hospital Medicine’s Pediatric Special Interest Group Executive Committee and is the chair of the Education Subcommittee. She is also an advisory board member for the New York/Westchester SHM Chapter.
References
1. Kumaraiah D et al. Innovative ICU physician care models: Covid-19 pandemic at NewYork-Presbyterian. NEJM Catal. 2020 Apr 28. doi: 10.1056/CAT.20.0158.
2. Kim MK et al. A primer for clinician deployment to the medicine floors from an epicenter of Covid-19. NEJM Catal. 2020 May 4. doi: 10.1056/CAT.20.0180.
3. Philips K, et al. Rapid Implementation of an Adult COVID-19 Unit in a Children’s Hospital. J Pediatr. 2020. doi: 10.1016/j.jpeds.2020.04.060.
Many children with COVID-19 present without classic symptoms
Most children who tested positive for SARS-CoV-2 had no respiratory illness, according to data from a retrospective study of 22 patients at a single center.
To date, children account for less than 5% of COVID-19 cases in the United States, but details of the clinical presentations in children are limited, wrote Rabia Agha, MD, and colleagues of Maimonides Children’s Hospital, Brooklyn, N.Y.
In a study published in Hospital Pediatrics, the researchers reviewed data from 22 children aged 0-18 years who tested positive for SARS-CoV-2 by polymerase chain reaction (PCR) and were admitted to a single hospital over a 4-week period from March 18, 2020, to April 15, 2020.
Of four patients requiring mechanical ventilation, two had underlying pulmonary disease. The other two patients who required intubation were one with cerebral palsy and status epilepticus and one who presented in a state of cardiac arrest.
The study population ranged from 11 days to 18 years of age, but 45% were infants younger than 1 year. None of the children had a travel history that might increase their risk for SARS-CoV-2 infection; 27% had confirmed exposure to the virus.
Most of the children (82%) were hospitalized within 3 days of the onset of symptoms, and no deaths occurred during the study period. The most common symptom was fever without a source in five (23%) otherwise healthy infants aged 11-35 days. All five of these children underwent a sepsis evaluation, received empiric antibiotics, and were discharged home with negative bacterial cultures within 48-72 hours. Another 10 children had fever in combination with other symptoms.
Other presenting symptoms were respiratory (9), fatigue (6), seizures (2), and headache (1).
Most children with respiratory illness were treated with supportive therapy and antibiotics, but three of those on mechanical ventilation also were treated with remdesivir; all three were ultimately extubated.
Neurological abnormalities occurred in two patients: an 11-year-old otherwise healthy boy who presented with fever, headache, confusion, and seizure but ultimately improved without short-term sequelae; and a 12-year-old girl with cerebral palsy who developed new onset seizures and required mechanical ventilation, but ultimately improved to baseline.
Positive PCR results were identified in seven patients (32%) during the second half of the study period who were initially hospitalized for non-COVID related symptoms; four with bacterial infections, two with illnesses of unknown etiology, and one with cardiac arrest. Another two children were completely asymptomatic at the time of admission but then tested positive by PCR; one child had been admitted for routine chemotherapy and the other for social reasons, Dr. Agha and associates said.
The study findings contrast with early data from China in which respiratory illness of varying severity was the major presentation in children with COVID-19, but support a more recent meta-analysis of 551 cases, the researchers noted. The findings also highlight the value of universal testing for children.
“Our initial testing strategy was according to the federal and local guidelines that recommended PCR testing for the symptoms of fever, cough and shortness of breath, or travel to certain countries or close contact with a confirmed case,” Dr. Agha and colleagues said.
“With the implementation of our universal screening strategy of all admitted pediatric patients, we identified 9 (41%) patients with COVID-19 that would have been missed, as they did not meet the then-recommended criteria for testing,” they wrote.
The results suggest the need for broader guidelines to test pediatric patients because children presenting with other illnesses may be positive for SARS-CoV-2 as well, the researchers said.
“Testing of all hospitalized patients will not only identify cases early in the course of their admission process, but will also help prevent inadvertent exposure of other patients and health care workers, assist in cohorting infected patients, and aid in conservation of personal protective equipment,” Dr. Agha and associates concluded.
The current study is important as clinicians continue to learn about how infection with SARS-CoV-2 presents in different populations, Diana Lee, MD, of the Icahn School of Medicine at Mount Sinai, New York, said in an interview.
“Understanding how it can present in the pediatric population is important in identifying children who may have the infection and developing strategies for testing,” she said.
“I was not surprised by the finding that most children did not present with the classic symptoms of COVID-19 in adults based on other published studies and my personal clinical experience taking care of hospitalized children in New York City,” said Dr. Lee. “Studies from the U.S. and other countries have reported that fewer children experience fever, cough, and shortness of breath [compared with] adults, and that most children have a milder clinical course, though there is a small percentage of children who can have severe or critical illness,” she said.
“A multisystem inflammatory syndrome in children associated with COVID-19 has also emerged and appears to be a postinfectious process with a presentation that often differs from classic COVID-19 infection in adults,” she added.
The take-home message for clinicians is the reminder that SARS-CoV-2 infection often presents differently in children than in adults, said Dr. Lee.
“Children who present to the hospital with non-classic COVID-19 symptoms or with other diagnoses may be positive for SARS-CoV-2 on testing. Broadly testing hospitalized children for SARS-CoV-2 and instituting appropriate isolation precautions may help to protect other individuals from being exposed to the virus,” she said.
“Further research is needed to understand which individuals are contagious and how to accurately distinguish those who are infectious versus those who are not,” said Dr. Lee. “There have been individuals who persistently test positive for SARS-CoV-2 RNA (the genetic material of the virus), but were not found to have virus in their bodies that can replicate and thereby infect others,” she emphasized. “Further study is needed regarding the likelihood of household exposures in children with SARS-CoV-2 infection given that this study was done early in the epidemic in New York City when testing and contact tracing was less established,” she said.
The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Lee had no financial conflicts to disclose.
SOURCE: Agha R et al. Hosp Pediatr. 2020 July. doi: 10.1542/hpeds.2020-000257.
Most children who tested positive for SARS-CoV-2 had no respiratory illness, according to data from a retrospective study of 22 patients at a single center.
To date, children account for less than 5% of COVID-19 cases in the United States, but details of the clinical presentations in children are limited, wrote Rabia Agha, MD, and colleagues of Maimonides Children’s Hospital, Brooklyn, N.Y.
In a study published in Hospital Pediatrics, the researchers reviewed data from 22 children aged 0-18 years who tested positive for SARS-CoV-2 by polymerase chain reaction (PCR) and were admitted to a single hospital over a 4-week period from March 18, 2020, to April 15, 2020.
Of four patients requiring mechanical ventilation, two had underlying pulmonary disease. The other two patients who required intubation were one with cerebral palsy and status epilepticus and one who presented in a state of cardiac arrest.
The study population ranged from 11 days to 18 years of age, but 45% were infants younger than 1 year. None of the children had a travel history that might increase their risk for SARS-CoV-2 infection; 27% had confirmed exposure to the virus.
Most of the children (82%) were hospitalized within 3 days of the onset of symptoms, and no deaths occurred during the study period. The most common symptom was fever without a source in five (23%) otherwise healthy infants aged 11-35 days. All five of these children underwent a sepsis evaluation, received empiric antibiotics, and were discharged home with negative bacterial cultures within 48-72 hours. Another 10 children had fever in combination with other symptoms.
Other presenting symptoms were respiratory (9), fatigue (6), seizures (2), and headache (1).
Most children with respiratory illness were treated with supportive therapy and antibiotics, but three of those on mechanical ventilation also were treated with remdesivir; all three were ultimately extubated.
Neurological abnormalities occurred in two patients: an 11-year-old otherwise healthy boy who presented with fever, headache, confusion, and seizure but ultimately improved without short-term sequelae; and a 12-year-old girl with cerebral palsy who developed new onset seizures and required mechanical ventilation, but ultimately improved to baseline.
Positive PCR results were identified in seven patients (32%) during the second half of the study period who were initially hospitalized for non-COVID related symptoms; four with bacterial infections, two with illnesses of unknown etiology, and one with cardiac arrest. Another two children were completely asymptomatic at the time of admission but then tested positive by PCR; one child had been admitted for routine chemotherapy and the other for social reasons, Dr. Agha and associates said.
The study findings contrast with early data from China in which respiratory illness of varying severity was the major presentation in children with COVID-19, but support a more recent meta-analysis of 551 cases, the researchers noted. The findings also highlight the value of universal testing for children.
“Our initial testing strategy was according to the federal and local guidelines that recommended PCR testing for the symptoms of fever, cough and shortness of breath, or travel to certain countries or close contact with a confirmed case,” Dr. Agha and colleagues said.
“With the implementation of our universal screening strategy of all admitted pediatric patients, we identified 9 (41%) patients with COVID-19 that would have been missed, as they did not meet the then-recommended criteria for testing,” they wrote.
The results suggest the need for broader guidelines to test pediatric patients because children presenting with other illnesses may be positive for SARS-CoV-2 as well, the researchers said.
“Testing of all hospitalized patients will not only identify cases early in the course of their admission process, but will also help prevent inadvertent exposure of other patients and health care workers, assist in cohorting infected patients, and aid in conservation of personal protective equipment,” Dr. Agha and associates concluded.
The current study is important as clinicians continue to learn about how infection with SARS-CoV-2 presents in different populations, Diana Lee, MD, of the Icahn School of Medicine at Mount Sinai, New York, said in an interview.
“Understanding how it can present in the pediatric population is important in identifying children who may have the infection and developing strategies for testing,” she said.
“I was not surprised by the finding that most children did not present with the classic symptoms of COVID-19 in adults based on other published studies and my personal clinical experience taking care of hospitalized children in New York City,” said Dr. Lee. “Studies from the U.S. and other countries have reported that fewer children experience fever, cough, and shortness of breath [compared with] adults, and that most children have a milder clinical course, though there is a small percentage of children who can have severe or critical illness,” she said.
“A multisystem inflammatory syndrome in children associated with COVID-19 has also emerged and appears to be a postinfectious process with a presentation that often differs from classic COVID-19 infection in adults,” she added.
The take-home message for clinicians is the reminder that SARS-CoV-2 infection often presents differently in children than in adults, said Dr. Lee.
“Children who present to the hospital with non-classic COVID-19 symptoms or with other diagnoses may be positive for SARS-CoV-2 on testing. Broadly testing hospitalized children for SARS-CoV-2 and instituting appropriate isolation precautions may help to protect other individuals from being exposed to the virus,” she said.
“Further research is needed to understand which individuals are contagious and how to accurately distinguish those who are infectious versus those who are not,” said Dr. Lee. “There have been individuals who persistently test positive for SARS-CoV-2 RNA (the genetic material of the virus), but were not found to have virus in their bodies that can replicate and thereby infect others,” she emphasized. “Further study is needed regarding the likelihood of household exposures in children with SARS-CoV-2 infection given that this study was done early in the epidemic in New York City when testing and contact tracing was less established,” she said.
The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Lee had no financial conflicts to disclose.
SOURCE: Agha R et al. Hosp Pediatr. 2020 July. doi: 10.1542/hpeds.2020-000257.
Most children who tested positive for SARS-CoV-2 had no respiratory illness, according to data from a retrospective study of 22 patients at a single center.
To date, children account for less than 5% of COVID-19 cases in the United States, but details of the clinical presentations in children are limited, wrote Rabia Agha, MD, and colleagues of Maimonides Children’s Hospital, Brooklyn, N.Y.
In a study published in Hospital Pediatrics, the researchers reviewed data from 22 children aged 0-18 years who tested positive for SARS-CoV-2 by polymerase chain reaction (PCR) and were admitted to a single hospital over a 4-week period from March 18, 2020, to April 15, 2020.
Of four patients requiring mechanical ventilation, two had underlying pulmonary disease. The other two patients who required intubation were one with cerebral palsy and status epilepticus and one who presented in a state of cardiac arrest.
The study population ranged from 11 days to 18 years of age, but 45% were infants younger than 1 year. None of the children had a travel history that might increase their risk for SARS-CoV-2 infection; 27% had confirmed exposure to the virus.
Most of the children (82%) were hospitalized within 3 days of the onset of symptoms, and no deaths occurred during the study period. The most common symptom was fever without a source in five (23%) otherwise healthy infants aged 11-35 days. All five of these children underwent a sepsis evaluation, received empiric antibiotics, and were discharged home with negative bacterial cultures within 48-72 hours. Another 10 children had fever in combination with other symptoms.
Other presenting symptoms were respiratory (9), fatigue (6), seizures (2), and headache (1).
Most children with respiratory illness were treated with supportive therapy and antibiotics, but three of those on mechanical ventilation also were treated with remdesivir; all three were ultimately extubated.
Neurological abnormalities occurred in two patients: an 11-year-old otherwise healthy boy who presented with fever, headache, confusion, and seizure but ultimately improved without short-term sequelae; and a 12-year-old girl with cerebral palsy who developed new onset seizures and required mechanical ventilation, but ultimately improved to baseline.
Positive PCR results were identified in seven patients (32%) during the second half of the study period who were initially hospitalized for non-COVID related symptoms; four with bacterial infections, two with illnesses of unknown etiology, and one with cardiac arrest. Another two children were completely asymptomatic at the time of admission but then tested positive by PCR; one child had been admitted for routine chemotherapy and the other for social reasons, Dr. Agha and associates said.
The study findings contrast with early data from China in which respiratory illness of varying severity was the major presentation in children with COVID-19, but support a more recent meta-analysis of 551 cases, the researchers noted. The findings also highlight the value of universal testing for children.
“Our initial testing strategy was according to the federal and local guidelines that recommended PCR testing for the symptoms of fever, cough and shortness of breath, or travel to certain countries or close contact with a confirmed case,” Dr. Agha and colleagues said.
“With the implementation of our universal screening strategy of all admitted pediatric patients, we identified 9 (41%) patients with COVID-19 that would have been missed, as they did not meet the then-recommended criteria for testing,” they wrote.
The results suggest the need for broader guidelines to test pediatric patients because children presenting with other illnesses may be positive for SARS-CoV-2 as well, the researchers said.
“Testing of all hospitalized patients will not only identify cases early in the course of their admission process, but will also help prevent inadvertent exposure of other patients and health care workers, assist in cohorting infected patients, and aid in conservation of personal protective equipment,” Dr. Agha and associates concluded.
The current study is important as clinicians continue to learn about how infection with SARS-CoV-2 presents in different populations, Diana Lee, MD, of the Icahn School of Medicine at Mount Sinai, New York, said in an interview.
“Understanding how it can present in the pediatric population is important in identifying children who may have the infection and developing strategies for testing,” she said.
“I was not surprised by the finding that most children did not present with the classic symptoms of COVID-19 in adults based on other published studies and my personal clinical experience taking care of hospitalized children in New York City,” said Dr. Lee. “Studies from the U.S. and other countries have reported that fewer children experience fever, cough, and shortness of breath [compared with] adults, and that most children have a milder clinical course, though there is a small percentage of children who can have severe or critical illness,” she said.
“A multisystem inflammatory syndrome in children associated with COVID-19 has also emerged and appears to be a postinfectious process with a presentation that often differs from classic COVID-19 infection in adults,” she added.
The take-home message for clinicians is the reminder that SARS-CoV-2 infection often presents differently in children than in adults, said Dr. Lee.
“Children who present to the hospital with non-classic COVID-19 symptoms or with other diagnoses may be positive for SARS-CoV-2 on testing. Broadly testing hospitalized children for SARS-CoV-2 and instituting appropriate isolation precautions may help to protect other individuals from being exposed to the virus,” she said.
“Further research is needed to understand which individuals are contagious and how to accurately distinguish those who are infectious versus those who are not,” said Dr. Lee. “There have been individuals who persistently test positive for SARS-CoV-2 RNA (the genetic material of the virus), but were not found to have virus in their bodies that can replicate and thereby infect others,” she emphasized. “Further study is needed regarding the likelihood of household exposures in children with SARS-CoV-2 infection given that this study was done early in the epidemic in New York City when testing and contact tracing was less established,” she said.
The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Lee had no financial conflicts to disclose.
SOURCE: Agha R et al. Hosp Pediatr. 2020 July. doi: 10.1542/hpeds.2020-000257.
FROM HOSPITAL PEDIATRICS