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A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic

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April 27, 2022
Summary

In the early days of the COVID-19 pandemic, New York Presbyterian Weill Cornell Medical Center and Lower Manhattan Hospital faced multiple challenges. During the first COVID-19 surge, the hospital staff experienced a relatively high patient census, including the doubling of use of intensive care unit (ICU) beds, as well as high patient acuity, scarcity of personal protective equipment (PPE), uncertainty about the nature of the virus, and patient and family communication challenges due to patients requiring isolation.1 Because of these challenges and because the protocol for working with patients with COVID-19 was evolving, there was a need for clear and frequent communication amongst providers and with patients and their friends and family.

As described by the innovation team, having enough staff to meet the patient care needs at the time was a major concern that was exacerbated by several providers’ need to work at home. Several hospitalists stayed offsite due to pregnancy, comorbidities, quarantine due to COVID-19 exposure, or recovery from illness. However, these staff were available to work virtually. Non-hospitalist physicians wanted to help but needed training and support.

The innovation team, led by experienced hospitalists, attempted to meet the demand for patient care while accommodating the need for some staff to work virtually. To meet the need, the team decided to try a new approach to staffing. They trained 15 experienced hospitalists to work virtually to support the onsite clinicians. The virtual hospitalists were able to address patient and family communication, write clinical notes, and train redeployed physicians (physicians that work outside of their specialties in the time of a disaster). Covering these duties freed up the onsite team to see more patients and focus on bedside clinical management of acutely ill patients. The innovation included planned redundancies to improve safety, according to the innovation team. To account for the fact that they were not onsite and treating patients in person, the virtual hospitalists were compensated at two-thirds their normal rate.

In their published article, the team report anecdotal evidence that the innovation helped address challenges with patient volume, centered patient safety, and reduced staff burnout. If given time to prepare, in the future the safety impact of such an initiative should be assessed through data collection and analysis of patient safety measures.

According to the innovation team, smooth implementation of this initiative required teamwork, adequate staffing resources, technological resources, leadership buy-in and support, team member flexibility, and a clear explanation to onsite team members of why some staff were working virtually.

Innovation Patient Safety Focus

This innovation is designed to maximize staff resources to maintain safe standards of care and avoid clinician burnout during times of crisis.

Resources Used and Skills Needed

The initiative requires teamwork and extensive coordination of care. Additionally, the innovation team reports that leaders need to be transparent with their team of clinicians when explaining why the workflow is being changed, and why some providers are permitted to work virtually.

Other resources and skills to consider, according to the innovation team, include emphasizing that the implementing team pay close attention to the Health Insurance Portability and Accountability Act (HIPAA) when communicating with families and rotating providers. Additionally, implementing clinicians need to be flexible and able to shift direction throughout the day to match real-time needs with real-time resources. It is helpful when team members are adept at working together in pairs and small groups. To implement the initiative also requires technological resources for telemedicine and communication between onsite and offsite team members. Finally, obtaining leadership buy-in is crucial. The innovation team emphasizes that the success of the innovation was contingent on the hospital leadership’s support and willingness to try new approaches.

Use By Other Organizations

The innovation team is working on creating centralized resources and data for those interested in the innovation. Additionally, the team has been in discussions about coverage by virtual hospitalists in other settings within the medical center. The innovation team is not aware of use of their specific virtual hospitalist model by other organizations; however, virtual hospitalists from New York Presbyterian Weill Cornell Medical Center helped to provide coverage in El Paso, Texas, when El Paso was experiencing a shortage of providers.

Date First Implemented
2020
Problem Addressed

During the start of the COVID-19 public health crisis, certain locations across the country were inundated with high-acuity patients who maxed out existing hospital resources. Lessons from other countries and early reports from the United States showed that staff at sites treating the first surges of patients had a high risk of burnout.3 Additionally, hospitalized patients and their families struggled with fear of unknown outcomes associated with COVID-19 infection and feelings of isolation from each other due to enforcement of strict contact precautions.1,4

At a time when healthcare workers were in demand, the Section of Hospital Medicine at Weill Cornell Medical Center decided it was equally important to minimize workplace exposure to protect staff at high risk for severe disease. Additionally, because of pregnancy or certain health conditions, some clinicians were advised not to have direct patient contact. Also, staff who were exposed to COVID-19 needed to quarantine.1

To meet the need for healthcare workers to treat an influx of patients, Weill Cornell Medical Center brought in physicians who were redeployed to settings outside their usual scope of practice. This group of workers required rapid onboarding to start their new clinical roles.1

Description of the Innovative Activity

Faced with an unexpected crisis, the innovation team attempted to address the increased demand for patient care while maximizing use of the staff that needed to work virtually in order to quarantine or avoid COVID-19 exposure.

In planning a response, the innovation team drew from several staffing models for solutions, including a telehealth model in which virtual intensivists work together with in-person non-intensivist providers, and a software engineering model, intended to improve accuracy and job satisfaction, in which teams of two work together with one dictating while the other writes code.1

As described by the innovation team, the innovation was a work stream and staffing model that incorporated 15 experienced hospitalists working virtually.1 The virtual hospitalists were paired with onsite clinicians with the intention of reducing the burden for onsite staff and providing training when appropriate. The virtual and onsite hospitalist schedules were created in parallel, with the intent to maximize efficiency and continuity of care for patients. Standardized workflows helped to delineate duties.

Virtual hospitalists conducted rounds with a paired onsite hospitalist and communicated via speakerphone or tablet. While the virtual hospitalists conducted chart reviews and paperwork, the onsite hospitalists focused on physical exams and patient treatment. The virtual hospitalists’ duties included remotely reviewing medications, laboratory results, and vital signs. They also assisted with planning and executing clinical care and focused on communication with patients and families. Virtual hospitalists addressed barriers to human contact by using phone and video visits with patients; virtual visits enabled hospitalists to interact with patients without the hindrances of personal protective equipment (PPE), fear of contagion, or need for haste.

For new admissions, the virtual hospitalist collected history from the patient and family via phone or video and chart review, performed medication reconciliation, drafted an admission note, and provided education and counseling to the patient and the family. Members of the virtual team were then available 24 hours a day to lead for urgent and often changing goals of care conversations with patients and families. Virtual hospitalists also conducted discharge planning and provided bereavement support and staffing for palliative care. Finally, the virtual hospitalists provided training and support to new hospitalists and redeployed non-hospitalist physicians who were recruited to help manage the increase in patient volume and acuity.

Unfortunately, given the need to quickly implement solutions, the team did not collect extensive data to show the impact of the staffing model, and evidence of impact was mostly anecdotal. For any similar initiatives in the future, qualitative and quantitative research is needed to measure associations using patient safety and quality measures.

Context of the Innovation

Between March and April 2020, at the New York Presbyterian Weill Cornell Medical Center and Lower Manhattan Hospital, the need for ICU beds more than doubled.2 The hospital admitted over 1,100 patients with COVID-19.2

At the implementing site and elsewhere, there were restrictions on visitors during the COVID-19 virus surge.1,4 Loneliness, despair, and fear were common emotions for patients hospitalized and in isolation due to COVID-19. Some COVID-19 patients’ families experienced solitude, powerlessness, and interruptions in the relationship with their loved one.3 Efforts to conserve PPE due to limited supplies contributed to patient isolation by reducing patient visits from clinical staff. At Weill Cornell Medical Center, families who were unable to visit their loved ones in the hospital reported a desire for more communication with healthcare provider teams than before the pandemic.

At the same time, early studies recorded high rates of isolation and burnout among healthcare workers caring for patients with COVID-19.4

Results

According to the innovation team, dividing up the work between pairs of providers (the onsite and virtual clinicians) allowed onsite clinicians to see more patients, reducing stress to the system. In their published article describing the innovation, the team provides anecdotal evidence suggesting that the sharing of duties and pairing of providers may have reduced clinician burnout by reducing certain elements of the onsite providers’ workload. Also, the pairing of two clinicians helped to reduce the feeling of isolation, the team reports.1 The innovation team also reports that the virtual hospitalists were able to address the concerns of patients’ families by providing attention to families without the depersonalizing aspect of PPE, fear of contagion, or need to expedite the conversation. Over the course of two months, the virtual hospitalists logged a daily median of 105 minutes on the phone with families, with some days of up to 540 minutes.1

Another benefit reported by the team was that the virtual hospitalists had the time to stay aware of best practices and rapidly evolving research on COVID-19 and then inform the onsite members of their teams.1

Planning and Development Process

Given the urgency of the crisis, the innovation team rapidly developed and planned the innovation. However, the team recommends that in the future, for the pre-implementation planning phase, facility efforts should explore which different pairings of virtual and onsite providers would be most effective.

They also note that it is important to ensure there is the necessary technical infrastructure to support the program (e.g., equipment to implement telemedicine and means for onsite and offsite clinicians to communicate). Finally, they said that it is crucial to begin to explain the initiative and its purpose to other providers in the same system.

Resources Used and Skills Needed

The initiative requires teamwork and extensive coordination of care. Additionally, the innovation team reports that leaders need to be transparent with their team of clinicians when explaining why the workflow is being changed, and why some providers are permitted to work virtually.

Other resources and skills to consider, according to the innovation team, include emphasizing that the implementing team pay close attention to the Health Insurance Portability and Accountability Act (HIPAA) when communicating with families and rotating providers. Additionally, implementing clinicians need to be flexible and able to shift direction throughout the day to match real-time needs with real-time resources. It is helpful when team members are adept at working together in pairs and small groups. To implement the initiative also requires technological resources for telemedicine and communication between onsite and offsite team members. Finally, obtaining leadership buy-in is crucial. The innovation team emphasizes that the success of the innovation was contingent on the hospital leadership’s support and willingness to try new approaches.

Funding Sources

The innovation was funded by Weill Cornell and philanthropic donations that helped purchase tablets and support faculty.

Sustaining This Innovation

To sustain this innovation, the innovation team recommends the following:

  • Make sure that all impacted staff understand the reasoning for the innovation—i.e., that those who work onsite understand why some are working virtually. Make sure the staff know offsite clinicians are earning less than those onsite (e.g., in the virtual hospitalist innovation at New York Presbyterian Weill Cornell Medical Center, the virtual hospitalists earned two-thirds of their typical pay).
  • Staff in all roles must be flexible—for example, flexibility in trying new onsite-virtual staffing combinations and division of duties.  
  • Securing leadership support is essential for sustaining the initiative.
  • Collect data to show potential impact, if possible.
References/Related Articles

Becker CD, Forman L, Gollapudi L, Nevins B, Scurlock C. Rapid implementation and adaptation of a telehospitalist service to coordinate and optimize care for COVID-19 patients. Telemed J E Health. 2021 Apr;27(4):388-396. doi:10.1089/tmj.2020.0232. Epub 2020 Aug 14. PMID: 32804055.

Bloom-Feshbach K, Berger RE, Dubroff RP, McNairy ML, Kim A, Evans AT. The virtual hospitalist: a critical innovation during the COVID-19 crisis. J Gen Intern Med. 2021;36(6):1771-1774. doi:10.1007/s11606-021-06675-y. Epub 2021 Mar 25. PMID: 33768500; PMCID: PMC7993080.

Bowden K, Burnham EL, Keniston A, et al. Harnessing the power of hospitalists in operational disaster planning: COVID-19. J Gen Intern Med. 2020 Sep;35(9):2732-2737. doi:10.1007/s11606-020-05952-6. Epub 2020 Jul 13. PMID: 32661930; PMCID: PMC7358298.

Cockburn A, Williams L. The costs and benefits of pair programming. In: Succi G, Marchesi M, eds. Extreme Programming Examined. Addison-Wesley Longman Publishing; 2001:223-243.

Curtis JR, Kross EK, Stapleton RD. The importance of addressing advance care planning and decisions about do-not-resuscitate orders during novel coronavirus 2019 (COVID-19). JAMA. 2020;323(18):1771-1772. doi:10.1001/jama.2020.4894.

Kuperman EF, Linson EL, Klefstad K, Perry E, Glenn K. The virtual hospitalist: a single-site implementation bringing hospitalist coverage to critical access hospitals. J Hosp Med. 2018 Nov 1;13(11):759-763. doi:10.12788/jhm.3061. Epub 2018 Sep 26. PMID: 30255859.

Yoon C, Lee J, Fong E, Lee JI. The virtual team member: remote engagement of medical students in COVID-19 care. Med Sci Educ. 2021 Oct 19:1-8. doi:10.1007/s40670-021-01422-8. Epub ahead of print. PMID: 34692228; PMCID: PMC8525619.

Footnotes
  1. Bloom-Feshbach K, Berger RE, Dubroff RP, McNairy ML, Kim A, Evans AT. The virtual hospitalist: a critical innovation during the COVID-19 crisis. J Gen Intern Med. 2021 Jun;36(6):1771-1774. doi:10.1007/s11606-021-06675-y. Epub 2021 Mar 25. PMID: 33768500; PMCID: PMC7993080.
  2. Goyal P, Ringel JB, Rajan M, et al. Obesity and COVID-19 in New York City: a retrospective cohort study. Ann Intern Med. 2020;173(10):855-858. doi:10.7326/M20-2730.
  3. Kentish-Barnes N, Cohen-Solal Z, Morin L, Souppart V, Pochard F, Azoulay E. Lived experiences of family members of patients with severe COVID-19 who died in intensive care units in France. JAMA Netw Open. 2021;4(6):e2113355. doi:10.1001/jamanetworkopen.2021.13355.
  4. Sasangohar F, Jones SL, Masud FN, Vahidy FS, Kash BA. Provider burnout and fatigue during the COVID-19 pandemic: lessons learned from a high-volume intensive care unit. Anesth Analg. 2020;131(1):106-111. doi:10.1213/ANE.0000000000004866.

FYI: You may notice that the PSNet Innovations Exchange has recently been updated (April 2022) to remove the evidence rating section. For more information or questions, please email psnetsupport@ahrq.hhs.gov.

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Contact the Innovator

Kimberly Bloom-Feshbach

kib9047@med.cornell.edu