Mobile stroke programs provide speedy evaluation and treatment of patients when every minute counts.
A Cincinnati-based health system with a history of innovation in stroke care has launched a mobile stroke unit.
Nearly 800,000 people have strokes annually, according to the American Heart Association. A rapid response to stroke is crucial for positive outcomes. If a stroke is caused by a clot lodging in a blood vessel supplying the brain, most patients need the clot-busting drug tissue plasminogen activator (tPA) within three hours.
UC Health crafted the FAST method for detecting stroke and played a leading role in the development of tPA in the late 1980s. FAST stands for Face drooping, Arm weakness, Speech difficulty, and Time to call 911.
In August, UC Health launched a mobile stroke unit that responds to a patient's home when acute stroke is suspected. "The overall goal of the Mobile Stroke Unit is to bring a lot of what we can do in the emergency department for acute stroke patients to the curbside of patients, so we can diagnose and potentially treat in a very timely manner," says Christopher Richards, MD, MS, medical director of UC Health's Mobile Stroke Unit program.
The Mobile Stroke Unit deploys out of the firehouse at Springfield Township, Ohio, which is centrally located in UC Health's service area. The service is available seven days a week from 7 a.m. to 7 p.m.
The startup costs for the program—including the ambulance, equipment, supplies, and training—were $1 million. The annual operating costs, which consist mainly of personnel and supplies, are about $500,000.
How the Mobile Stroke Unit works
The Mobile Stroke Unit ambulance is manned by a paramedic, nurse, CT scan technician, and EMT/driver. A key element of the personnel is a stroke neurologist who participates in Mobile Stroke Unit calls virtually, Richards says.
"The stroke neurologist who joins the team virtually is a critical part of the operation. The decisions about clot-busting medications, reversing bleeding strokes, and blood pressure management are beyond the scope of a critical care nurse or a paramedic. So, the consultation we have from the UC Health stroke team is a critical part of the Mobile Stroke Unit," he says.
The nurse and paramedic facilitate the stroke neurologist's examination with an iPad, so the physician can not only interact with the patient but also watch as the patient is screened for symptoms such as poor coordination and speech difficulty. "The evaluation is the same as a patient would receive in an emergency room," Richards says.
A patient receives a CT scan in UC Health's Mobile Stroke Unit. Photo Credit: UC Health
Having CT scan capability in the ambulance plays an essential role, he says. "When the patient is brought to the Mobile Stroke Unit, one of the first things the team can do is give a CT scan. That is a huge differentiator in stroke care to determine whether there is a bleeding stroke, which has a vastly different treatment pathway, or a more common ischemic stroke with blockage of an artery."
The Mobile Stroke Unit works in concert with local emergency medical services ambulances, Richards says.
"What typically happens is that a patient, loved one, or bystander will call 911. They communicate with a dispatcher about what is happening. If the dispatcher suspects stroke, they will dispatch a local EMS ambulance and may dispatch the Mobile Stroke Unit at the same time. Oftentimes, a local EMS paramedic will be on the scene first and conduct screening and evaluations, then the Mobile Stroke Unit arrives."
The local EMS crew takes charge of the scene, he says.
"We help in whatever way we can with patients. To foster that relationship before we launched, we did significant outreach to our EMS partners in the areas where we would be responding to make sure they understood what we could do, what we could not do, how we could help, and how we would interact on scene."
For patients suffering ischemic stroke, the Mobile Stroke Unit plays a pivotal role in speeding up administration of tPA to dissolve blood clots, Richards says.
"Without the Mobile Stroke Unit, the best scenario is paramedics get on scene quickly, they do some screening and recognize a stroke is occurring, then there is transport to the hospital, an intake process at the hospital, and a CT scan. By being able to bring a CT scanner, tPA, and a stroke team physician virtually to the curbside, the Mobile Stroke Unit cuts out a lot of time."
Other mobile stroke programs have reported that they can speed up administration of tPA by 30 to 45 minutes. "That time could be the difference in levels of disability and in receiving tPA or not," he says.
The Mobile Stroke Unit is at the curbside for as long as an hour, and most patients are transported to local hospitals.
Keys to success
There are five elements to operating a successful mobile stroke program, Richards says.
1. Accounting for the entire episode of care: The treatment of stroke is a "chain of survival" and the chain is only as strong as its weakest link, he says. "The chain stretches from laypersons at home recognizing that a loved one may be having stroke symptoms, to the 911 dispatcher, to paramedics, then all the way down the line to the hospital. The Mobile Stroke Unit is a way to compress that chain of survival."
2. Laying a foundation: The community must be involved in establishing a mobile stroke program, Richards says. "When we set up our program, one consideration was how the Mobile Stroke Unit was going to be received by the public, who is used to their local EMS ambulance showing up and knowing they are going to be on the scene for a short period of time. It is a change of mindset for the public. Our Mobile Stroke Unit is going to be on the scene for an extended period."
3. Engaging EMS partners: Establishing a working relationship with local EMS crews is crucial, he says. "We operate in a system where we ask to be invited to participate with our local EMS agencies."
4. Creating hospital partnerships: Once patients have been evaluated and treated as needed, the UC Health Mobile Stroke Unit sends patients to the closest and most appropriate hospital, regardless of whether the hospital is part of the health system. The logistics of sharing information is pivotal, Richards says.
"When we do a CT scan in the back of the Mobile Stroke Unit, our radiologists at UC Health read those images, but that read and those images have to be accessible to a receiving hospital if it is not a UC Health facility. So, we have worked through the logistics of the interoperability of systems, which has been a critical component of our program."
The Mobile Stroke Unit program also has established protocols for communication between the virtual stroke neurologist and the treatment teams at local hospitals, he says. "That has allowed us to do a couple of things. First, while we most commonly transport patients to an emergency department, we can go directly to an interventional suite if the patient has the type of clot that neuro-interventionists can take out. We also can go directly to a neurological intensive care unit."
5. Stocking supplies: It is essential for a mobile stroke program to have medical supplies to meet the needs of patients with suspected stroke, Richards says. "We have worked closely with our pharmacy colleagues to think about which medications we should have onboard."
ECMO life support can be used when coronavirus patients with acute respiratory distress syndrome respond poorly to mechanical ventilation.
Seriously ill coronavirus patients placed on extracorporeal membrane oxygenation life support have a similar mortality rate as other patients placed on ECMO with acute respiratory distress syndrome (ARDS), a recent research article says.
ECMO is a form of life support that features a machine that performs essential functions of the heart and lungs. The ECMO machine is connected to a patient through plastic tubes that are placed in large veins and arteries in the legs, neck, or chest, according to the American Thoracic Society. Blood flows through the ECMO machine, which adds oxygen to the blood and removes carbon dioxide, then the blood is returned to the patient.
The co-authors of the recent research article wrote that the study provides "provisional support" for using ECMO to treat coronavirus patients with acute hypoxemic respiratory failure. "In ECMO-supported patients with COVID-19 and characterized as having ARDS, estimated in-hospital mortality 90 days after ECMO initiation was 38.0%, consistent with previous mortality rates in non-COVID-19 ECMO-supported patients with ARDS and acute respiratory failure."
The recent journal article, which was published by The Lancet, features data collected from more than 1,000 ECMO patients at more than 200 hospitals. The study includes two key data points.
COVID-19 patients with ARDS who received respiratory (venovenous) ECMO had a 38.0% estimated cumulative incidence of in-hospital mortality 90 days after ECMO began.
COVID-19 patients with ARDS who received respiratory ECMO had a mortality rate similar to the mortality rate found in the largest randomized controlled trial of ECMO for ARDS patients without coronavirus—the ECMO to Rescue Lung Injury in Severe ARDS (EOLIA) trial. In the EOLIA trial, 60-day mortality for ECMO patients with ARDS was 35%.
Interpreting the data
The lead author of the study told HealthLeaders that the research is significant because it provides a generalizable estimate of mortality for ECMO-supported patients with COVID-19, and the estimate is similar to the reported mortality in other major studies of ECMO support for ARDS patients.
"If your center is experienced in providing ECMO support to patients with ARDS you might expect similar results when providing ECMO support to patients with COVID-19-related ARDS," said Ryan Barbaro, MD, MS, an assistant professor at University of Michigan in Ann Arbor, Michigan.
Organ injury is a key factor for survival of coronavirus patients with ARDS who receive ECMO, he said.
"We found that patients had a higher risk of dying if they had worse lung disease, required circulatory support, had kidney injury, or experienced a cardiac arrest. Our study did not answer when is the best time to initiate ECMO support for patients with COVID-19. However, it does suggest that patients who initiated ECMO support with less organ injury had less risk of dying."
Barbaro speculated that ECMO can be an effective treatment for coronavirus patients with ARDS because the technology avoids lung damage associated with mechanical ventilation and effectively oxygenates a patient's blood.
"The World Health Organization recommends doctors consider ECMO support in patients who have failed lung protective ventilation. In theory, ECMO benefits patients because it avoids the accumulation of injury caused by high ventilator pressures or caused by the inability to provide enough oxygen to the patient. In these cases, ECMO support can do the work of the lung outside of the body—this is analogous to how dialysis can do the work of the kidney outside of the body."
In healthcare, disruptive behaviors weigh heavily on physicians, nurses, and other staff members.
A former senior nurse is leading a for-profit institute dedicated to addressing bullying and incivility in healthcare settings.
Bullying and incivility are rampant in healthcare organizations. A 2018 study found that 43% of nurses had experienced at least two negative behaviors on a weekly or daily basis, and 12% of nurses self-identified as victims of negative behaviors. A 2020 study found that one or more of six disruptive behaviors were reported at 97.8% of healthcare workplaces, with disruptive behaviors associated with poorer teamwork climate, safety climate, job satisfaction, and perceptions of management.
Renee Thompson, DNP, RN, left nursing a decade ago to become a national speaker on bullying and incivility in healthcare. In 2017, she founded the Oldsmar, Florida-based Healthy Workforce Institute, which provides resources to curb bullying and incivility, consultancy services, and training for healthcare leaders.
Thompson recently talked with HealthLeaders about the scope of healthcare workplace bullying and incivility as well as the Healthy Workforce Institute's efforts to address the problem. The following is a lightly edited transcript of that conversation.
HealthLeaders: Why are bullying and incivility widespread in healthcare?
Renee Thompson, DNP, RN: There is more bullying and incivility in healthcare than any other industry. For many people, it is unexpected because healthcare is a caring and compassionate industry.
There are a couple of reasons. First, think about the high level of stress, particularly this year. Our healthcare teams are dealing with more stress than they ever have had to deal with before. When people are burned out and they are stressed, they do not behave well. There also is the unpredictability of care and the life-and-death situations that healthcare professionals find themselves in.
Another reason is we accept bad behavior as the norm in healthcare. One of the things we hear about physicians is that we tolerate bad behavior because of how excellent they are clinically. So, we have normalized deviant behaviors—we do workarounds, and we justify, and we rationalize for why someone behaves badly.
HL: What role can healthcare organization leaders play in addressing bullying and incivility?
Thompson: What we have found is that executives are not doing a good job equipping their frontline leaders with the skills and tools they need to address disruptive behaviors. Leaders need to be equipped with skills to address disruptive behaviors in the same way that they are equipped with skills for managing budgets and meeting regulatory requirements.
HL: What are the kinds of skills you teach healthcare leaders?
Thompson: First, we always start with heightening awareness. People in healthcare have been behaving badly for decades. You can't just come in and say, "We are going to start being nice to each other." You must heighten awareness because some people do not realize that their behavior needs to change.
We do things like build in content related to disruptive behaviors into new employee orientation, nurse residency programs, preceptor programs, and physician residency programs. It must be ongoing. You must infuse content related to behavior in everything you do.
With the leaders, we do the same thing. We equip them with the tools they need to heighten awareness among their staff. We teach them how to set behavioral expectations as a team.
We spend a lot of time teaching leaders how to confront disruptive behaviors. You may have a seasoned, experienced, and clinically excellent nurse who is toxic. We teach leaders how to have a conversation with that kind of an employee. We are big on scripting—giving leaders scripts to know what to say to someone, when to say it, and how to say it.
Leaders also have to hard wire addressing bullying and incivility. Once you create a caring culture, it can quickly regress if you do not hard wire healthy workforce best practices into the fabric of your hospital departments. For example, if a leader is interviewing a job candidate, the department norms should be pulled out. A leader should say, "This is what you can expect from us, and this is the behavior we expect of you. Things like kindness, respect, and giving and receiving feedback are not optional here—they are part of the job requirements."
HL: Is there a connection between bullying and incivility on one hand and burnout on the other?
Thompson: During the pandemic, we are seeing an uptick in bad behavior. There are some healthcare teams that are pulling together, but there are a lot of teams that are falling apart. You must acknowledge that when people are stressed and burned out, they do not behave well.
So, you must address burnout to address bullying and incivility. There is a strong connection between somebody's well-being, their stress level, and how they perform in the workplace. When you are under stress, you are not always behaving in a professional manner.
Burnout is one of the most vexing challenges facing physicians and other healthcare workers nationwide. Research published in September 2018 found that nearly half of physicians nationwide were experiencing burnout symptoms, and a study published in October 2018 found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction.
The summit is being hosted by The Ohio State University colleges of dentistry, medicine, nursing, optometry, pharmacy, public health, social work, and veterinary medicine, as well as The Ohio State University Wexner Medical Center and the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience.
The event was formed last year to address a pressing need among healthcare professionals, says summit co-chair Bernadette Melnyk, PhD, RN, APRN-CNP, dean of the College of Nursing and chief wellness officer at The Ohio State University in Columbus, Ohio.
"It was launched because we wanted to make an impact on the rates of clinician burnout, depression, and suicide. Now, with the coronavirus pandemic, those rates have worsened even more. Doctors and nurses are suffering now from post-traumatic stress disorder, burnout, anxiety, and depression," she says.
The mission of the summit is to share best practices on how to improve healthcare professional well-being and resilience as well as to spur people to action, Melnyk says.
"This year, we are going to have a call to action for the 90 days after the summit. What are you going to do personally as well as at your workplace to take some of the evidence-based strategies you have learned at the summit and implement them? I am going to send a follow-up survey 90 days after the event, so we can document some outcomes from the summit."
Summit agenda highlights
This year's summit has five themes:
1. Promoting well-being and healthy lifestyle behaviors in healthcare professionals
2. Promoting well-being and healthy lifestyle behaviors in health sciences students and faculty
3. Organizational and systemwide initiatives to enhance workplace wellness culture
4. Innovations to promote well-being, resilience, and healthy lifestyle behaviors
5. Innovative solutions launched during the coronavirus pandemic
The summit will begin with several workshops during the afternoon of Oct. 21. Then full days of sessions will be held on Oct. 22 and Oct. 23.
U.S. Surgeon General Jerome Adams, MD, MPH, is a late addition to the roster of presenters. He is slated to speak at 9 a.m. on Oct. 22.
There will be two keynote presentations:
Liselotte "Lotte" Dyrbye, MD, MHPE, of Mayo Clinic will conduct a presentation titled "Burnout: Strategies to Get to System-Level Solutions"
Doug Smith, MBA, who is co-founder of Positive Foundry and a former CEO of Kraft Foods Canada, will conduct a presentation titled "The Science and Skill of Flourishing"
Phoenix-based Equality Health gathers social determinant data at primary care practices to connect patients with social services.
Equality Health has included addressing social determinants of health in the health system's care delivery system, with primary care practices playing a leading role.
Social determinants of health (SDOH) such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. By making direct investments in initiatives designed to address social determinants and working with community partners, healthcare organizations can help their patients in profound ways beyond the traditional provision of medical services.
"The model for our delivery of healthcare incorporates social determinants and a cultural approach to care. For us, social determinants are not a standalone project. That is a key element of the success that we have seen so far. It is not a bolt-on program. We are not doing it to be compliant with a government mandate. We are addressing social determinants because we think it is the best way to deliver care and improve outcomes," says Mark Stephan, MD, MBA, chief medical officer of Equality Health.
Including social needs in care delivery
Primary care practices are a foundational element of Equality Health's social determinant efforts, screening patients for social needs and cultural preferences with the health system's Social Cultural Risk Assessment survey. The risk assessment tool queries patient about housing, transportation, food insecurity, cultural beliefs and preferences around healthcare and medications, behavioral health, physical activity, sense of wellbeing, and spiritual needs.
The risk assessment survey, which was developed by Equality Health and has undergone several revisions, is administered to patients while they wait for their primary care appointments.
"It is a brief questionnaire but covers a lot of ground," Stephan says.
Primary care practices were chosen to play a frontline role in the effort to address SDOH because the clinics have relationships with patients, he says. "The doctor's office is still very much a trusted source of care. There is a doctor-patient relationship. It is an effective area to collect a survey from a workflow perspective."
Equality Health's onboarding of new primary care practices features four hours of training, which includes instruction on cultural awareness and SDOH for the entire staff.
"We go beyond cultural competence in our training to what I call cultural care delivery. There are three levels. One is cultural awareness. Another is cultural competence—being sensitive to how things are presented. Finally, there is cultural care delivery, which means we are expecting there to be cultural preferences in how healthcare is accessed and utilized," Stephan says.
An example of cultural care delivery is accommodating the participation of several family members during primary care visits, which is a cultural preference of many ethnic minority groups.
If a patient screens positive for a social need, clinicians can make referrals to community-based organizations and other local resources. The referrals are managed digitally in a two-step process, he says. First, social needs referrals are entered in Equality Health's care coordination platform with other "wrap-around" services such as patient education counseling. Second, social needs referrals are placed on a social determinants platform that can be accessed by local social services providers.
"The next step is making the social determinants platform available so that a referral done at a practice will go directly into that platform," he says.
Equality Health has curated its network of social service providers, Stephan says. "It is a mix, but the majority are community-based organizations."
The health system engages patients to make sure referrals result in action, he says. "On the surface, you think you just point people in the right direction of a community-based organization and hope for the best. But we reach out to patients digitally and we reach out telephonically."
Primary care practices receive a quarterly financial incentive from Equality Health for administering the Social Cultural Risk Assessment survey, he says. "What we have done is break incentives down into quarterly payments, so that we are closer to real time. It gives more immediate feedback on the activities that doctors have done to earn the incentive."
Addressing healthcare disparities
Tackling SDOH is only part of Equality Health's approach to closing healthcare disparity gaps, Stephan says.
"Socioeconomic status makes a difference in people's ability to access care and to understand the plan of care; but beyond that is the core of our thesis, which is how you perceive the delivery of care and how you perceive the relationship with the clinicians and practices that are delivering care. That matters as much as anything because when it comes down to it, when you are discussing going through a procedure the key to success is the relationship between the clinician and the patient."
Cultural care delivery promotes positive relationships between clinicians and members of minority ethnic groups, he says. "There has to be trust. The more trust and deeper the relationship, the more mutual understanding, and the more likelihood that the care plan will be successful and there will be a better health outcome."
While it is difficult to tease out the impact of social needs referrals and cultural care delivery, Equality Health believes its approach is making a difference for the health system and the communities it serves, Stephan says.
"We know directionally that by incorporating this survey, by doing the training, by deploying our model across our network, we are being successful partnering with health plans and physician practices, and better outcomes are happening. The cost of care is going down and the quality is improving."
New research shows total primary care visits decreased 21.4% in the second quarter of 2020 compared to the second quarters of 2018 and 2019.
Despite a significant increase in telemedicine visits, primary care utilization has fallen significantly during the coronavirus pandemic, a new research article shows.
COVID-19 is a highly infectious and potentially deadly illness. As of Oct. 5, more than 7.6 million Americans had been infected, with more than 210,000 deaths, according to worldometer. Largely due to concern over the spread of the virus in healthcare settings, many patients have avoided in-person primary care visits and physician practices have expanded telemedicine visits.
The new research article, which was published last week by JAMA Network Open, features data collected from millions of primary care visits in the 10 calendar quarters between Q1 of 2018 and Q2 2020. The study has several key data points.
From January 2018 to December 2019, quarterly primary care visits ranged from 122.4 million to 130.3 million, with 92.9% of visits conducted in person.
In 2020, Q1 primary care visits decreased to 117.9 million and Q2 primary care visits decreased to 99.3 million. The Q2 visits were 21.4% lower than the average Q2 levels in 2018 and 2019.
In-person primary care visits decreased 50.2% in Q2 2020 compared to Q2 in 2018 and 2019.
Telemedicine primary care visits increased from 1.1% of the total visits in Q2 of 2018 and 2019 to 35.3% of the total visits in Q2 of 2020.
In Q2 2020 compared to Q2 2018 and Q2 2019, blood pressure level assessment decreased 50.1% and cholesterol level assessment decreased 36.9%.
Blood pressure and cholesterol assessments were lower in telemedicine visits compared to in-person visits. Blood pressure was assessed in 9.6% of telemedicine visits vs. 69.7% of in-person visits. Cholesterol was assessed in 13.5% of telemedicine visits vs. 21.6% of in-person visits.
Interpreting the data
During the pandemic, telemedicine visits have partially offset a significant decrease in total primary care visits, the new research article's co-authors wrote. "The pandemic has been associated with a more than 25% decrease in primary care volume, which has been offset in part by increases in the delivery of telemedicine, which accounted for 35.3% of encounters during the second quarter of 2020."
Primary care assessment of cardiovascular risk factors such as blood pressure and cholesterol levels have decreased during the pandemic, due to a reduction in total visit volume and lower assessment rates in telemedicine visits compared to in-person visits. The reduced assessments in telemedicine visits suggest a significant limitation of how telehealth is being practiced, the study's co-authors wrote.
"Our finding that such visits were less likely to include blood pressure or cholesterol assessments underscores the limitation of telemedicine, at least in its current form, for an important component of primary care prevention and chronic disease management," they wrote.
Primary care has undergone fundamental changes during the pandemic, they wrote. "The COVID-19 pandemic has been associated with changes in the structure of primary care, with the content of telemedicine visits differing from that of office-based encounters."
In the first six months of the coronavirus pandemic, one-fifth of nursing homes reported shortages of staff and personal protective equipment.
During the coronavirus pandemic, many nursing homes have struggled with shortages of staff and personal protective equipment (PPE), a new research article shows.
Through July, nearly half of the country's COVID-19 deaths had occurred in nursing homes or other long-term care facilities, with 60,000 deaths. The virus also has taken a heavy toll on long-term care healthcare workers, with 760 deaths through July.
"Many nursing homes in the United States are poorly prepared to prevent and manage COVID-19 outbreaks, given a lack of essential PPE and staff. Despite intense policy attention and mounting mortality, the shortages did not meaningfully improve from May to July 2020," says the new research article, which was published today by Health Affairs.
The study features information gathered from more than 15,000 nursing homes. The research includes several key data points:
At the end of the study in July, 19.1% of nursing homes reported severe shortages of PPE, particularly N95 respirator masks and gowns.
At the end of the study, 21.9% of nursing homes reported staff shortages.
Nurse aids led staff shortages at 18.5%, followed by nurses at 16.0% and other staff at 9.3%
Nursing homes with the highest star ratings from the Centers for Medicare & Medicaid Services (CMS) were less likely to report staffing shortages. Compared to nursing homes with a one-star overall rating, five-star nursing homes were 6.4 percentage points to 7.5 percentage points less likely to report staffing shortages.
PPE shortages were nationwide, with dire shortfalls in northern New England, Alabama, North Carolina, Tennessee, and West Virginia.
Staff shortages were concentrated in the South and Midwest, particularly Alabama, Eastern Texas, Georgia, and Louisiana.
"Using the most comprehensive survey of nursing homes during the COVID-19 pandemic to date, we found that roughly one in five facilities faced a staff shortage or a severe shortage of PPE in early July 2020. Despite a slight decrease in facilities with any PPE shortage driven by the higher availability of gowns, overall PPE and staff shortages had not meaningfully improved since late May 2020," the research article's co-authors wrote.
Interpreting the data
Since the beginning of the pandemic, nursing homes have established good protocols for infection control, visitation, quarantine procedures, and testing. But resources remain a concern, the lead author of the research article told HealthLeaders.
"Our study looked at two fundamental resources, PPE and staffing, and found that about 20% of facilities reported each type of shortage. This obviously raises significant concerns that a lack of adequate PPE or a workforce spread too thin will be the weak points in managing COVID-19 patients and preventing outbreaks as we head into fall and winter and future COVID-19 outbreaks," said Brian McGarry, PhD, an assistant professor in the Department of Medicine at University of Rochester in Rochester, New York.
Specific types of nursing homes are at highest risk of PPE and staff shortages, he said.
"With respect to PPE shortages, we found that for-profit, chain-affiliated, and lower quality—as measured by the CMS 5-star quality score)—were more likely to report shortages. Facilities that reported having had COVID-19 cases among their residents and staff were also more likely to report a PPE shortage," McGarry said.
"In terms of staff shortages, these were more common among facilities that are government owned, have greater shares of revenue from Medicaid, and lower quality facilities, in terms of both the overall quality score and a staffing-specific quality score. Additionally, having had COVID-19 cases among staff was also associated with an increased likelihood of reporting a staff shortage," he said.
The findings indicate a pattern, McGarry said. "Disadvantaged facilities—those with lower quality and those that disproportionately serve residents with safety-net Medicaid coverage—were more likely to report shortages. These facilities may be more financially constrained and may have difficulty buying additional PPE stocks or hiring additional staff."
The American Medical Association says healthcare organizations should address physician stressors during the coronavirus pandemic.
The American Medical Association has launched five online resources to help physicians promote their wellbeing during the coronavirus disease 2019 (COVID-19) pandemic.
Research published in September 2018 indicated that nearly half of physicians nationwide were experiencing burnout symptoms. Now, the COVID-19 pandemic has introduced new burdens on physicians, including high mortality among coronavirus patients, and worry over contracting the virus and infecting family members.
Physicians need support for their mental health, Marie Brown, MD, the AMA's director of practice redesign told HealthLeaders last week.
"While it is always important to focus on physician mental health, the emergence of the COVID-19 pandemic has brought new challenges and exceptional demands that strain physicians. The AMA has responded by quickly moving new resources into the field that support the well-being of physicians during a time of acute stress," she said.
The five new online modules focus on how health systems can boost physician wellbeing during the pandemic.
Unexpected crises are stressful and thrust uncertainty and increased workload on clinicians. The model identifies common stresses on healthcare workers during a crisis and offers strategies to overcome strains and build resilient organizations.
A chief wellness officer is responsible for strategies and programs designed to foster healthcare worker wellbeing. This model has a step-by-step approach to establishing and maintaining a chief wellness officer position.
A chief wellness officer must know how to implement initiatives that bolster healthcare worker wellbeing. This model features steps to improve wellbeing and the practice environment as well as advice for avoiding pitfalls.
Peer support is essential for clinicians during a crisis such as the pandemic. This module describes how to recruit and train peer leaders as well as how to build a peer support program.
Patient portals benefit patients and physicians by boosting communication, accessibility and efficiency that can reduce office visits during the pandemic. This module provides five steps for improving patient portals.
Coping with the pandemic
There are four primary sources of stress for physicians during the pandemic, Brown told HealthLeaders.
Life Threat: Many physicians fear they will contaminate their families due to work exposure.
Inner conflict: Physicians may experience moral distress when triaging and treating patients as well as from rationing personal protective equipment. Not having the tools to effectively prevent or treat COVID-19 may make physicians feel helpless. Some physicians have been redeployed to care for COVID-19 patients in unfamiliar settings and feel less prepared to provide care.
Loss: Many physicians are experiencing overwhelming numbers of patients, colleagues, and family members suffering or dying. In addition, many physicians have isolated themselves to protect their families from the virus and are unable to be with their loved ones.
Wear and tear: The constant accumulation of demands and relentless workload can result in tremendous physical and mental fatigue if there is little, or any, time for rest and recovery. Work-related stress is exacerbated if physicians are prevented from recharging with their family and friends.
"Early intervention may preclude the stress injury from turning into a chronic stress reaction that may include burnout, depression, exiting practice, substance use, post-traumatic stress disorder, or suicide," Brown said.
She said there are six keys to success for chief wellness officers.
Ensure that your organization's leadership embraces supporting clinicians to improve patient care and lower costs
Define scope of the job and identify needed resources to achieve your goals
Identify what programs and team members already exist within the organization
Communicate often with leadership and physicians—provide simple channels for physicians to communicate concerns and solutions
Visualize what success might look like for your team and organization
Measure burnout regularly
Peer support is a valuable resource for physicians during the COVID-19 pandemic, she said. "Developing a peer support program trains physicians to help their colleagues while providing greater opportunity for stressed physicians to receive help during distress. Peer support has added significance when physicians face barriers to seeking professional mental health services."
Effective patient portals are a win-win for patients and physicians, she said. "The principle driver of physician satisfaction and well-being is being able to deliver great quality care. When we use technology such as the patient portal to increase the quality of the care, we deliver for our patients—everyone benefits."
Contrary to popular perception, older patients appear ready to embrace telemedicine.
Telemedicine is a powerful tool in the clinical care of older patients, according to a pair of experts.
The COVID-19 pandemic has spurred widespread adoption of telemedicine along several fronts at health systems, hospitals, and physician practices—primarily over concern about the spread of the novel coronavirus in healthcare settings. Telemedicine visits for nonemergency care also have been shown to be efficient and effective from both the healthcare provider and patient perspectives.
Contrary to popular perception, older patients appear ready to embrace telemedicine as shown in a recent report from Strata Decision Technology. The report is based on data collected from 43 health systems as well as telehealth visit data drawn from the American Medical Association and the Centers for Medicare & Medicaid Services.
As a percentage of all medical visits from March to July 2020, the report found telehealth visit utilization was highest for the 30–39 age cohort, at 27.95% of all medical visits. However, telehealth visit utilization also was significant for older age cohorts:
50–59: 24.70%
60–69: 23.61%
70–79: 22.52%
80–89: 20.29%
Over 90: 19.04%
Telehealth visits provide older patients with greater access to medical care than in-person visits, says Jeffrey Gelblum, MD, a practicing neurologist at First Choice Neurology in Aventura, Florida, and an associate professor at Nova Southeastern University in Fort Lauderdale, Florida.
"Historically, we had to deal with older folks who may not be able to drive and older folks who would have difficulty finding a parking space. If the weather was bad, some older folks did not want to go to a doctor appointment. Driving for older folks is problematic in terms of compliance. But now with telehealth, that situation has been resolved," he says.
Telemedicine also gives medical practices an opportunity to see older patients more frequently than in-person visits, says Kristofer Smith, MD, MPP, president of home-based medical care at Brentwood, Tennessee–based naviHealth and former senior vice president of population health at Manhattan, New York–based Northwell Health.
"If you can increase the number of interactions with patients and families to build a relationship, you tend to get stickier relationships faster," Smith says.
Rising to the challenges
Dealing with the technology requirements of telehealth visits is the primary telemedicine challenge for older patients, Smith and Gelblum say.
"The first challenge is the ability to have enough Wi-Fi or broadband data access so that you can have a visit beyond a telephone call and have a video visit. Between 25% and 40% of communities do not have sufficient access. For many older patients, they are not technologically comfortable, so that is another challenge," Smith says.
Encouraging older patients to conduct telehealth visits on their smartphones is a prime strategy to overcome the Internet access challenge, Gelblum says.
"We tell our older patients that they got their Apple phones for a reason and, 'let's go there for your telehealth encounter. The quality is going to be great. If you do not have Internet access, there are no worries—you go on a 4G or 5G network.' So, the smartphone is much more liberating for our senior population. At least down here in South Florida, most older patients are smartphone-equipped," Gelblum says.
At Northwell Health, the health system enlisted emergency medical technicians to facilitate telehealth visits in patient homes, Smith says. The EMTs would bring Wi-Fi devices with them as well as a laptop or iPad.
With the EMT model of telehealth care, Northwell Health was able to achieve nearly 100% execution of video visits. In addition to facilitating the telehealth visits, having an EMT present has an added benefit, Smith says. "When the healthcare provider in the central location needed additional information such as a physical exam or a medication review, we had a trained professional who could augment the video visit with additional data so that we could make better clinical decisions about the next steps for the patients."
The EMT model is only possible for patients who have insurance coverage through at-risk contracts such as Medicare Advantage, he says. "For the frail elderly practice that we ran at Northwell Health, we were at risk for total cost of care. So, we were responsible for keeping patients out of the emergency room and the hospital. With being at risk for total cost of care, we could afford these types of augmentation for clinical care. In a fee-for-service model, it simply does not work."
Best practices in telehealth visits for older patients
Unlike younger patients, who are intimately familiar with using computer and smartphone technology, older patients should be walked through their telehealth visits, Gelblum says. "There has to be clear, succinct, step-by-step instructions because the technology is not intuitive for them. So, we have an instruction sheet that we send to them via email that gives them step-by-step instructions."
For older patients, a telehealth visit must be simple, Smith says. "The pace of the interaction has to be slow and clear. So, you need to work with the patients and families to make sure you are asking single questions at a time. You pause to make sure that the patient heard the question because many of these patients are hard of hearing. You pause to make sure you get the answer."
To make sure older patients are comfortable during a telehealth visit, it is important to engage them on a personal level, Gelblum says.
"As far as I am concerned, a telemedicine visit is an old-fashioned house call with a smartphone. I like to engage my patients with what they are doing. I might see something on the stove in the background and I will ask what they are cooking. Then the conversation may become a 10-minute discourse on a homemade recipe for cabbage soup."
Telehealth visits present significant opportunities for patient engagement, Gelblum says.
"For any clinicians getting into conducting visits via telemedicine, I would tell them that they are going to have great avenues of discussion—more avenues of discussion than you could ever get in your office. That is because your office is your environment. When you use telehealth, you are seeing the ultimate in the activities of daily living and emotional status."
The new plan includes promoting an organizational culture of wellness and adoption of targeted programs.
The Ohio State University College of Nursing and the Health Policy Institute of Ohio have released a comprehensive plan to improve clinician wellbeing.
Burnout is one of the top challenges facing clinicians and other healthcare workers nationwide. In a report published last week by The Physicians Foundation, 30% of more than 2,300 physicians surveyed cited feelings of hopelessness or having no purpose due to changes in their practices related to the coronavirus pandemic. Research published in September 2018 indicates that nearly half of physicians across the country are experiencing burnout symptoms.
The new comprehensive plan to improve clinician wellbeing has four primary components.
1. Wellness culture
The plan calls on health systems and hospitals to advance an organizational culture that supports wellness such as appointing a chief wellness officer.
"You must take a systematic, multi-component approach to culture. That means you have got to work this from the grassroots to managers, supervisors, and top leaders. You have got to hit all of those areas if you really expect to change culture," says Bernadette Melnyk, PhD, RN, APRN-CNP, dean of the College of Nursing and chief wellness officer at The Ohio State University in Columbus, Ohio.
She gave several examples of a multi-faceted strategy to establish a wellness culture.
"You have got to have policies that are directed to people's wellbeing. You have got to have a system-wide team under the chief wellness officer that can work with point-of-care clinicians. But first, anybody who is serious about creating a culture of wellness must assess the extent of the issue—that is super important. To do a survey for the sake of doing a survey is not worth doing. You need to assess the problem first, then use that data for targeted interventions."
Flex work is a good example of a policy that supports clinician wellness, Melnyk says. "Clinicians need leaders to give them permission to have some flexibility in their work."
2. Targeted programs
To foster clinician wellness, health systems and hospitals should promote programs that reduce burnout and strengthen resiliency among healthcare students and clinicians such as cognitive behavioral therapy and trauma support.
Promoting resiliency is a preventive measure to address burnout, Melnyk says. "It is protective against burnout, and it is protective against depression and anxiety. There is a big misperception about resiliency. A lot of people think you are either born with it or not. That could not be further from the truth. Resiliency skills can be built across your lifetime."
Clinicians should not view resiliency training as a form of victim blaming, she says.
"To fix the burnout problem, you cannot just put it on the clinicians and the nurses because we have major system problems that need to be fixed. When you spend more of your time in the electronic health record than you do taking care of your patients—which is the main reason nurses and physicians came into the profession—you have a system problem that is taking away purpose and joy in work. So, we must fix the system, but we also must give clinicians permission to take good self-care. How can we be at our best or fully engaged in our practices and in our jobs if we are totally burned out?"
3. Focus on mental health
Health systems and hospitals should require confidential mental health and addiction screening, provide referral and treatment services for healthcare students and clinicians, and address mental health and addiction prejudice such as stigmatizing language on clinician licensure applications.
Provision of mental health services is a key factor in promoting clinician wellness, Melnyk says. "In a national study I did, depression among nurses was the leading cause of medical errors. In this sample, I had nearly 1,800 nurses from across the country. Depression also is the biggest predictor of suicide."
4. Statewide reporting system
Health systems and hospitals should participate in a statewide reporting mechanism to monitor and track data on healthcare student and clinician wellness.
This kind of reporting system can play a pivotal role in boosting clinician wellness and addressing burnout, Melnyk says. "You need reporting so you can hot-spot problem areas and target them with interventions."
A statewide reporting system should not only include clinician outcomes such as depression, burnout, anxiety, and suicidal intent, she says.
"In addition to tracking clinician outcomes, you need to track key outcome indicators for the hospitals and health systems. With that information, you can see what is predictive of factors such as clinician turnover, patient complications, and medical errors."
