CME-MOC Credit

Time Stamps

  • 02:37 Entrance and Exit strategy 
  • 04:25 Prioritizing patient acuity 
  • 08:10 PPE uses
  • 11:14 Respiratory concerns in COVID-19 patients
  • 16:35 Patient examination 
  • 18:49  Admission Conversation with goals of care and expectations for family updates
  • 20:56 Documentation and sign-out
  • 23:12  EMR hygiene 
  • 24:23 Discharging patients
  • 31:00 Self-Care

Show Notes

Tips and questions to think through given every hospital will be different

Tip #1: Have a consistent daily hospital entrance and exit strategy that works for you 

Tip #2: Prepping a morning routine to set yourself up for the day

  • How will you prioritize and delegate, particularly with modified teams? 
  • What does pre-rounding and rounding look like on a Covid-19 team?

Tip #3: Strategize conserving PPE and other protective equipment utilization

  • Where do you store your PPE when not participating in patient care?
  • How do you prevent unnecessary PPE usage? 

Tip #4: Brush up on next steps with respiratory decompensation

Tip #5: Develop a list of key things to check-in about for your known follow-up patients with COVID

  • How will you keep assess respiratory status and other key symptoms with Covid-19? 

Tip #6: Try to set yourself up for success early with goals of care discussion and expectations

  • How do you proactively manage expectations and address goals of care?
  • What is your system for making sure that family is updated and connected to their loved one? 

Tip #7: Maximize documentation efficiency and clarity for COVID patients

  • What is your strategy to ensure succinct and timely documentation?
  •  What specific information is important to consider including in signout?

Tip #8: Optimize EMR orders to minimize risk of exposure for self and colleagues 

  • What are strategies to minimize unnecessary exposure for our colleagues? 

Tip #9: Prepare patients with discharge instructions for self-isolation and return precautions 

  • What criteria must be met for a patient to go home or to a subacute rehabilitation facility from your hospital?
  • How do you counsel your patients on self-quarantine and return precautions after hospital stay?

Tip #10:  Prioritize self-care and acknowledge moral distress and grief in COVID patient care

  • How do you practice self-care in the era of Covid-19?

Transcript

Dr. Desai: I think the most important part they need to know is that there’s an algorithm and there are these subset of meds that you’re going to use depending on their symptom onset, their other factors of contraindicating meds or QTC, and then their O2 requirement. And these are gonna affect which meds you choose.

Shreya: Yes there is an algorithm you probably need to know and it’s different based on whichever hospital you’re at; who gets plaquenil, who gets the remdesivir, what daily labs your epidemiologist want you to get and because that is so unique – what we’re going to focus on the practical tips in taking care of patients with COVID-19. To help me to do this, I am joined by:

Tim: Hi guys, I’m Dr. Tim Rowe, a third year resident at University of Wisconsin – Madison. Our routines have changed so much in the past month. And as we learn more about COVID we’re each going to have to adjust and readjust our practice patterns.

Shreya: And probably have to readjust one more time as we learn more – a very humbling process. I think as hospitals are hitting their surges now, we were initially gearing this episode towards outpatient clinicians who are getting called in to help on COVID floors. But the more we produced this episode, the more there were tons of inpatient clinicians who said – no, this is helpful for all of us to hear how each other are organizing our days, and other tips on what effective care looks like on COVID floors. 

And so to do that we sat down with Dr. Dr. Desai Desai who is a hospitalist at NYU Brooklyn and has been on the frontlines for more than a month now taking care of an incredible volume of patients. She is someone I respect as a clinician and would trust to care for my family members if god forbid they were ever sick. 

Tim: We also talked with Dr. Dr. LaMotte LaMotte, who is a hospitalist at University of Washington Medical Center to get his practical tips after spending time on his hospital’s COVID wards. After talking to them both, we came up with 10 practical tips, or areas of hospital medicine to be mindful of when taking care of inpatients with COVID infection.

Shreya: We want to fully acknowledge that they are going to share their take and strategies around the these 10 areas and their tips. But I’m sure everyone has a different approach, and it looks different depending on what environment you’re in. So, please Tweet us if you have any other tips that you want to add, or comment on the episode’s CORE IM page so we can all learn from each other. And with that, let’s get started! Tip #1: Have a consistent daily entrance and exit strategy of what works for you and the resources at your hospital

Entrance strategy

Dr. Desai: My day usually starts by, I organize my day the night before. So I have my clean scrubs ready to go. I always wear a pair of clothes underneath my clean scrubs and I get to work. At work I have one specific bag, which is strictly a work bag and a work jacket. So, I do not bring any of those items into my home and my shoes also never come into the home. 

Exit strategy

Dr. Desai: At the end of the day, I remove my dirty scrubs, put them in a dirty Ziploc bag that I labeled “dirty.” Or you could do a plastic bag, but I just wanted something that’s sealed – everyone does it differently. You could just hold them and take them downstairs. I then dispose of the dirty scrubs and pick up a new pair for the next day. I then take wipes and I clean all of my stuff – my phone, my headphones, my water bottle, my ID, my keys, my wallet – everything that I’ve used throughout the day gets cleaned and put in a ziploc bag and then into my bigger bag. And then I head home. When I come home I directly put my clothes into the wash after washing my hands and then I shower immediately. Maybe too much information, but…[laughs] 

Shreya: It is not too much information – all of it is important. Some have also mentioned not wearing jewelry or always tying their hair up when they go to work. Whatever that routine is, I think it gives some mental peace that I’m doing something consistently to protect.

Tim: And once you get to the hospital, tip #2 is to prep your morning routine and set yourself up for success. Each day may look a little bit different, especially as hospitals reach surge capacity. There may be people on your team from other specialties like ortho, neurology and podiatry – so you might find yourself working with someone who is not quite as familiar with the medicine wards as you are! It may save you trouble later on if you start off by setting expectations and maybe even explicitly discuss your “call me” criteria, which could go something like this:

Setting expectations/Coaching off-service/APPs on “call me” criteria

Dr. Desai: If they come to a patient that looks sick, and when I say sick, I tell them vital signs are abnormal, they’re very tachycardic, they’re in respiratory distress. The nurse is telling you they’re concerned – you need to call me right away. Those are the things that I usually try to outline.  Or, if something just doesn’t feel right, call me. Trust your instincts. If they’re feeling overwhelmed they need to call you and that’s really going to be from day to day. But I think they just need to know that they’re supported and that you’re there to help them as much as they’re there to help you.

Tim: I would argue that open communication and expectation setting is always helpful, even when you’re just working with your usual team of medicine residents. And then it’s all about triaging – Dr. Desai stressed the importance of having open communication with your whole team, triaging tasks based on skill set – is this gonna be the person who takes 6-8 of our stable follow-up patients? 1 or 2 new admissions? Or are they gonna be the person to help me coordinate the discharges today? 

Prioritizing the higher acuity patients

Dr. Desai: So typically the patients who are on the non-rebreathers whose respiratory rates are high, those are the ones that I specifically see. Fever does not always mean the sickest. It’s really, I think the respiratory status that to me entitles that being the patient that I have to prioritize to see, and giving the more stable nasal cannula patients to the APPs and PAs and residents that are not as experienced. Because sending them into a room with a very distressed patient is probably going to be very overwhelming to them. Or we go together. 

Tim: As we pointed out, each morning’s routine can be different based on resources you have. While taking on an attending only COVID team, Dr. LaMotte had a very different morning routine than his usual. But to minimize time spent in PPE, he took advantage of first calling into patients’ room phones to gather new information. 

Extended preround

Dr. LaMotte: The flow of my day was pretty different when I was on the COVID service than a usual hospitalist service. I decided to try to do as much as I could for my patients before doing my rounds. So, I really put off my morning rounds until like 11:00 AM or maybe even a little bit later to just try to do all my pre-rounding, try to call patients on the phone for those patients who I could call to kind of get some history from them and update them on the plan. I found it helpful to be able to do that, to be able to take better notes, without having to worry about my PPE, and got in touch with nurses to make sure we’re kind of on the same page about the plan. 

Tim: The room phones were also helpful for non-english speaking patients. He called the interpreter line from his workroom and then asked the translator to call his patient’s room on 3-way. This seemed to minimize the background noise in negative pressure rooms. And organizing his morning like this had one more unexpected benefit: 

Dr. LaMotte: And also a lot of the patient’s stories are pretty similar in terms of both the timing and the symptoms and so it can be a little bit difficult if you have a lot of patients all infected with COVID to keep their stories straight. So it was really helpful for me to be able to just go through a pretty comprehensive review of systems with all of them and be able to take notes over the phone.

Tim: Yeah I guess it’d be kinda hard to take notes on your list while you’re in full PPE, and even harder to keep it clean — which, I am a big note taker too – so I really appreciate that point. The caveat here is that most of these patients are pretty sick and might not always be up to holding the phone up while they’re talking. But if your patient can and your hospital is set up well for this, it may be more efficient to call patients from your workroom to plug their subjective updates into your progress note and save the middle man on that scrappy list.

Shreya: So, when you are done setting expectations with your team for that day, and maybe if you’re like Dr. LaMotte and you’re able to call into patient’s room ahead of time. Now its time to actually see your patients and put on that personal protective equipment (PPE). And that leads us to Tip #3 have a strategy to conserve your PPE and other protective equipment. Again, this is hospital dependent, but here is what Dr. Desai does. 

Use plastic bag for phone and PPE “brown bag” strategy

Dr. Desai: The other part is just this whole conservation of PPE. So first thing for my PPE, you can protect your phone, number one – the nurses have a clear plastic that are always on the station where they put specimens in –  and your phone can go in there, and you can actually type through it and hear through it. It’s a little bit harder, but you can actually type through it. Everyone gets a brown bag. I use one Brown bag for my N95 and my face shield and I do not put anything else in that bag. I also put my N95 in a separate plastic bag within that brown bag to protect my N95 on its own. That’s not something everybody does, but that’s something I do. I never mix that bag with anything else. 

Shreya: And following the PPE hygiene strictly can be quite time-consuming.

Dr. Desai: From what I understand from an infection control standpoint, you are supposed to clean your face shield from room to room. I don’t know the answer to this. I feel like people are still going from room to room without cleaning the face shield technically, because you’re still going from COVID to COVID to COVID to COVID. If you go from a COVID to a negative, that’s a problem. You shouldn’t take your gear into a COVID negative room. 

Shreya: One thing that Dr. Desai does to conserve, at least her gowns and gloves, is triaging between the patients who are on droplet precautions.

Dr. Desai: I think what’s really helpful is that once you get to know a patient, you don’t always need to go into the room. And I think that’s the way that you can conserve PPE. If I get to know a patient on the subsequent days, if they’re sitting in the room by the door, I talk to them from the door. If I feel that it’s strictly respiratory [concerns] that we’re dealing with, listening to their lungs is not that helpful to me. I will talk to them through the, from the doorway. I will put my face-, my N95 and my face shield on. I will not put on a gown and I will talk to them from the door.

That was a great way to see them, talk to them, let them know that I’m there for them, but I didn’t have to use a gown and gloves or gear that we’re trying to conserve. So that was something I thought it was really helpful.

Shreya: Keep in mind, we can’t do this for patients on airborne precautions. I appreciate her honesty there on triaging who needs a lung exam and who doesn’t. That is something many hospitalists around the country have said they are thinking about too: which exams that will make a difference in management for that day.  

Brush up on next steps with respiratory decompensation

Tim: We were really pressing the hospitalists to give us their routine of how they organize their day, but their message was clear: there really is no routine day on the COVID floors

Dr. Desai: I think the hard part about saying that every day is the same is because in this era with COVID it’s not. Unfortunately patients are super sick when you walk in and it totally messes up the flow of your day or they’re RRT-ing every five minutes on your unit. So I think it’s having a general sense of how you want to structure your day and then you’re going to have to make accommodations for when all these hiccups come along. Because you can say you want to see all your patients between 9 and 11, or 7 and 10 and then one sick patient takes up two to three hours in the morning.

Tim: Let’s listen to Dr. Desai talk about rolling with the punches, particularly with Tip #4 Brush up on next steps for decompensating patients

Respiratory decompensations

Dr. Desai: Remember if you’re on your own, it definitely takes more time. But when you have a resident and intern and other people to support you, it shouldn’t take that long. But if I get called that a patient’s in distress, the biggest issue is getting the upgrades to the oxygen that you need. You need to get respiratory. Someone needs to bring you high flow, someone needs to get that up there. Then you find out you can’t get through to respiratory because respiratory is calling going to all these RRTs. Then you’re trying to get critical care, and critical care’s busy. So they’ll say, well, we’ll get there when we get there. So you’re managing this patient who’s not doing as well. In the beginning, at first I was like, what, what am I going to do? I totally agree with you. I felt helpless. I felt how – something – I gotta be able to do something.

Tim: So if you find yourself stepping into a role you never trained for – remember, you’re not alone. This goes for outpatient docs who suddenly find themselves on the wards, but also hospitalists who may have forgotten some of the finer points of inpatient respiratory care. 

Expanding our comfort zone and asking for help when needed

Dr. Desai: A lot of what we’re somewhat doing is what a respiratory therapist does because there’s not enough respiratory therapists. So sometimes you’re going to be titrating and deescalating O2, something that you’ve never done before. But I think the good thing is for the outpatient docs – you’re not going to be alone. Hopefully you’re paired with someone who is experienced with that, who has done that. You can do nasal cannula to non-breather, because nursing can do that for you. You ask the nurse to put your patient on non-rebreather and they can set that up for you. It’s really the high flow (nasal cannula) and BiPAP that require the respiratory therapist.

Tim: If you’re like me, listening to her talk about decompensating patients spiked your blood pressure, and you’re now frantically scrambling the internet for helpful respiratory care tips. 

Shreya: I am a diaphoresing a little bit, yeah Tim. Why you dont you give us the rundown on some basic oxygen support: 

Tim: Alright – here’s how I break it down – first, standard nasal cannula will get you to 6L/min. Once your patient maxes out on that, I’d reach for non-rebreather, which goes up to 15L/min. After that, high flow nasal cannula will get you to 30-60L per minute at 70-100% FiO2. I like High flow because it comes with the added bonus of air humidification, allowing your patient continue to eat and talk, and providing a little bit of PEEP.  

Shreya: Well that’s a nice bonus, what about using CPAP or BiPAP – actually I heard some hospitals are trying to avoid those oxygen support systems.

Tim: That’s right – CPAP or BiPAP actually has not been shown to reduce risk of intubation relative to high flow and may carry increased risk of COVID transmission through increased aerosolization. 

Shreya: Hmm, that is good to know.

Tim: But while taking care of their immediate respiratory needs, it’s also important not to get locked into “COVID mode”. 

Dr. Desai: I kind of still did what I normally do with my patients. I still look at their X-ray. I re-order an X-Ray. I look to make sure that I’m not missing something else. I think about diuretics, I think about, is there anything I’m missing? The patient’s been here for 10 days, they’re still spiking temps – do I need to consider bacterial pneumonia? So these are all things that I’m still doing, in addition to helping them get more oxygen requirements. Make sure the need is met and also asking for help to move. One of the biggest problems is that patients can’t always move. There’s not enough ICU beds, there’s no step-down beds. The patient is still on your floor, on your service, and you have to take care of them and manage them in that situation. 

Tim: This is an important tip even for your patients without COVID – stay open-minded about what else could be going on: do they have a superimposed bacterial infection or is that worsening tachycardia or tachypnea from new clot? And remember guys, especially while you are juggling many tasks at once and trying to keep an open mind, closed loop communication is key. 

Closed loop communication

Dr. Desai: It’s also one of the most challenging things because you’re multitasking so many things all at the same time. I always circle back to make sure that they’re being done. You always have to circle back to check in. “Hey was that done?” Or I sometimes will ask them to please let me know that when it’s taken care of so that I can cross that off my list or that it’s been addressed. 

Shreya: When you are not putting out fires for patients who have worsening respiratory distress, there is going to see your other follow-up patients with COVID— each hospitalist had a different approach with Tip #5: develop a list of things to check in about in that daily subjective convos with the stable follow-up patients 

Daily subjective/examination

Dr. Desai: With COVID it’s respiratory. So the respiratory I hit first making sure that their breathing has improved. How is their cough? How are they feeling with their fevers? I really encourage patients to be prone. I remind them that that position is the best position for them to be lying in if they can tolerate it. A lot of times you’ll tell them and then they come back in and they’re not prone. I always talk about if they’re eating, how much they’re drinking and what’s going on with their bowels. Because with COVID and the meds you’re getting a lot of diarrhea and other symptoms. So our usual standard of giving everybody Miralax is really not the best standard anymore, because a lot of patients are having GI distress, and then you give them Miralax and it makes them feel even worse. So that helps me to decide if they should get that or not. And urine, are they making urine?

Shreya: Dr. LaMotte had a similar list of questions that he would ask over the phone but then when he would go see his patients, would note their work of breathing. So for example, a patient may say over the phone they were feeling less short of breath, but they were gasping for air every sentence, which was an objective thing he noted, to track their progress. He also had another trick of up his sleeve tracking of changes in respiratory status.

Oxygen titration

Dr. LaMotte: I found it helpful to try to target an O2 saturation of 92%, which would encourage nurses to down titrate the oxygen, so that it was easier for me to tell how much oxygen is someone really needing crucially. And then also to have a little bit earlier notification if someone is getting worse. I wanted to be paged anytime someone’s oxygen needs were going up. And I think that if someone’s satting at 97% on 3 liters and then later they’re satting at, 93 or 94%, you might not get paged, even though someone’s getting a little bit worse.

Tim: Noted – I’ll definitely try that next time I am on the floors. After you are done seeing the patients on your list, you’re probably getting called for new admissions, which leads to Tip#6 Set yourself up for success with early, proactive goals of care discussions and expectation setting around family communication. Let’s listen to the schpeel that Dr. Desai developed over the weeks working with new COVID admissions in New York City:

Dr. Desai: Explained to them the struggles we have with coronavirus very gently that, you know, we’re here to support them. We’re doing everything we can. We’re giving them some medicines to help with inflammation, but it’s not a cure. And we’ll take it day by day. But sometimes if the respiratory condition gets worse we need to know what you would like us to do. 

Tim: It’s a hard balance to strike — not overwhelming them but at the same time, doing a good goals of care discussion. Some would argue they do aggressive goals of care discussions with everyone because you never know how rapidly someone is going to deteriorate on you. And if their family knows their wishes.

Dr. Desai: The next thing I always do is I talk about their family. I ask them who they live with, who’s their family, um, who they want me to talk to and that I promise them that I will always keep in touch with their family members, um, to make sure they know the, how they’re doing at all times and to reassure them that we’re here for them when their family can’t be. 

Tim: But as busy as we are, we can’t lose sight of the family members at home, and that in many cases we are the only link to updates about their loved ones. So expectation setting is key.

Family updates – no news is good news

Dr. LaMotte: I tried to call family members once a day. One thing that I tried to reassure them was, you know, I have your contact number – I know I can reach you here. If your family member is getting sick, which some people with this disease can do pretty rapidly, you’d be the first person I’d call, after doing the things I need to do to take care of your loved one. And so, I want you to know that as much as I’m trying to update you each day, if you’re not hearing from me, no news is good news because it means that your loved one hasn’t gotten worse.

Tim: This is especially useful for the unexpected days where you may be inundated, and not have the bandwidth to call all 10 or 20 family members on your list.

Shreya: So when you are not seeing patients or updating families, you are documenting. I really appreciate that in the time of COVID, many are favoring Tip #7: Maximize documentation efficiency with being succinct and only writing the essentials.

Succinct documentation summary

Dr. Desai: I think the most important thing in your note is to talk about how they’re doing for that day so that people know whether they’re improving, they’re stable, they’re worse, what their O2 requirements are. What relevant things from the physical exam are really important to know. I think at this point in time it’s sad, but the physical exam is like the least part of our encounter with the patients. What their code status is. If you’ve had goals of care conversation, you need to have an ACP note. If they are DNR/DNI, there needs to be an eMOLST and that you spoke to the family and updated them.

Shreya: It’s been great to see that so many hospitals have stepped up and created an easy Dotphrase, for people to use, that pulls in from the chart “#COVID 19”; their day of hospitalization, their oxygen status, oxygen device, the FIO2 and flow rate and their medications. There’s even Dotphrases for family contacts and being updated. So there’s just that little bit of cognitive load that’s decreased with documentation. The other documentation load – in addition to the daily progress note is going to be on your signout, and thinking about what your nocturnist colleagues are going to need to know. 

Effective signout

Dr. LaMotte: Especially when staffing is lower at night, that’s something to think about. So just trying to support nocturnists as much as possible with helpful sign-out. I found it helpful to leave information on that, the day of illness for them,because it’s helpful to know that when you’re thinking about someone’s clinical trajectory and whether they might get worse. So almost like someone on chemotherapy course. Saying you know, this is day 8 of their COVID infection based on the first day of symptoms. Also leaving contact information in the sign-out and any communication difficulties the patient has. So that they can know if they want to talk with the patient – should they try calling the patient, or should they just go right to the room and don the PPE.

Clustering medications

Tim: While you’re finishing up with documentation for the day, remember Tip #8 Review the EMR orders and optimize them to minimize exposure for yourself and colleagues

Dr. Desai: Every patient that I had every day, as a part of signing my note was also making sure that the medication timings were aligned. So I would also tell my support staff that when you order the medication, please look at the previous meds and match the times so that nursing is not going in every two to three hours to give meds. If the patient was already getting a Q8 hour medication, then I ordered heparin subQ so that I matched the time and that everybody’s not getting Lovenox. I feel like eventually we’re gonna run out of Lovenox. But if they would not getting a Q8 hr med, I gave them Lovenox and I matched that Lovenox time to another med that they might be receiving. So that is extremely important. Same thing with bloodwork and draws.

Tim: And don’t forget about things like unnecessary QID fingersticks that sometimes get blown into order sets when you put your diabetic patient on insulin. So if I see their morning fasting sugars are controlled and they are not on steroids, then I talk with nursing and decrease the frequency as much as possible.

Discharge criteria logistics, SAR and home self-quarantine

Shreya: One of the really tricky things about COVID is its unpredictable clinical course. So when do you feel comfortable sending someone home? This leads us to Tip #9 Review your hospital’s criteria for discharging patients depending on their where they are going to go and prepare patients for their discharge with good isolation instructions and return precautions

Dr. Desai: So I base my discharges on – obviously the patient is clearly is clinically improving, stable vital signs, but they don’t have to be on room air and they don’t have to be afebrile. So our standard is – if you’re less three liters of O2 requirement and respiratory stability – so you’re not in distress, you can get up and go to the bathroom on the O2, you’re eating. We plan for those patients to go home with home O2. That being said, it’s insurance-driven. There’s other factors involved. You know, they have to be able to have someone at home to accept the oxygen. But that’s what we’ve been doing. And a lot of patients are going home with O2. They do not have to be afebrile in my mind. Because we have people who are COVID positive who have fever and cough, no respiratory symptoms, and they stay home. So the fever is not the reason to stay in the hospital unless you think it’s for a different reason. 

Shreya: But the fever does matter, depending on where they are going after the hospitalization

Dr. Desai: The other thing about subacute rehabs is that they are taking patients, but they want patients to be afebrile for 72 hours before they take them. So fever matters for SAR discharges and not as much for home discharges, and discharges are also a contingent on home environment. So, the family has to be able to accommodate the patient. They have to be able to isolate at home. They have to have some supports, because people will need to get them things. So it’s really important to coordinate the discharges with the family. And that’s something I ask up front – what their home environment is like.

How many people live in your house, how many rooms do you have and are you able to be in a room by yourself? That gives you a good sense of what you need. And then you can kind of engage the social worker upfront. Hey, this patient is not going to be able to home isolate. Can you see what we can do when the time comes to these ready to go home? Because there have been some options of hotel discharges, but that really requires social work and care management coordination.

Shreya: Yep I am making a note to myself to add asking about home environment and possibility to self-isolate to the things from Tip #6 when talking to patients on admission, and things to talk to patients about up front, especially because patients may be in situations like this

Specific example of logistical barriers

Dr. Desai: I had one patient who could go home, but he had himself and four children, and two adults living in the home and they only had two rooms – two bedrooms. So two kids slept in each room, adults slept in there. I enlisted social work and care management from day one because he gave me the sense that he wasn’t going to be able to go home and isolate until either he met the needs for isolation or we had to find an alternative solution.

Shreya: And on discharge, its gonna be a little bit of different discharge education, particularly on instructions for quarantining.

Graduating from home isolation post-discharge

Dr. Desai: So it’s actually multiple things. One, if you are exposed to someone; so lets start with the patient’s family members. So if the patient is coronavirus positive and the family was exposed to them, they have to quarantine for 14 days from the last time they saw the person. Now the patient, if they’re in hospital and they’re ready to go home, they have to remain on home isolation. The only way to come off is they have to be seven days from their symptom onset and they have to be fever free for three days with no Tylenol. You have to have both. If there’s a cough present, they should still be wearing a mask and their respiratory symptoms, cough symptoms need to be markedly improved. So it’s all of those things that get the patient off of home isolation. 

Shreya: Another thing some of my friends who are Hospitalists at Cornell have said is that they will also add to their discharge AND admission spiel is that symptoms from coronavirus can last for more than 20 days — so giving a heads up it’s gonna take time before they feel back to themselves and also giving them good return precautions

Return precautions

Dr. Desai: And most importantly, I still feel that with what’s going on with the coronavirus people are, going home and coming back with worsening respiratory symptoms. So I am very clear to patients and families that when they go home, if they have any change in their respiratory condition that’s significant or different or feels bad, they have to come back. That’s the big one for me. That they have to know that, that they’re not going to go home and be completely out of the woods. It’s something they need to be proactive about for themselves to pay attention to their symptoms.  

Shreya: It would be great if all our patients could be sent home with pulse ox’s so that they can go home and monitor themselves.

Tim: Hey, maybe that will be the next update for the Apple watch.

Shreya: But I think that giving them return precautions is particularly important, because we do have a bunch of patients who are admitted early on in their symptom course, on day three and they are “ready to go home” on day 5. But it is so hard to know what their symptom trajectory is going to be. Are they going to be one of those patients who is going to worsen on day 8? They might, they might not. Do you keep them in the hospital? Hard decisions! I think the other thing to keep in mind is that when you are sending these patients home, in addition to doing good education, is to think about how weak they might be. That they might not be able to pick up their meds. Some hospitals are being really proactive about this. 

Meds to beds

Dr. LaMotte: So one thing was, and we don’t routinely do this for all our patients,  it’s been more of kind of a pilot. Bringing discharge medications to the patients room – we call it “meds to beds”. That’s not what we usually do – we usually have all patients go to the discharge pharmacy in our hospital to pick up their medications. But especially for patients with COVID, we don’t really want them or their family members traveling unnecessarily in our hospitals. So delivering all the discharge meds to patients was one thing we did.

Tim: While so much of our energy these days is rightfully focused on just getting through our tasks, we really need to be mindful to protect our own well-being.

Self care and acknowledging moral distress

Dr. Desai: One, we have to stay healthy, so I make sure I eat. I make sure I drink water. These all seem like silly things, but they’re actually really important. I am very vigilant about hand hygiene – this is really important to protect yourself and the staff around you. We didn’t really talk about how hard it is in the first couple days that you’re on this service. And what is the hardest for me was watching these patients in a room isolated, no family in distress and suffering. So I think that was the hardest thing to wrap my head around, and then talking to their families and seeing how distressed they are because they can’t see them, or they can’t talk to them, or their phone died and they can’t reach them. So that is really the part that I think took the biggest toll on me. But how I get through it is that I feel that as their doctors, we are there support for them in the hospital The patient’s family feedback for how grateful they were to hear from us and to know that we are caring for them and that we care about all of them is what got me through it. 

Tim: And it’s really healthy to take a mental inventory of the things that drain you, and to reach out to colleagues or friends to help process these crazy times,

And with that we will leave you with some closing thoughts: 

Dr. Desai: I hope it’s useful and helpful to people because it’s just so much information and I do believe that it’s very overwhelming in the beginning. And I really want to thank the people who are coming out of their comfortable zones and making themselves uncomfortable in this environment when it’s already tough for the people who do this every day that I feel so grateful and thankful to them for helping us. Like, I really do.

Shreya: And something that is easy for everyone to forget, even the seasoned hospitalist: 

Dr. Desai: It is hard for us to ask for help as physician sometimes, but you need to ask for help in this situation. Some things are changing every day. Policies are changing. PPE is changing, where you get things is changing and what’s available is changing. So I think you should utilize everyone that’s there to help you and ask for help because that’s the only way we’re going to all get through this as if we get through this together.

Shreya: That’s a wrap for today’s episode. Tweet us and send us a comment on our website page, on instagram or facebook page if you want to add any of your own tips. Lets all learn from each other. Thank you to Dr. Kabao Vang from University Minnesota for the accompanying graphic, to Dr. Becky MacAllister, Dr. Rebecca Berger for their input on this episode, to Harit Shah for editing this very quickly on a Friday night and thanks to you! Look for more episodes on goals of care discussions and advanced care planning in the coming week. Let us know if there is something else you’d like us to cover. 

If you found this episode helpful, give it a rating on Apple podcasts or whatever podcast app you use! It really does help people find us! As always we are open to constructive feedback, email us at hello@coreimpodcast.com. Opinions expressed are our own and do not represent the opinions of any affiliated institutions.

References

 


Tags: