Director’s Corner – Who works the COVID Unit?

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Front line communication and coordination is essential in protecting your team.

Dear Director,


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I have a couple of docs who are older or are at higher risk of a bad outcome if they get COVID and have asked not to see these patients. What do you think?

We have about 200 people who work in my ER. Docs, advanced practice providers, nurses, techs, secretaries, registration clerks and so on. We’ve had a handful of people out already for COVID-19 and it’s likely that more will get sick over this year. However, my biggest fear is that someone from our ED gets critically ill or dies.  It’s a real possibility.  We started seeing potential COVID patients when the State Department started to evacuate employees from China in February so although we haven’t been hit as hard as parts of NYC, we’ve been living it for longer than most and occasionally get called a “hot spot.”

Since the very beginning, I’ve been focusing on keeping our team safe. If the team isn’t safe, they’re at higher risk of getting sick and not being able to work.  And if they don’t feel safe, they’re at higher risk of calling out. While there’s no guarantee that we can protect our staff with 100% confidence  — even with enough PPE —  keeping a focus on staff safety and knowing what other hospitals are doing to protect your staff may help you in your discussions with hospital administration.


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Healthcare has always tried to limit risks to provider and nurses, whether it be avoiding pregnant women from seeing patients with zoster or looking for volunteers when the Ebola patient possibility was in play. But there are limitations based on the number of providers to see the patients both on a shift and in the group and the percentage of patients presenting with possible COVID.  A small group with multiple physicians over the age of 60 that does single coverage in an ED will have a much harder time keeping the only doc on site from seeing a COVID patient than a large practice filled with younger docs that staffs three docs throughout the day and evening shifts who should have more flexibility in what doc sees which patient.

One of our higher risk cases came on an apneic, unresponsive 22-year-old who collapsed after walking into the ED for triage.  It’s not in our nature to pause before going into care for this patient, but it is our way of life for the foreseeable future to make sure we are protected.  Fortunately, our doc had a surgical mask on, did a quick assessment and then was handed an N95 and a face shield prior to intubation.  She knew what she needed, but the team also made sure to call her attention to it.

Some groups also may have enough younger, healthier docs who volunteer to take these procedures or patients in the COVID hot zones from the older docs.  As I’ve asked my younger docs about this, all have enthusiastically said they would volunteer to keep our higher risk docs away from the COVID patients or out of higher risk situations.  As I’ve asked my older docs their thoughts on this, all have said they’re happy to keep showing up and doing their job, albeit with perhaps some extra PPE, although privately they admitted the extra stress weighs on them a bit.

We know the risk of COVID transmission from patient to HCW is higher during high risk procedures, proximity to the airway, failing to use the appropriate mask and the duration of time with the patient. Looking to reduce risk of COVID transmission can be viewed through those issues.


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We’re emergency physicians and by nature, pretty adaptable.  I’ve been working in my ED for nine years and between scribes, iPads and human interpreters, I never knew how to call our interpreter service on the phone.  We all learned pretty quickly when COVID became an everyday part of our lives.

In order to minimize my time in the room, I typically go to the patient’s room to eye ball them.  Tachypneic, sick appearing, vitals, etc…I poke my head in and assuming they are awake enough to use the phone, I tell them I’ll call them in a minute. Much of my history is done over the phone.  I then go in and do a quick exam.  In order to avoid reusing our stethoscopes, and after we quickly figured out the disposable stethoscopes were useless, we found and got the hospital to purchase, low cost, but decent quality reusable stethoscopes that live in the patient’s room and get cleaned after the patient leaves the room.  They bought enough for the ER, ICU and our in-patient COVID units.

Many EDs have developed a COVID section or hot zone.  Although I consider pretty much every patient coming through the ED as possibly having COVID, arranging staffing to minimize our high-risk providers from working in the COVID zone is one option. The CDC and ACOG have published guidelines on risk factors. I’m pretty sure there are laws against me asking my docs about their medical problems, so certainly if someone has a risk factor, they would need to bring it up.

A couple of months ago, we thought it would be easy to keep our pregnant doc from seeing the occasional patient sent by the health department for evaluation.  However, as 50% of our patients are clearly high risk COVID patients and our fast track volume has disappeared, it’s hard to not have everyone involved in caring for this patient population during a shift. As we now have three months of experience around the hospital, we’ve been lucky not to have a lot of hospital staff become sick.  Of those we believe got it from patients, it was earlier in our learning curve before everyone was masked and before we had improved testing capacity.

What we’ve learned is that PPE works pretty well and wearing a mask and goggles into every patient encounter in the ED has reduced the likelihood of transmission to staff.  Likely our highest risk of exposure comes during intubation so many hospitals did turn to an airway team who used PAPRs.  We should work with our hospital partners to maintain necessary equipment such as PAPRs, N-95’s, or N-100 respirators.

Some groups are large enough to use physicians at high risk of complications to fill telemedicine shifts while those originally scheduled pull extra time in the ED. There may also be some docs who voluntarily request to be taken off the schedule for some period of time because of their own concerns for their health. As administrators, we should work to make that possible. While I am completely fine with docs taking a leave of absence for a period of time, I do believe that COVID will be around in the ED patients for the foreseeable future so ultimately these docs need to have a plan on returning to work.

At the end of the day, I don’t see a one size fits all answer.  As directors, we need to minimize risk, so our team is safe.  We also have to respect those physicians who are at higher risk of a bad outcome if they get COVID and are looking for non-clinical options.  I don’t have the perfect solution, but I know it requires front line communication and coordination among the docs working, colleagues willing to look out for one another, flexibility, and creativity so that we keep each other safe.

It also requires a director who is willing to have conversations with individuals about their own concerns and then talks to others to find solutions while making sure coverage is maintained and patients are properly treated.  It goes back to my original thought that we need to work to keep our staff safe, particularly the most vulnerable.

References

https://www.acog.org/clinical-information/physician-faqs/covid-19-faqs-for-ob-gyns-obstetrics
https://www.cdc.gov/coronavirus/2019-ncov/hcp/underlying-conditions.html

ABOUT THE AUTHOR

EXECUTIVE EDITOR Dr. Silverman is Chairman of Emergency Medicine at the Virginia Hospital Center. He also serves as the Chief Performance Officer with Emergency Medicine Associates, a founding partner of Alteon Health. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

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