CHEST Physician

Despite mounting evidence that low-dose CT screening reduces lung cancer mortality in people at high risk, the uptake of screening in the United States has been slow, and some researchers caution that the risks involved need to be better understood.

It has been almost 10 years since the landmark National Lung Screening Trial (NLST) provided the scientific evidence used by the United States Preventive Services Task Force to recommend annual screening for adults 55 to 80 years of age who have a 30 pack-year smoking history and currently smoke or have quit in the previous 15 years.

But just 4.2% of Americans who qualified for screening in 2018 were tested, according to an American Lung Association report. If everyone at high risk had been tested, 48,000 American lives could have been saved.

Final results from the NELSON trial, published earlier this year, support those from NLST.

Mortality was 24% lower with low-dose CT screening than with no screening in the NELSON cohort, which consisted of 13,195 men and 2594 women at high risk for lung cancer because they were current or former smokers.

“With the NELSON results, the efficacy of low-dose CT screening for lung cancer is confirmed,” wrote the authors of an editorial accompanying the NELSON results. “Our job is no longer to assess whether low-dose CT screening for lung cancer works: it does. Our job is to identify the target population in which it will be acceptable and cost-effective.”

That sentiment is echoed by Michael Gould, MD, from Kaiser Permanente Southern California.

“Lo and behold, we have confirmation of NLST results from NELSON,” Dr. Gould said in an interview. “Now that we have consistent data from the NELSON confirmatory trial, can we finally believe NLST?”

Even though NELSON confirms the benefits of screening in clinical trials, many questions remain about how lung cancer screening translates into everyday practice, said Dr. Gould, who had been scheduled to discuss the trials and the state of lung screening at the American Thoracic Society 2020 International Conference, which will now run virtually in August.

For starters, the target population needs more scrutiny. Research has shown that, outside of clinical trials, the harms of screening can sometimes outweigh the benefits.

In 2018, the rate of overdiagnosis was shown to be 67.2% in the Danish Lung Cancer Screening Trial (DLCST).

And 56% of people screened with low-dose CT had false-positive results that required follow-up testing and procedures, according to a 2017 study of current and former heavy smokers. That rate is more than double the 18.5% false-positive rate in NLST.

“Only 20% of NLST participants were over age 65,” Dr. Gould said. “The NELSON cohort was younger.”

And although the USPSTF recommends lung screening in high-risk people, “there were some in the NLST cohort whose risk was not particularly high.” Others in the trial, he said, had a high risk, but some of those had one or more comorbid conditions, “so the risk was unbalanced.

“Risk is more complicated than simply saying that anyone who meets the NLST criteria should get scanned,” he added.

Weighing risks and benefits needs to be done on a patient-by-patient basis, Dr. Gould said. “Do they have the ability to tolerate surgery? What’s important to them? We can’t just say, ‘you have a 30-pack-year history, go get a test’.”

Often, he said, it’s the people who have the most to gain from screening who are also at highest risk from biopsies and surgical and nonsurgical treatments because of comorbidities.

The NLST population might also have cast a wider net for those eligible for screening; NELSON had a lower threshold for amount smoked (30 vs. 15 pack-years). “NLST points to scanning a bigger population and lighter smokers,” Dr. Gould said.
 

Psychological risks of screening

Neither the NLST nor NELSON reported relevant psychological aspects of harm from CT screening for lung cancer, two researchers reported in a letter responding to the NELSON findings.

The trial-participation request letters, which were sent to 606,409 people in the general population, “in order to identify 15,792 persons (2.6%) who were eligible to participate, may have caused fear,” wrote Jes Lindholt, MD, DMSc, and Rikke Søgaard, PhD, from Odense University Hospital in Denmark.

“That raises the question: Do people want to be screened? I can’t understand why the US and Britain consider it so definitive to start a screening program,” Dr. Lindholt said in an interview.

In addition to a psychological cost, he questioned the financial cost-benefit ratio of a screening program. “What strikes me is that they haven’t done any cost analysis on any of these randomized trials.”

“Of the 203 men who got the diagnosis of lung cancer, 160 (78.8%) died from lung cancer. Whether screening actually improved or prolonged their remaining lifetime should be considered,” Dr. Lindholt and Dr. Søgaard wrote.
 

Challenges of implementation

Despite the extensive trials, there are still questions about how to implement screening in the real world. “Did NLST select patients who were, on average, healthier and less likely to have complications?” Dr. Gould asked.

Everyday practice might not find the same favorable outcomes as NLST. “Can the results of the NTLST be replicated in real-world settings? Not yet,” he said. Hospitals and health systems are struggling to implement screening.

Follow-up and tracking are not where they should be. General practitioners don’t have the same resources as the NLST researchers had, he explained. They were able to remind patients to come back for another test and call them with the results, all under the umbrella of implementation, “and they’re still not on target.”

Getting people scanned is key, said Michael Barry, MD, from Massachusetts General Hospital in Boston, who is a current member of the USPSTF and is working on new lung cancer screening recommendations to be published this summer.

“We have an implementation problem,” he said. “The heavier smokers are being way underscreened.”

People need to have more information to review the pros and cons of screening, Dr. Barry said. “We’ve got large trials that show that benefits outweigh the harms, but we could benefit from implementation research. This is an issue for many screening tasks.”

Eight million Americans meet the eligibility requirements for lung cancer screening with low-dose CT, according to a 2019 report from the American College of Radiology.

Screening tests are covered by Medicare, but getting people to the clinic has not been easy. In 2018, Saved by the Scan, a big-budget national advertising campaign launched by the ALA, featured ex-smokers who survived lung cancer because of early detection with a low-dose CT scan, as reported by Medscape Medical News.

And many people being scanned are not part of the USPSTF target group. In 2017, lung cancer screening was reported “by 12.5% of smokers who met USPSTF criteria and 7.9% of smokers aged 55-80 years who did not meet USPSTF criteria,” according to a recent analysis of data from the Behavioral Risk Factor Surveillance System published by the Centers for Disease Control and Prevention.

The CDC report concludes that some people are being screened without needing screening, and that “avoidance of screening inconsistent with USPSTF criteria could reduce the potential for harms such as overdiagnosis and overtreatment.”

Dr. Gould said he agrees that this factor needs to be looked at. “There is underutilization in those who need screening, and maybe overscreening in those who aren’t at risk.”

There are also epidemiologic data that show that black Americans are at higher risk at a younger age for the same level of smoking. “So should there be a lower threshold for smoking and lower age, particularly in the African American population?” Dr. Gould asked.

The NELSON trial had significant results in a population younger than that in NLST, he pointed out. “That needs to be considered.”
 

Smokers dismiss medical advice

People in the high-risk group need to better understand the benefits of screening, said Christine D. Berg, MD, an NLST researcher from the National Cancer Institute.

“We know the uptake of lung cancer screening has been slow,” she said.

She described encouraging her neighbor, a heavy smoker, to get screened. “But she said she didn’t want to know if she had lung cancer, so she didn’t go.”

“Now she’s dead,” Dr. Berg continued. Unfortunately, “what we see is that those who continue to smoke, and smoke heavily, are not likely to heed medical advice.”

The fear of finding out you have lung cancer needs to be overcome, she said. Smokers need to understand that they can add a decade to their lives if lung cancer is detected early.

Some places in the United States have better screening rates than others. “We see a lot of variation from state to state,” she said. For instance, in Massachusetts, 12.3% of high-risk people have been screened; in Nevada, the rate is just 0.5%.

There are many reasons for that. First, there are logistics. Screening covered by Medicare must be done in a certified center “with good equipment and that can track results,” Dr. Berg said. That might be one hurdle. But the greater hurdle is the patients themselves.

There are studies that point to risks associated with invasive procedures, such as biopsy after screening, which can lead to complications, even when no cancer is found. “My answer to that is, if you need a biopsy, check the data. The Society of Thoracic Surgeons has a database of all the complications, and it’s publicly accessible. You can find hospitals in your region that report data,” she explained, and “that have highest volume and lowest complication rates.”

Second, imaging has improved since the NLST trial. “We have a better ability to estimate cancer in the nodules we find,” Dr. Berg explained. Nodules that previously needed a biopsy to confirm malignancy can now be assessed with AI and machine learning.

“I think the probability of false positives and problems from biopsy have changed dramatically over the last 10 years,” she said.

And we are catching more lung cancer earlier and saving lives. Overall, early detection is increasing, and late-stage detection is decreasing. “We’re bending the curve, making progress,” she said.

In 2019, the 5-year survival rate for lung cancer was 21.7%, up from 17.2% a decade earlier, according to the ALA. Much of that is because of early diagnosis, when the disease is still curable, which could be related to increased screening.

“NELSON showed benefit to CT screening and is useful in helping convince some of the skeptics,” Dr. Berg said.

Diagnosis is also improving with new technologies. Electronic health records can be scanned to identify patients at increased risk, and patient portals can send reminders, notifications, and other educational information to encourage patients to discuss options with their doctor, which could improve the national lung cancer prognosis, Dr. Gould said.

At the end of the day, it still comes down to the patient and doctor having a conversation about the risks and benefits.

“But we have to get to that point,” Dr. Gould said. “We need to continue to develop tools to facilitate that conversation. It’s complicated, and there’s a lot of information to weigh.”

“We’re still working out how to do that,” he added.

Dr. Barry, Dr. Gould, and Dr. Berg have disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

Despite mounting evidence that low-dose CT screening reduces lung cancer mortality in people at high risk, the uptake of screening in the United States has been slow, and some researchers caution that the risks involved need to be better understood.

It has been almost 10 years since the landmark National Lung Screening Trial (NLST) provided the scientific evidence used by the United States Preventive Services Task Force to recommend annual screening for adults 55 to 80 years of age who have a 30 pack-year smoking history and currently smoke or have quit in the previous 15 years.

But just 4.2% of Americans who qualified for screening in 2018 were tested, according to an American Lung Association report. If everyone at high risk had been tested, 48,000 American lives could have been saved.

Final results from the NELSON trial, published earlier this year, support those from NLST.

Mortality was 24% lower with low-dose CT screening than with no screening in the NELSON cohort, which consisted of 13,195 men and 2594 women at high risk for lung cancer because they were current or former smokers.

“With the NELSON results, the efficacy of low-dose CT screening for lung cancer is confirmed,” wrote the authors of an editorial accompanying the NELSON results. “Our job is no longer to assess whether low-dose CT screening for lung cancer works: it does. Our job is to identify the target population in which it will be acceptable and cost-effective.”

That sentiment is echoed by Michael Gould, MD, from Kaiser Permanente Southern California.

“Lo and behold, we have confirmation of NLST results from NELSON,” Dr. Gould said in an interview. “Now that we have consistent data from the NELSON confirmatory trial, can we finally believe NLST?”

Even though NELSON confirms the benefits of screening in clinical trials, many questions remain about how lung cancer screening translates into everyday practice, said Dr. Gould, who had been scheduled to discuss the trials and the state of lung screening at the American Thoracic Society 2020 International Conference, which will now run virtually in August.

For starters, the target population needs more scrutiny. Research has shown that, outside of clinical trials, the harms of screening can sometimes outweigh the benefits.

In 2018, the rate of overdiagnosis was shown to be 67.2% in the Danish Lung Cancer Screening Trial (DLCST).

And 56% of people screened with low-dose CT had false-positive results that required follow-up testing and procedures, according to a 2017 study of current and former heavy smokers. That rate is more than double the 18.5% false-positive rate in NLST.

“Only 20% of NLST participants were over age 65,” Dr. Gould said. “The NELSON cohort was younger.”

And although the USPSTF recommends lung screening in high-risk people, “there were some in the NLST cohort whose risk was not particularly high.” Others in the trial, he said, had a high risk, but some of those had one or more comorbid conditions, “so the risk was unbalanced.

“Risk is more complicated than simply saying that anyone who meets the NLST criteria should get scanned,” he added.

Weighing risks and benefits needs to be done on a patient-by-patient basis, Dr. Gould said. “Do they have the ability to tolerate surgery? What’s important to them? We can’t just say, ‘you have a 30-pack-year history, go get a test’.”

Often, he said, it’s the people who have the most to gain from screening who are also at highest risk from biopsies and surgical and nonsurgical treatments because of comorbidities.

The NLST population might also have cast a wider net for those eligible for screening; NELSON had a lower threshold for amount smoked (30 vs. 15 pack-years). “NLST points to scanning a bigger population and lighter smokers,” Dr. Gould said.
 

Psychological risks of screening

Neither the NLST nor NELSON reported relevant psychological aspects of harm from CT screening for lung cancer, two researchers reported in a letter responding to the NELSON findings.

The trial-participation request letters, which were sent to 606,409 people in the general population, “in order to identify 15,792 persons (2.6%) who were eligible to participate, may have caused fear,” wrote Jes Lindholt, MD, DMSc, and Rikke Søgaard, PhD, from Odense University Hospital in Denmark.

“That raises the question: Do people want to be screened? I can’t understand why the US and Britain consider it so definitive to start a screening program,” Dr. Lindholt said in an interview.

In addition to a psychological cost, he questioned the financial cost-benefit ratio of a screening program. “What strikes me is that they haven’t done any cost analysis on any of these randomized trials.”

“Of the 203 men who got the diagnosis of lung cancer, 160 (78.8%) died from lung cancer. Whether screening actually improved or prolonged their remaining lifetime should be considered,” Dr. Lindholt and Dr. Søgaard wrote.
 

Challenges of implementation

Despite the extensive trials, there are still questions about how to implement screening in the real world. “Did NLST select patients who were, on average, healthier and less likely to have complications?” Dr. Gould asked.

Everyday practice might not find the same favorable outcomes as NLST. “Can the results of the NTLST be replicated in real-world settings? Not yet,” he said. Hospitals and health systems are struggling to implement screening.

Follow-up and tracking are not where they should be. General practitioners don’t have the same resources as the NLST researchers had, he explained. They were able to remind patients to come back for another test and call them with the results, all under the umbrella of implementation, “and they’re still not on target.”

Getting people scanned is key, said Michael Barry, MD, from Massachusetts General Hospital in Boston, who is a current member of the USPSTF and is working on new lung cancer screening recommendations to be published this summer.

“We have an implementation problem,” he said. “The heavier smokers are being way underscreened.”

People need to have more information to review the pros and cons of screening, Dr. Barry said. “We’ve got large trials that show that benefits outweigh the harms, but we could benefit from implementation research. This is an issue for many screening tasks.”

Eight million Americans meet the eligibility requirements for lung cancer screening with low-dose CT, according to a 2019 report from the American College of Radiology.

Screening tests are covered by Medicare, but getting people to the clinic has not been easy. In 2018, Saved by the Scan, a big-budget national advertising campaign launched by the ALA, featured ex-smokers who survived lung cancer because of early detection with a low-dose CT scan, as reported by Medscape Medical News.

And many people being scanned are not part of the USPSTF target group. In 2017, lung cancer screening was reported “by 12.5% of smokers who met USPSTF criteria and 7.9% of smokers aged 55-80 years who did not meet USPSTF criteria,” according to a recent analysis of data from the Behavioral Risk Factor Surveillance System published by the Centers for Disease Control and Prevention.

The CDC report concludes that some people are being screened without needing screening, and that “avoidance of screening inconsistent with USPSTF criteria could reduce the potential for harms such as overdiagnosis and overtreatment.”

Dr. Gould said he agrees that this factor needs to be looked at. “There is underutilization in those who need screening, and maybe overscreening in those who aren’t at risk.”

There are also epidemiologic data that show that black Americans are at higher risk at a younger age for the same level of smoking. “So should there be a lower threshold for smoking and lower age, particularly in the African American population?” Dr. Gould asked.

The NELSON trial had significant results in a population younger than that in NLST, he pointed out. “That needs to be considered.”
 

Smokers dismiss medical advice

People in the high-risk group need to better understand the benefits of screening, said Christine D. Berg, MD, an NLST researcher from the National Cancer Institute.

“We know the uptake of lung cancer screening has been slow,” she said.

She described encouraging her neighbor, a heavy smoker, to get screened. “But she said she didn’t want to know if she had lung cancer, so she didn’t go.”

“Now she’s dead,” Dr. Berg continued. Unfortunately, “what we see is that those who continue to smoke, and smoke heavily, are not likely to heed medical advice.”

The fear of finding out you have lung cancer needs to be overcome, she said. Smokers need to understand that they can add a decade to their lives if lung cancer is detected early.

Some places in the United States have better screening rates than others. “We see a lot of variation from state to state,” she said. For instance, in Massachusetts, 12.3% of high-risk people have been screened; in Nevada, the rate is just 0.5%.

There are many reasons for that. First, there are logistics. Screening covered by Medicare must be done in a certified center “with good equipment and that can track results,” Dr. Berg said. That might be one hurdle. But the greater hurdle is the patients themselves.

There are studies that point to risks associated with invasive procedures, such as biopsy after screening, which can lead to complications, even when no cancer is found. “My answer to that is, if you need a biopsy, check the data. The Society of Thoracic Surgeons has a database of all the complications, and it’s publicly accessible. You can find hospitals in your region that report data,” she explained, and “that have highest volume and lowest complication rates.”

Second, imaging has improved since the NLST trial. “We have a better ability to estimate cancer in the nodules we find,” Dr. Berg explained. Nodules that previously needed a biopsy to confirm malignancy can now be assessed with AI and machine learning.

“I think the probability of false positives and problems from biopsy have changed dramatically over the last 10 years,” she said.

And we are catching more lung cancer earlier and saving lives. Overall, early detection is increasing, and late-stage detection is decreasing. “We’re bending the curve, making progress,” she said.

In 2019, the 5-year survival rate for lung cancer was 21.7%, up from 17.2% a decade earlier, according to the ALA. Much of that is because of early diagnosis, when the disease is still curable, which could be related to increased screening.

“NELSON showed benefit to CT screening and is useful in helping convince some of the skeptics,” Dr. Berg said.

Diagnosis is also improving with new technologies. Electronic health records can be scanned to identify patients at increased risk, and patient portals can send reminders, notifications, and other educational information to encourage patients to discuss options with their doctor, which could improve the national lung cancer prognosis, Dr. Gould said.

At the end of the day, it still comes down to the patient and doctor having a conversation about the risks and benefits.

“But we have to get to that point,” Dr. Gould said. “We need to continue to develop tools to facilitate that conversation. It’s complicated, and there’s a lot of information to weigh.”

“We’re still working out how to do that,” he added.

Dr. Barry, Dr. Gould, and Dr. Berg have disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

Despite mounting evidence that low-dose CT screening reduces lung cancer mortality in people at high risk, the uptake of screening in the United States has been slow, and some researchers caution that the risks involved need to be better understood.

It has been almost 10 years since the landmark National Lung Screening Trial (NLST) provided the scientific evidence used by the United States Preventive Services Task Force to recommend annual screening for adults 55 to 80 years of age who have a 30 pack-year smoking history and currently smoke or have quit in the previous 15 years.

But just 4.2% of Americans who qualified for screening in 2018 were tested, according to an American Lung Association report. If everyone at high risk had been tested, 48,000 American lives could have been saved.

Final results from the NELSON trial, published earlier this year, support those from NLST.

Mortality was 24% lower with low-dose CT screening than with no screening in the NELSON cohort, which consisted of 13,195 men and 2594 women at high risk for lung cancer because they were current or former smokers.

“With the NELSON results, the efficacy of low-dose CT screening for lung cancer is confirmed,” wrote the authors of an editorial accompanying the NELSON results. “Our job is no longer to assess whether low-dose CT screening for lung cancer works: it does. Our job is to identify the target population in which it will be acceptable and cost-effective.”

That sentiment is echoed by Michael Gould, MD, from Kaiser Permanente Southern California.

“Lo and behold, we have confirmation of NLST results from NELSON,” Dr. Gould said in an interview. “Now that we have consistent data from the NELSON confirmatory trial, can we finally believe NLST?”

Even though NELSON confirms the benefits of screening in clinical trials, many questions remain about how lung cancer screening translates into everyday practice, said Dr. Gould, who had been scheduled to discuss the trials and the state of lung screening at the American Thoracic Society 2020 International Conference, which will now run virtually in August.

For starters, the target population needs more scrutiny. Research has shown that, outside of clinical trials, the harms of screening can sometimes outweigh the benefits.

In 2018, the rate of overdiagnosis was shown to be 67.2% in the Danish Lung Cancer Screening Trial (DLCST).

And 56% of people screened with low-dose CT had false-positive results that required follow-up testing and procedures, according to a 2017 study of current and former heavy smokers. That rate is more than double the 18.5% false-positive rate in NLST.

“Only 20% of NLST participants were over age 65,” Dr. Gould said. “The NELSON cohort was younger.”

And although the USPSTF recommends lung screening in high-risk people, “there were some in the NLST cohort whose risk was not particularly high.” Others in the trial, he said, had a high risk, but some of those had one or more comorbid conditions, “so the risk was unbalanced.

“Risk is more complicated than simply saying that anyone who meets the NLST criteria should get scanned,” he added.

Weighing risks and benefits needs to be done on a patient-by-patient basis, Dr. Gould said. “Do they have the ability to tolerate surgery? What’s important to them? We can’t just say, ‘you have a 30-pack-year history, go get a test’.”

Often, he said, it’s the people who have the most to gain from screening who are also at highest risk from biopsies and surgical and nonsurgical treatments because of comorbidities.

The NLST population might also have cast a wider net for those eligible for screening; NELSON had a lower threshold for amount smoked (30 vs. 15 pack-years). “NLST points to scanning a bigger population and lighter smokers,” Dr. Gould said.
 

Psychological risks of screening

Neither the NLST nor NELSON reported relevant psychological aspects of harm from CT screening for lung cancer, two researchers reported in a letter responding to the NELSON findings.

The trial-participation request letters, which were sent to 606,409 people in the general population, “in order to identify 15,792 persons (2.6%) who were eligible to participate, may have caused fear,” wrote Jes Lindholt, MD, DMSc, and Rikke Søgaard, PhD, from Odense University Hospital in Denmark.

“That raises the question: Do people want to be screened? I can’t understand why the US and Britain consider it so definitive to start a screening program,” Dr. Lindholt said in an interview.

In addition to a psychological cost, he questioned the financial cost-benefit ratio of a screening program. “What strikes me is that they haven’t done any cost analysis on any of these randomized trials.”

“Of the 203 men who got the diagnosis of lung cancer, 160 (78.8%) died from lung cancer. Whether screening actually improved or prolonged their remaining lifetime should be considered,” Dr. Lindholt and Dr. Søgaard wrote.
 

Challenges of implementation

Despite the extensive trials, there are still questions about how to implement screening in the real world. “Did NLST select patients who were, on average, healthier and less likely to have complications?” Dr. Gould asked.

Everyday practice might not find the same favorable outcomes as NLST. “Can the results of the NTLST be replicated in real-world settings? Not yet,” he said. Hospitals and health systems are struggling to implement screening.

Follow-up and tracking are not where they should be. General practitioners don’t have the same resources as the NLST researchers had, he explained. They were able to remind patients to come back for another test and call them with the results, all under the umbrella of implementation, “and they’re still not on target.”

Getting people scanned is key, said Michael Barry, MD, from Massachusetts General Hospital in Boston, who is a current member of the USPSTF and is working on new lung cancer screening recommendations to be published this summer.

“We have an implementation problem,” he said. “The heavier smokers are being way underscreened.”

People need to have more information to review the pros and cons of screening, Dr. Barry said. “We’ve got large trials that show that benefits outweigh the harms, but we could benefit from implementation research. This is an issue for many screening tasks.”

Eight million Americans meet the eligibility requirements for lung cancer screening with low-dose CT, according to a 2019 report from the American College of Radiology.

Screening tests are covered by Medicare, but getting people to the clinic has not been easy. In 2018, Saved by the Scan, a big-budget national advertising campaign launched by the ALA, featured ex-smokers who survived lung cancer because of early detection with a low-dose CT scan, as reported by Medscape Medical News.

And many people being scanned are not part of the USPSTF target group. In 2017, lung cancer screening was reported “by 12.5% of smokers who met USPSTF criteria and 7.9% of smokers aged 55-80 years who did not meet USPSTF criteria,” according to a recent analysis of data from the Behavioral Risk Factor Surveillance System published by the Centers for Disease Control and Prevention.

The CDC report concludes that some people are being screened without needing screening, and that “avoidance of screening inconsistent with USPSTF criteria could reduce the potential for harms such as overdiagnosis and overtreatment.”

Dr. Gould said he agrees that this factor needs to be looked at. “There is underutilization in those who need screening, and maybe overscreening in those who aren’t at risk.”

There are also epidemiologic data that show that black Americans are at higher risk at a younger age for the same level of smoking. “So should there be a lower threshold for smoking and lower age, particularly in the African American population?” Dr. Gould asked.

The NELSON trial had significant results in a population younger than that in NLST, he pointed out. “That needs to be considered.”
 

Smokers dismiss medical advice

People in the high-risk group need to better understand the benefits of screening, said Christine D. Berg, MD, an NLST researcher from the National Cancer Institute.

“We know the uptake of lung cancer screening has been slow,” she said.

She described encouraging her neighbor, a heavy smoker, to get screened. “But she said she didn’t want to know if she had lung cancer, so she didn’t go.”

“Now she’s dead,” Dr. Berg continued. Unfortunately, “what we see is that those who continue to smoke, and smoke heavily, are not likely to heed medical advice.”

The fear of finding out you have lung cancer needs to be overcome, she said. Smokers need to understand that they can add a decade to their lives if lung cancer is detected early.

Some places in the United States have better screening rates than others. “We see a lot of variation from state to state,” she said. For instance, in Massachusetts, 12.3% of high-risk people have been screened; in Nevada, the rate is just 0.5%.

There are many reasons for that. First, there are logistics. Screening covered by Medicare must be done in a certified center “with good equipment and that can track results,” Dr. Berg said. That might be one hurdle. But the greater hurdle is the patients themselves.

There are studies that point to risks associated with invasive procedures, such as biopsy after screening, which can lead to complications, even when no cancer is found. “My answer to that is, if you need a biopsy, check the data. The Society of Thoracic Surgeons has a database of all the complications, and it’s publicly accessible. You can find hospitals in your region that report data,” she explained, and “that have highest volume and lowest complication rates.”

Second, imaging has improved since the NLST trial. “We have a better ability to estimate cancer in the nodules we find,” Dr. Berg explained. Nodules that previously needed a biopsy to confirm malignancy can now be assessed with AI and machine learning.

“I think the probability of false positives and problems from biopsy have changed dramatically over the last 10 years,” she said.

And we are catching more lung cancer earlier and saving lives. Overall, early detection is increasing, and late-stage detection is decreasing. “We’re bending the curve, making progress,” she said.

In 2019, the 5-year survival rate for lung cancer was 21.7%, up from 17.2% a decade earlier, according to the ALA. Much of that is because of early diagnosis, when the disease is still curable, which could be related to increased screening.

“NELSON showed benefit to CT screening and is useful in helping convince some of the skeptics,” Dr. Berg said.

Diagnosis is also improving with new technologies. Electronic health records can be scanned to identify patients at increased risk, and patient portals can send reminders, notifications, and other educational information to encourage patients to discuss options with their doctor, which could improve the national lung cancer prognosis, Dr. Gould said.

At the end of the day, it still comes down to the patient and doctor having a conversation about the risks and benefits.

“But we have to get to that point,” Dr. Gould said. “We need to continue to develop tools to facilitate that conversation. It’s complicated, and there’s a lot of information to weigh.”

“We’re still working out how to do that,” he added.

Dr. Barry, Dr. Gould, and Dr. Berg have disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

Here are the stories our MDedge editors across specialties think you need to know about today:

A ‘Fraternity of People Who Are Struggling’

Kathleen Ronan spent a week in a New Jersey hospital, including 5 days in the ICU, battling the novel coronavirus.

Her years of working as a home health nurse told her that the return home wouldn’t be easy, but nothing prepared her for just how much she would struggle. The once-active Ronan, 51, now needed a walker to traverse the few steps from her bed to the toilet, an effort that left her gasping for air. Her brain couldn’t even focus on an audiobook, let alone a short magazine article. “It just completely knocked the stuffing out of me,” Ronan said.

Ronan’s lingering symptoms aren’t unique to COVID-19 patients. In as many as 80% of patients leaving the ICU, researchers have documented what they call post–intensive care syndrome (PICS) — a constellation of physical, cognitive, and psychiatric symptoms that result from an ICU stay. Although underlying illness plays a role in these symptoms, the amount of time spent in critical care is a major factor.

The good news is that over the past decade, researchers have made important strides in understanding what makes PICS symptoms worse and how critical care physicians can tweak ICU protocols to reduce PICS severity. Practitioners will need to draw on this knowledge to help Ronan and the thousands of COVID-19 ICU patients like her. Read more.

The evolution of ‘COVIDists’

At the start of the pandemic earlier this year hospitalists at Baystate Health in Western Massachusetts realized the necessity of a new model of care for COVID-19 patients. Challenges included a massive surge of COVID-19 patients, a limited supply of PPE, an inadequate number of intensivists for managing the anticipated ventilated patients, and the potential of losing some of our workforce if they became infected. Hospitalists there came up with an elaborate plan to manage the disease burden and the strain on resources effectively.

A focused group of 10 hospitalists who volunteered to take care of COVID-19 patients with a particular interest in the pandemic and experience in critical care were selected, and the term “COVIDists” was coined to refer to them. The group underwent rapid training in various treatment protocols and ongoing clinical trials.

All the hospitalized COVID-19 patients were grouped together to COVID units, and the COVIDists were deployed to those units geographically. COVIDists were given lighter than usual patient loads to deal with the extra time needed for donning and doffing of PPE and for coordination with specialists. COVIDists were almost the only clinicians physically visiting the patients in most cases, and they became the “eyes and ears” of specialists since the specialists were advised to minimize exposure and pursue telemedicine consults. Read more.

How low should you go?

Cardiovascular risk continues to reduce as systolic blood pressure decreases right down to levels as low as 90 mm Hg, according to a new study.

Researchers analyzed data from a cohort of 1,457 participants (mean age, 58 years) who did not have any traditional cardiovascular risk factors and had a systolic blood pressure level between 90 and 129 mm Hg at baseline. Results showed that, during a mean follow-up of 14.5 years, there was an increase in traditional cardiovascular risk factors, coronary artery calcium, and incident cardiovascular events with increasing systolic blood pressure levels.

“We modeled systolic blood pressure on a continuous scale and saw the risk increasing in a linear fashion as blood pressure increased and this occurred right down to 90 mm Hg. We didn’t see any nadir or J-point where there may be an increased risk at lower pressures,” said lead author Seamus Whelton, MD, assistant professor of medicine at the division of cardiology at Johns Hopkins Medicine, Baltimore.

“From an individual level we can now say that in healthy individuals, a systolic pressure in the 90s is not too low. It is a positive thing. And it is recommended to try and keep systolic pressure at these levels if possible by maintaining a healthy lifestyle,” Dr. Whelton said in an interview. Read more.
 

Asthma tops spending on avoidable pediatric inpatient stays

Asthma costs nearly equaled potentially avoidable hospital bills for diabetes, gastroenteritis, and UTIs combined in a study of in-patient stays among children aged 3 months to 17 years.

Indeed, hospital charges for the treatment of children with asthma made up nearly half of all potentially avoidable pediatric inpatient costs in 2017, according to the Agency for Healthcare Research and Quality.

The cost of potentially avoidable visits for asthma that year was $278 million, versus $284 million combined for the other three conditions, Kimberly W. McDermott, PhD, and H. Joanna Jiang, PhD, reported in an AHRQ statistical brief.

The state inpatient databases of the AHRQ’s Healthcare Cost and Utilization Project included 1.4 million inpatient stays among children aged 3 months to 17 years in 2017, of which 8% (108,300) were deemed potentially preventable.

Rates of potentially avoidable stays for asthma (159 per 100,000 population), gastroenteritis (90 per 100,000), and UTIs (41 per 100,000) were highest for children aged 0-4 years and generally decreased with age, but diabetes stays increased with age, rising from 12 per 100,000 in children aged 5-9 years to 38 per 100,000 for those 15-17 years old, the researchers said. Read more.

Adding monoclonal antibodies to Botox for migraine prevention

Adjunctive preventive therapy with a calcitonin gene–related peptide monoclonal antibody (CGRP-mAb) medication is safe and effective in patients with chronic migraine who have only achieved a partial response to onabotulinumtoxinA (Botox) treatment.

Investigators found the CGRP-mAbs significantly reduced the number of headache days and pain severity with adverse event rates similar to those reported in previous trials of these medications.

Although Botox is associated with significant clinical improvement in chronic migraine, it often fails to adequately control headache frequency and additional medications are needed. Three CGRP-mAbs have recently been approved for migraine prevention, with results from clinical trials demonstrating they are effective for both chronic and episodic migraine. Patients treated with Botox had been excluded from these earlier trials, however. Read more.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

Here are the stories our MDedge editors across specialties think you need to know about today:

A ‘Fraternity of People Who Are Struggling’

Kathleen Ronan spent a week in a New Jersey hospital, including 5 days in the ICU, battling the novel coronavirus.

Her years of working as a home health nurse told her that the return home wouldn’t be easy, but nothing prepared her for just how much she would struggle. The once-active Ronan, 51, now needed a walker to traverse the few steps from her bed to the toilet, an effort that left her gasping for air. Her brain couldn’t even focus on an audiobook, let alone a short magazine article. “It just completely knocked the stuffing out of me,” Ronan said.

Ronan’s lingering symptoms aren’t unique to COVID-19 patients. In as many as 80% of patients leaving the ICU, researchers have documented what they call post–intensive care syndrome (PICS) — a constellation of physical, cognitive, and psychiatric symptoms that result from an ICU stay. Although underlying illness plays a role in these symptoms, the amount of time spent in critical care is a major factor.

The good news is that over the past decade, researchers have made important strides in understanding what makes PICS symptoms worse and how critical care physicians can tweak ICU protocols to reduce PICS severity. Practitioners will need to draw on this knowledge to help Ronan and the thousands of COVID-19 ICU patients like her. Read more.

The evolution of ‘COVIDists’

At the start of the pandemic earlier this year hospitalists at Baystate Health in Western Massachusetts realized the necessity of a new model of care for COVID-19 patients. Challenges included a massive surge of COVID-19 patients, a limited supply of PPE, an inadequate number of intensivists for managing the anticipated ventilated patients, and the potential of losing some of our workforce if they became infected. Hospitalists there came up with an elaborate plan to manage the disease burden and the strain on resources effectively.

A focused group of 10 hospitalists who volunteered to take care of COVID-19 patients with a particular interest in the pandemic and experience in critical care were selected, and the term “COVIDists” was coined to refer to them. The group underwent rapid training in various treatment protocols and ongoing clinical trials.

All the hospitalized COVID-19 patients were grouped together to COVID units, and the COVIDists were deployed to those units geographically. COVIDists were given lighter than usual patient loads to deal with the extra time needed for donning and doffing of PPE and for coordination with specialists. COVIDists were almost the only clinicians physically visiting the patients in most cases, and they became the “eyes and ears” of specialists since the specialists were advised to minimize exposure and pursue telemedicine consults. Read more.

How low should you go?

Cardiovascular risk continues to reduce as systolic blood pressure decreases right down to levels as low as 90 mm Hg, according to a new study.

Researchers analyzed data from a cohort of 1,457 participants (mean age, 58 years) who did not have any traditional cardiovascular risk factors and had a systolic blood pressure level between 90 and 129 mm Hg at baseline. Results showed that, during a mean follow-up of 14.5 years, there was an increase in traditional cardiovascular risk factors, coronary artery calcium, and incident cardiovascular events with increasing systolic blood pressure levels.

“We modeled systolic blood pressure on a continuous scale and saw the risk increasing in a linear fashion as blood pressure increased and this occurred right down to 90 mm Hg. We didn’t see any nadir or J-point where there may be an increased risk at lower pressures,” said lead author Seamus Whelton, MD, assistant professor of medicine at the division of cardiology at Johns Hopkins Medicine, Baltimore.

“From an individual level we can now say that in healthy individuals, a systolic pressure in the 90s is not too low. It is a positive thing. And it is recommended to try and keep systolic pressure at these levels if possible by maintaining a healthy lifestyle,” Dr. Whelton said in an interview. Read more.
 

Asthma tops spending on avoidable pediatric inpatient stays

Asthma costs nearly equaled potentially avoidable hospital bills for diabetes, gastroenteritis, and UTIs combined in a study of in-patient stays among children aged 3 months to 17 years.

Indeed, hospital charges for the treatment of children with asthma made up nearly half of all potentially avoidable pediatric inpatient costs in 2017, according to the Agency for Healthcare Research and Quality.

The cost of potentially avoidable visits for asthma that year was $278 million, versus $284 million combined for the other three conditions, Kimberly W. McDermott, PhD, and H. Joanna Jiang, PhD, reported in an AHRQ statistical brief.

The state inpatient databases of the AHRQ’s Healthcare Cost and Utilization Project included 1.4 million inpatient stays among children aged 3 months to 17 years in 2017, of which 8% (108,300) were deemed potentially preventable.

Rates of potentially avoidable stays for asthma (159 per 100,000 population), gastroenteritis (90 per 100,000), and UTIs (41 per 100,000) were highest for children aged 0-4 years and generally decreased with age, but diabetes stays increased with age, rising from 12 per 100,000 in children aged 5-9 years to 38 per 100,000 for those 15-17 years old, the researchers said. Read more.

Adding monoclonal antibodies to Botox for migraine prevention

Adjunctive preventive therapy with a calcitonin gene–related peptide monoclonal antibody (CGRP-mAb) medication is safe and effective in patients with chronic migraine who have only achieved a partial response to onabotulinumtoxinA (Botox) treatment.

Investigators found the CGRP-mAbs significantly reduced the number of headache days and pain severity with adverse event rates similar to those reported in previous trials of these medications.

Although Botox is associated with significant clinical improvement in chronic migraine, it often fails to adequately control headache frequency and additional medications are needed. Three CGRP-mAbs have recently been approved for migraine prevention, with results from clinical trials demonstrating they are effective for both chronic and episodic migraine. Patients treated with Botox had been excluded from these earlier trials, however. Read more.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

Here are the stories our MDedge editors across specialties think you need to know about today:

A ‘Fraternity of People Who Are Struggling’

Kathleen Ronan spent a week in a New Jersey hospital, including 5 days in the ICU, battling the novel coronavirus.

Her years of working as a home health nurse told her that the return home wouldn’t be easy, but nothing prepared her for just how much she would struggle. The once-active Ronan, 51, now needed a walker to traverse the few steps from her bed to the toilet, an effort that left her gasping for air. Her brain couldn’t even focus on an audiobook, let alone a short magazine article. “It just completely knocked the stuffing out of me,” Ronan said.

Ronan’s lingering symptoms aren’t unique to COVID-19 patients. In as many as 80% of patients leaving the ICU, researchers have documented what they call post–intensive care syndrome (PICS) — a constellation of physical, cognitive, and psychiatric symptoms that result from an ICU stay. Although underlying illness plays a role in these symptoms, the amount of time spent in critical care is a major factor.

The good news is that over the past decade, researchers have made important strides in understanding what makes PICS symptoms worse and how critical care physicians can tweak ICU protocols to reduce PICS severity. Practitioners will need to draw on this knowledge to help Ronan and the thousands of COVID-19 ICU patients like her. Read more.

The evolution of ‘COVIDists’

At the start of the pandemic earlier this year hospitalists at Baystate Health in Western Massachusetts realized the necessity of a new model of care for COVID-19 patients. Challenges included a massive surge of COVID-19 patients, a limited supply of PPE, an inadequate number of intensivists for managing the anticipated ventilated patients, and the potential of losing some of our workforce if they became infected. Hospitalists there came up with an elaborate plan to manage the disease burden and the strain on resources effectively.

A focused group of 10 hospitalists who volunteered to take care of COVID-19 patients with a particular interest in the pandemic and experience in critical care were selected, and the term “COVIDists” was coined to refer to them. The group underwent rapid training in various treatment protocols and ongoing clinical trials.

All the hospitalized COVID-19 patients were grouped together to COVID units, and the COVIDists were deployed to those units geographically. COVIDists were given lighter than usual patient loads to deal with the extra time needed for donning and doffing of PPE and for coordination with specialists. COVIDists were almost the only clinicians physically visiting the patients in most cases, and they became the “eyes and ears” of specialists since the specialists were advised to minimize exposure and pursue telemedicine consults. Read more.

How low should you go?

Cardiovascular risk continues to reduce as systolic blood pressure decreases right down to levels as low as 90 mm Hg, according to a new study.

Researchers analyzed data from a cohort of 1,457 participants (mean age, 58 years) who did not have any traditional cardiovascular risk factors and had a systolic blood pressure level between 90 and 129 mm Hg at baseline. Results showed that, during a mean follow-up of 14.5 years, there was an increase in traditional cardiovascular risk factors, coronary artery calcium, and incident cardiovascular events with increasing systolic blood pressure levels.

“We modeled systolic blood pressure on a continuous scale and saw the risk increasing in a linear fashion as blood pressure increased and this occurred right down to 90 mm Hg. We didn’t see any nadir or J-point where there may be an increased risk at lower pressures,” said lead author Seamus Whelton, MD, assistant professor of medicine at the division of cardiology at Johns Hopkins Medicine, Baltimore.

“From an individual level we can now say that in healthy individuals, a systolic pressure in the 90s is not too low. It is a positive thing. And it is recommended to try and keep systolic pressure at these levels if possible by maintaining a healthy lifestyle,” Dr. Whelton said in an interview. Read more.
 

Asthma tops spending on avoidable pediatric inpatient stays

Asthma costs nearly equaled potentially avoidable hospital bills for diabetes, gastroenteritis, and UTIs combined in a study of in-patient stays among children aged 3 months to 17 years.

Indeed, hospital charges for the treatment of children with asthma made up nearly half of all potentially avoidable pediatric inpatient costs in 2017, according to the Agency for Healthcare Research and Quality.

The cost of potentially avoidable visits for asthma that year was $278 million, versus $284 million combined for the other three conditions, Kimberly W. McDermott, PhD, and H. Joanna Jiang, PhD, reported in an AHRQ statistical brief.

The state inpatient databases of the AHRQ’s Healthcare Cost and Utilization Project included 1.4 million inpatient stays among children aged 3 months to 17 years in 2017, of which 8% (108,300) were deemed potentially preventable.

Rates of potentially avoidable stays for asthma (159 per 100,000 population), gastroenteritis (90 per 100,000), and UTIs (41 per 100,000) were highest for children aged 0-4 years and generally decreased with age, but diabetes stays increased with age, rising from 12 per 100,000 in children aged 5-9 years to 38 per 100,000 for those 15-17 years old, the researchers said. Read more.

Adding monoclonal antibodies to Botox for migraine prevention

Adjunctive preventive therapy with a calcitonin gene–related peptide monoclonal antibody (CGRP-mAb) medication is safe and effective in patients with chronic migraine who have only achieved a partial response to onabotulinumtoxinA (Botox) treatment.

Investigators found the CGRP-mAbs significantly reduced the number of headache days and pain severity with adverse event rates similar to those reported in previous trials of these medications.

Although Botox is associated with significant clinical improvement in chronic migraine, it often fails to adequately control headache frequency and additional medications are needed. Three CGRP-mAbs have recently been approved for migraine prevention, with results from clinical trials demonstrating they are effective for both chronic and episodic migraine. Patients treated with Botox had been excluded from these earlier trials, however. Read more.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

By the time she was discharged from a suburban New Jersey hospital on April 10, Kathleen Ronan thought the worst was behind her. For a week before her husband rushed her to the emergency department (ED), incoherent and struggling to breathe, the novel coronavirus had ravaged her body. She tried to treat her fevers with acetaminophen and ice packs. Despite taking enough Tylenol to risk liver damage and packing herself on ice like the catch of the day, Ronan’s fever continued to rise. By the time her temperature reached 104.5° F, Ronan knew the time had come for more drastic measures.

A team of masked and gowned nurses greeted her at a triage tent outside the ED, and from there, everything becomes hazy for Ronan. She was immediately rushed to the hospital’s special COVID-19 intensive care unit (ICU), where she spent 5 days. But she has few distinct memories from this time. What she does remember is the exhaustion, the pain, the loneliness, and the fear. Her family couldn’t visit, and though Ronan works as a home health nurse, her brain was so addled with fever that she couldn’t make sense of what was happening. After a week in the hospital, 5 days of which were spent in the ICU, 51-year-old Ronan was discharged.

Her years of working as a home health nurse told her that the return home wouldn’t be easy, but nothing prepared her for just how much she would struggle. The once-active Ronan, who had supplemented long days on her feet caring for others as a nurse with regular trips to the gym, now needed a walker to traverse the few steps from her bed to the toilet, an effort that left her gasping for air. Her brain couldn’t even focus on an audiobook, let alone a short magazine article.

“It just completely knocked the stuffing out of me,” Ronan said.

Ronan’s lingering symptoms aren’t unique to COVID-19 patients. In as many as 80% of patients leaving the ICU, researchers have documented what they call post–intensive care syndrome (PICS) — a constellation of physical, cognitive, and psychiatric symptoms that result from an ICU stay. Although underlying illness plays a role in these symptoms, the amount of time spent in critical care is a major factor.

Nor is PICS simply a set of side effects that will go away on their own. It includes ongoing cognitive difficulties and physical weakness, both of which can lead to employment problems. Beyond that, depression and anxiety can exacerbate – and be exacerbated by – these challenges. Psychologist Jim Jackson, PsyD, assistant director of the ICU Recovery Center at Vanderbilt University Medical Center, Nashville, Tennessee, recently spoke with a former ICU patient who has struggled since her discharge 30 years ago.

“Her life essentially stopped with her critical care stay. She hasn’t been able to move forward,” he said. “She’s part of a whole fraternity of people who are struggling.”

The good news is that over the past decade, researchers have made important strides in understanding what makes PICS symptoms worse and how critical care physicians can tweak ICU protocols to reduce PICS severity. Practitioners will need to draw on this knowledge to help Ronan and the thousands of COVID-19 ICU patients like her.
 

Surviving the ICU

Although the new coronavirus has pushed the world’s critical care system to its limits, it was an outbreak in 1952 that inspired the creation of intensive care units. That summer, a wave of paralytic polio swept over Copenhagen, Denmark, and anesthesiologist Bjørn Ibsen, MD, PhD, used mechanical ventilation — physically operated by medical and dental students – to help 316 children breathe for weeks at a time while their small bodies worked to fight off the virus. The effort halved the mortality rate from polio that affected breathing, from 80% to 40%.

In these wards, dedicated to the very sickest, each patient was assigned his or her own nurse. Over the next decade, hospitals in the United Kingdom and the United States established their own ICUs to treat patients with a variety of conditions. Although it helped improve survival, mortality rates in critical care units remained stubbornly high, owing to the patients’ severe underlying illnesses.

“We thought we were doing a good job if the patient survived, but we had no idea what happened after discharge,” said Carla Sevin, MD, medical director of Vanderbilt’s ICU Recovery Center. Nor did their efforts to find out always bring answers. “We struggled to get people to come in for support — they were debilitated, physically burdened, and weak.”

Through further advances in life support, by the early 2000s, the average mortality rates in American ICUs had dropped to 8% to 19%. As the number of critical care survivors began to climb, clinical researchers noticed that the lives of these patients and their families were profoundly altered by their severe illness.

As Dale Needham, MD, PhD, began his pulmonology and critical care residency in Toronto, Canada, in 2005, a group of physicians there began a 5-year longitudinal study to assess long-term outcomes of patients who developed acute respiratory distress syndrome (ARDS). Although ARDS is an acute condition, the investigators found that patients felt effects for years. Younger patients recovered better than older ones, but none of the patients› physical functioning was equivalent to that of age-matched control persons. Even 5 years later, former ICU patients only reached 76% of expected physical functioning, according to results published in the New England Journal of Medicine. The study was a wake-up call.

At a meeting in Chicago in 2010, Needham, now an intensivist at Johns Hopkins Hospital in Baltimore, Maryland, gathered an interdisciplinary group of colleagues, including patients and caregivers, to clarify the phenomena they were seeing. What emerged from that meeting, published in 2012 in Critical Care Medicine, were the diagnostic criteria for PICS: According to the new definition, PICS is characterized by new or worsening physical and neuropsychiatric deficits that range from forgetfulness and loss of motivation to physical weakness and insomnia.

The issue, Needham says, is that although the trouble starts in the ICU, it only becomes clear once patients leave. “ICU doctors aren’t the ones dealing with this,” Needham said. “We need to build stronger bridges between critical care and other professions.” That’s where PICS comes in, a definition that exists explicitly to alert healthcare providers about the constellation of challenges many of these individuals face as they try to reenter “normal” life.
 

Defining the problem

As an ICU nurse at the Mayo Clinic in Rochester, Minnesota, Annie Johnson, ACNP-BC, knew lots about helping hospitalized patients, but she says she didn’t know anything about what to do after discharge – at least not until her own mother became a patient.

On the first day of retirement in October 2014, Johnson’s mother flatlined. Quick-thinking paramedics resuscitated her, and after several days in critical care, she was discharged. Since then, her heart has remained healthy. Johnson’s sister, who spent time worrying over her mother at the hospital, also had lingering effects. Both have since struggled, plagued by nightmares, flashbacks, and insomnia.

Johnson initially believed her mom’s and sister’s neuropsychiatric, post-ICU struggles were unique to her family. It was only a year later, at a seminar she was attending, that she first heard the words “post–intensive care syndrome.” Suddenly, Johnson had a name for her family’s experiences, and she began to create support groups and resources to help other families like hers.

“I thought of all the patients I had treated over the years who had been on ventilators for days and days and days. And if this happened to my mom after 48 hours, what must they be going through?” she asked.

Once physicians formally defined PICS, the Society for Critical Care Medicine helped create programs to educate ICU staff, patients, and families about potential post-discharge challenges. Researchers also began to investigate factors affecting post-ICU functioning. Follow-up studies of patients with delirium (ranging from general confusion about time and place to extreme agitation and violence) showed they had striking cognitive deficits. Problems with short-term memory, flexible thinking, and motivation plagued patients for years after their critical illness, similar to the physical deficiencies seen after ARDS. Delirium was one of the strongest risk factors for neuropsychiatric problems.

“Delirium is basically a stress test for the brain,” said Babar Khan, MD, a critical care specialist at Indiana University’s Regenstrief Institute, in Bloomington. But whether delirium accentuates preexisting cognitive difficulties or creates them afresh isn’t yet clear.

Sophia Wang, MD, a geriatric psychiatrist at Indiana University who works with many critical care patients, says patients who had experienced delirium in the ICU showed significant defects in memory and executive functioning long after their hospital stay. She points to a 2015 study that followed 47 ICU patients for a year post discharge. Among those who experienced delirium, brain volumes, as measured by MRI, were smaller at 3 months, something associated with cognitive problems at 1 year. Many struggled at work, and unemployment was common. Depression and posttraumatic stress compounded these difficulties. Among those with acute respiratory distress, ICU patients who are young, female, and unemployed are most likely to suffer from posttraumatic stress disorder after they are discharge.

Critical care medicine may have given these patients a second chance at life, Wang says, but the life they return to often looks nothing like the one they had before their illness.

Prolonged mechanical ventilation and the heavy sedation that often accompanies it are predictors of PICS severity. Some of these links could be explained by the gravity of the illness that landed someone in critical care, but others are more likely to be iatrogenic, says Gerald Weinhouse, MD, a pulmonology and critical care physician and co-director of the Critical Illness Recovery Program at the Brigham and Women’s Hospital in Boston. The involvement of loved ones at the patient’s bedside, however, improved the entire family’s outcome.

When Weinhouse saw those data, he and his colleagues founded a peer support program for ICU survivors. In a study published in 2019 in Critical Care Medicine, they identified six different models for peer support for those with PICS and their families, including both online and in-person approaches. An ongoing challenge for physicians, Weinhouse says, is getting patients to engage with these programs, given that their calendars are crowded with medical appointments and that they suffer from increased physical and mental disability.

Studies such as these led critical care physicians to form the ICU Liberation Collaborative to rethink critical care medicine. At Vanderbilt, Sevin and Jackson headed up one of the world’s first post-ICU clinics, which uses an interdisciplinary team to help patients maximize their functioning. They redesigned their critical care unit in a way that allows families to spend the night and that encourages patient mobility. Both Needham and Weinhouse continue tracking patient outcomes.

Even before the novel coronavirus struck, the United States — and the world — had begun to realize that graduating from the ICU was only the start of what was often an extensive recovery.
 

The long road back

When COVID-19 patients began flooding intensive care wards around the world, physicians scrambled to meet their complex and desperate acute medical needs. Over the past few months, physicians have focused on keeping these patients alive. “We’ve never seen anything like it ― not even during polio — with the sheer number of patients, all with respiratory distress,” Needham said.

But he and his colleagues know this is only the beginning.

“We’re aware that survivorship issues are coming. There’s going to be a wave of sick people who survived the coronavirus but are going to need more help,” Weinhouse said.

Intensivists have been drawing on PICS research in their fight to help COVID-19 patients. Work from the past few years has shown that although sedation is required during intubation itself, not everyone needs it while on a ventilator. Titrating down sedating medication helps reduce delirium, Wang says. Such medication has been shown to contribute to later cognitive problems. Needham’s studies showing that prolonged bedrest by ICU patients causes muscular atrophy has led him to encourage patients to move as much as possible. With the help of physical therapists, many patients on ventilators can be awake, alert, and moving around the ward.

One of the biggest challenges critical-care coronavirus patients face is prolonged isolation. The constant presence of a familiar face helps orient confused and delirious patients and provides emotional support during a frightening time. But because the immediate need for infection control outweighs these benefits, few hospitals allow visitors, especially for COVID-19 patients.

To address this, some units have been using video technology to allow loved ones to call in. At Johns Hopkins, physicians have also been relying on the expertise of occupational therapists (OTs). Needham says that one OT found that rubbing the hand and back of an agitated, delirious patient helped soothe and calm him better than many medications.

Ronan, who spent 5 days in intensive care, echoes that problem. She says she found the relative lack of human contact to be one of the most challenging parts of being in a bed on a COVID-19 ward. Separated from her husband and daughter, suffering from high fever and severe illness, she lost all track of time.

Her return home was difficult, too. Although her job as a home health nurse had prepared her on some level for the challenges she would face after discharge, Ronan says the hospital provided little practical help.

“Everything is so much harder at home, even little things like going to the bathroom,” she said. “I feel like I’m trying to bail out a sinking ship with a teacup.”

Khan and other physicians, aware of the challenges Ronan and others face once home, aim to create post-ICU clinics specifically for COVID-19 patients. They want to build what Khan calls a “one-stop shop” for all the support patients need to recover. Some of that can be provided via telehealth, which may also help ease the physical burden.

Because there’s so much physicians don’t know about the coronavirus, Johnson says, such clinics are not only a chance to help the sickest COVID-19 patients, they will also help researchers learn more about the virus and improve critical care for other illnesses.

Today, nearly 2 months after discharge, Ronan is back on the job but struggles with a persistent cough — likely due to the lung damage she sustained while ill. She has constant fatigue, as well as ongoing upset stomach from all the medications she took to reduce fever and body aches. When she dons a mask for work, the tangible reminder of her hospital stay sends her into a panic attack. Physically, she’s weaker than before.

Researchers are still trying to understand everything that Ronan and other COVID-19 patients need to move on with their lives after being in the ICU. Mysteries abound, but the ground laid by Sevin, Needham, Weinhouse, and others has provided a solid foundation on which to build.
 

This article first appeared on Medscape.com.

By the time she was discharged from a suburban New Jersey hospital on April 10, Kathleen Ronan thought the worst was behind her. For a week before her husband rushed her to the emergency department (ED), incoherent and struggling to breathe, the novel coronavirus had ravaged her body. She tried to treat her fevers with acetaminophen and ice packs. Despite taking enough Tylenol to risk liver damage and packing herself on ice like the catch of the day, Ronan’s fever continued to rise. By the time her temperature reached 104.5° F, Ronan knew the time had come for more drastic measures.

A team of masked and gowned nurses greeted her at a triage tent outside the ED, and from there, everything becomes hazy for Ronan. She was immediately rushed to the hospital’s special COVID-19 intensive care unit (ICU), where she spent 5 days. But she has few distinct memories from this time. What she does remember is the exhaustion, the pain, the loneliness, and the fear. Her family couldn’t visit, and though Ronan works as a home health nurse, her brain was so addled with fever that she couldn’t make sense of what was happening. After a week in the hospital, 5 days of which were spent in the ICU, 51-year-old Ronan was discharged.

Her years of working as a home health nurse told her that the return home wouldn’t be easy, but nothing prepared her for just how much she would struggle. The once-active Ronan, who had supplemented long days on her feet caring for others as a nurse with regular trips to the gym, now needed a walker to traverse the few steps from her bed to the toilet, an effort that left her gasping for air. Her brain couldn’t even focus on an audiobook, let alone a short magazine article.

“It just completely knocked the stuffing out of me,” Ronan said.

Ronan’s lingering symptoms aren’t unique to COVID-19 patients. In as many as 80% of patients leaving the ICU, researchers have documented what they call post–intensive care syndrome (PICS) — a constellation of physical, cognitive, and psychiatric symptoms that result from an ICU stay. Although underlying illness plays a role in these symptoms, the amount of time spent in critical care is a major factor.

Nor is PICS simply a set of side effects that will go away on their own. It includes ongoing cognitive difficulties and physical weakness, both of which can lead to employment problems. Beyond that, depression and anxiety can exacerbate – and be exacerbated by – these challenges. Psychologist Jim Jackson, PsyD, assistant director of the ICU Recovery Center at Vanderbilt University Medical Center, Nashville, Tennessee, recently spoke with a former ICU patient who has struggled since her discharge 30 years ago.

“Her life essentially stopped with her critical care stay. She hasn’t been able to move forward,” he said. “She’s part of a whole fraternity of people who are struggling.”

The good news is that over the past decade, researchers have made important strides in understanding what makes PICS symptoms worse and how critical care physicians can tweak ICU protocols to reduce PICS severity. Practitioners will need to draw on this knowledge to help Ronan and the thousands of COVID-19 ICU patients like her.
 

Surviving the ICU

Although the new coronavirus has pushed the world’s critical care system to its limits, it was an outbreak in 1952 that inspired the creation of intensive care units. That summer, a wave of paralytic polio swept over Copenhagen, Denmark, and anesthesiologist Bjørn Ibsen, MD, PhD, used mechanical ventilation — physically operated by medical and dental students – to help 316 children breathe for weeks at a time while their small bodies worked to fight off the virus. The effort halved the mortality rate from polio that affected breathing, from 80% to 40%.

In these wards, dedicated to the very sickest, each patient was assigned his or her own nurse. Over the next decade, hospitals in the United Kingdom and the United States established their own ICUs to treat patients with a variety of conditions. Although it helped improve survival, mortality rates in critical care units remained stubbornly high, owing to the patients’ severe underlying illnesses.

“We thought we were doing a good job if the patient survived, but we had no idea what happened after discharge,” said Carla Sevin, MD, medical director of Vanderbilt’s ICU Recovery Center. Nor did their efforts to find out always bring answers. “We struggled to get people to come in for support — they were debilitated, physically burdened, and weak.”

Through further advances in life support, by the early 2000s, the average mortality rates in American ICUs had dropped to 8% to 19%. As the number of critical care survivors began to climb, clinical researchers noticed that the lives of these patients and their families were profoundly altered by their severe illness.

As Dale Needham, MD, PhD, began his pulmonology and critical care residency in Toronto, Canada, in 2005, a group of physicians there began a 5-year longitudinal study to assess long-term outcomes of patients who developed acute respiratory distress syndrome (ARDS). Although ARDS is an acute condition, the investigators found that patients felt effects for years. Younger patients recovered better than older ones, but none of the patients› physical functioning was equivalent to that of age-matched control persons. Even 5 years later, former ICU patients only reached 76% of expected physical functioning, according to results published in the New England Journal of Medicine. The study was a wake-up call.

At a meeting in Chicago in 2010, Needham, now an intensivist at Johns Hopkins Hospital in Baltimore, Maryland, gathered an interdisciplinary group of colleagues, including patients and caregivers, to clarify the phenomena they were seeing. What emerged from that meeting, published in 2012 in Critical Care Medicine, were the diagnostic criteria for PICS: According to the new definition, PICS is characterized by new or worsening physical and neuropsychiatric deficits that range from forgetfulness and loss of motivation to physical weakness and insomnia.

The issue, Needham says, is that although the trouble starts in the ICU, it only becomes clear once patients leave. “ICU doctors aren’t the ones dealing with this,” Needham said. “We need to build stronger bridges between critical care and other professions.” That’s where PICS comes in, a definition that exists explicitly to alert healthcare providers about the constellation of challenges many of these individuals face as they try to reenter “normal” life.
 

Defining the problem

As an ICU nurse at the Mayo Clinic in Rochester, Minnesota, Annie Johnson, ACNP-BC, knew lots about helping hospitalized patients, but she says she didn’t know anything about what to do after discharge – at least not until her own mother became a patient.

On the first day of retirement in October 2014, Johnson’s mother flatlined. Quick-thinking paramedics resuscitated her, and after several days in critical care, she was discharged. Since then, her heart has remained healthy. Johnson’s sister, who spent time worrying over her mother at the hospital, also had lingering effects. Both have since struggled, plagued by nightmares, flashbacks, and insomnia.

Johnson initially believed her mom’s and sister’s neuropsychiatric, post-ICU struggles were unique to her family. It was only a year later, at a seminar she was attending, that she first heard the words “post–intensive care syndrome.” Suddenly, Johnson had a name for her family’s experiences, and she began to create support groups and resources to help other families like hers.

“I thought of all the patients I had treated over the years who had been on ventilators for days and days and days. And if this happened to my mom after 48 hours, what must they be going through?” she asked.

Once physicians formally defined PICS, the Society for Critical Care Medicine helped create programs to educate ICU staff, patients, and families about potential post-discharge challenges. Researchers also began to investigate factors affecting post-ICU functioning. Follow-up studies of patients with delirium (ranging from general confusion about time and place to extreme agitation and violence) showed they had striking cognitive deficits. Problems with short-term memory, flexible thinking, and motivation plagued patients for years after their critical illness, similar to the physical deficiencies seen after ARDS. Delirium was one of the strongest risk factors for neuropsychiatric problems.

“Delirium is basically a stress test for the brain,” said Babar Khan, MD, a critical care specialist at Indiana University’s Regenstrief Institute, in Bloomington. But whether delirium accentuates preexisting cognitive difficulties or creates them afresh isn’t yet clear.

Sophia Wang, MD, a geriatric psychiatrist at Indiana University who works with many critical care patients, says patients who had experienced delirium in the ICU showed significant defects in memory and executive functioning long after their hospital stay. She points to a 2015 study that followed 47 ICU patients for a year post discharge. Among those who experienced delirium, brain volumes, as measured by MRI, were smaller at 3 months, something associated with cognitive problems at 1 year. Many struggled at work, and unemployment was common. Depression and posttraumatic stress compounded these difficulties. Among those with acute respiratory distress, ICU patients who are young, female, and unemployed are most likely to suffer from posttraumatic stress disorder after they are discharge.

Critical care medicine may have given these patients a second chance at life, Wang says, but the life they return to often looks nothing like the one they had before their illness.

Prolonged mechanical ventilation and the heavy sedation that often accompanies it are predictors of PICS severity. Some of these links could be explained by the gravity of the illness that landed someone in critical care, but others are more likely to be iatrogenic, says Gerald Weinhouse, MD, a pulmonology and critical care physician and co-director of the Critical Illness Recovery Program at the Brigham and Women’s Hospital in Boston. The involvement of loved ones at the patient’s bedside, however, improved the entire family’s outcome.

When Weinhouse saw those data, he and his colleagues founded a peer support program for ICU survivors. In a study published in 2019 in Critical Care Medicine, they identified six different models for peer support for those with PICS and their families, including both online and in-person approaches. An ongoing challenge for physicians, Weinhouse says, is getting patients to engage with these programs, given that their calendars are crowded with medical appointments and that they suffer from increased physical and mental disability.

Studies such as these led critical care physicians to form the ICU Liberation Collaborative to rethink critical care medicine. At Vanderbilt, Sevin and Jackson headed up one of the world’s first post-ICU clinics, which uses an interdisciplinary team to help patients maximize their functioning. They redesigned their critical care unit in a way that allows families to spend the night and that encourages patient mobility. Both Needham and Weinhouse continue tracking patient outcomes.

Even before the novel coronavirus struck, the United States — and the world — had begun to realize that graduating from the ICU was only the start of what was often an extensive recovery.
 

The long road back

When COVID-19 patients began flooding intensive care wards around the world, physicians scrambled to meet their complex and desperate acute medical needs. Over the past few months, physicians have focused on keeping these patients alive. “We’ve never seen anything like it ― not even during polio — with the sheer number of patients, all with respiratory distress,” Needham said.

But he and his colleagues know this is only the beginning.

“We’re aware that survivorship issues are coming. There’s going to be a wave of sick people who survived the coronavirus but are going to need more help,” Weinhouse said.

Intensivists have been drawing on PICS research in their fight to help COVID-19 patients. Work from the past few years has shown that although sedation is required during intubation itself, not everyone needs it while on a ventilator. Titrating down sedating medication helps reduce delirium, Wang says. Such medication has been shown to contribute to later cognitive problems. Needham’s studies showing that prolonged bedrest by ICU patients causes muscular atrophy has led him to encourage patients to move as much as possible. With the help of physical therapists, many patients on ventilators can be awake, alert, and moving around the ward.

One of the biggest challenges critical-care coronavirus patients face is prolonged isolation. The constant presence of a familiar face helps orient confused and delirious patients and provides emotional support during a frightening time. But because the immediate need for infection control outweighs these benefits, few hospitals allow visitors, especially for COVID-19 patients.

To address this, some units have been using video technology to allow loved ones to call in. At Johns Hopkins, physicians have also been relying on the expertise of occupational therapists (OTs). Needham says that one OT found that rubbing the hand and back of an agitated, delirious patient helped soothe and calm him better than many medications.

Ronan, who spent 5 days in intensive care, echoes that problem. She says she found the relative lack of human contact to be one of the most challenging parts of being in a bed on a COVID-19 ward. Separated from her husband and daughter, suffering from high fever and severe illness, she lost all track of time.

Her return home was difficult, too. Although her job as a home health nurse had prepared her on some level for the challenges she would face after discharge, Ronan says the hospital provided little practical help.

“Everything is so much harder at home, even little things like going to the bathroom,” she said. “I feel like I’m trying to bail out a sinking ship with a teacup.”

Khan and other physicians, aware of the challenges Ronan and others face once home, aim to create post-ICU clinics specifically for COVID-19 patients. They want to build what Khan calls a “one-stop shop” for all the support patients need to recover. Some of that can be provided via telehealth, which may also help ease the physical burden.

Because there’s so much physicians don’t know about the coronavirus, Johnson says, such clinics are not only a chance to help the sickest COVID-19 patients, they will also help researchers learn more about the virus and improve critical care for other illnesses.

Today, nearly 2 months after discharge, Ronan is back on the job but struggles with a persistent cough — likely due to the lung damage she sustained while ill. She has constant fatigue, as well as ongoing upset stomach from all the medications she took to reduce fever and body aches. When she dons a mask for work, the tangible reminder of her hospital stay sends her into a panic attack. Physically, she’s weaker than before.

Researchers are still trying to understand everything that Ronan and other COVID-19 patients need to move on with their lives after being in the ICU. Mysteries abound, but the ground laid by Sevin, Needham, Weinhouse, and others has provided a solid foundation on which to build.
 

This article first appeared on Medscape.com.

By the time she was discharged from a suburban New Jersey hospital on April 10, Kathleen Ronan thought the worst was behind her. For a week before her husband rushed her to the emergency department (ED), incoherent and struggling to breathe, the novel coronavirus had ravaged her body. She tried to treat her fevers with acetaminophen and ice packs. Despite taking enough Tylenol to risk liver damage and packing herself on ice like the catch of the day, Ronan’s fever continued to rise. By the time her temperature reached 104.5° F, Ronan knew the time had come for more drastic measures.

A team of masked and gowned nurses greeted her at a triage tent outside the ED, and from there, everything becomes hazy for Ronan. She was immediately rushed to the hospital’s special COVID-19 intensive care unit (ICU), where she spent 5 days. But she has few distinct memories from this time. What she does remember is the exhaustion, the pain, the loneliness, and the fear. Her family couldn’t visit, and though Ronan works as a home health nurse, her brain was so addled with fever that she couldn’t make sense of what was happening. After a week in the hospital, 5 days of which were spent in the ICU, 51-year-old Ronan was discharged.

Her years of working as a home health nurse told her that the return home wouldn’t be easy, but nothing prepared her for just how much she would struggle. The once-active Ronan, who had supplemented long days on her feet caring for others as a nurse with regular trips to the gym, now needed a walker to traverse the few steps from her bed to the toilet, an effort that left her gasping for air. Her brain couldn’t even focus on an audiobook, let alone a short magazine article.

“It just completely knocked the stuffing out of me,” Ronan said.

Ronan’s lingering symptoms aren’t unique to COVID-19 patients. In as many as 80% of patients leaving the ICU, researchers have documented what they call post–intensive care syndrome (PICS) — a constellation of physical, cognitive, and psychiatric symptoms that result from an ICU stay. Although underlying illness plays a role in these symptoms, the amount of time spent in critical care is a major factor.

Nor is PICS simply a set of side effects that will go away on their own. It includes ongoing cognitive difficulties and physical weakness, both of which can lead to employment problems. Beyond that, depression and anxiety can exacerbate – and be exacerbated by – these challenges. Psychologist Jim Jackson, PsyD, assistant director of the ICU Recovery Center at Vanderbilt University Medical Center, Nashville, Tennessee, recently spoke with a former ICU patient who has struggled since her discharge 30 years ago.

“Her life essentially stopped with her critical care stay. She hasn’t been able to move forward,” he said. “She’s part of a whole fraternity of people who are struggling.”

The good news is that over the past decade, researchers have made important strides in understanding what makes PICS symptoms worse and how critical care physicians can tweak ICU protocols to reduce PICS severity. Practitioners will need to draw on this knowledge to help Ronan and the thousands of COVID-19 ICU patients like her.
 

Surviving the ICU

Although the new coronavirus has pushed the world’s critical care system to its limits, it was an outbreak in 1952 that inspired the creation of intensive care units. That summer, a wave of paralytic polio swept over Copenhagen, Denmark, and anesthesiologist Bjørn Ibsen, MD, PhD, used mechanical ventilation — physically operated by medical and dental students – to help 316 children breathe for weeks at a time while their small bodies worked to fight off the virus. The effort halved the mortality rate from polio that affected breathing, from 80% to 40%.

In these wards, dedicated to the very sickest, each patient was assigned his or her own nurse. Over the next decade, hospitals in the United Kingdom and the United States established their own ICUs to treat patients with a variety of conditions. Although it helped improve survival, mortality rates in critical care units remained stubbornly high, owing to the patients’ severe underlying illnesses.

“We thought we were doing a good job if the patient survived, but we had no idea what happened after discharge,” said Carla Sevin, MD, medical director of Vanderbilt’s ICU Recovery Center. Nor did their efforts to find out always bring answers. “We struggled to get people to come in for support — they were debilitated, physically burdened, and weak.”

Through further advances in life support, by the early 2000s, the average mortality rates in American ICUs had dropped to 8% to 19%. As the number of critical care survivors began to climb, clinical researchers noticed that the lives of these patients and their families were profoundly altered by their severe illness.

As Dale Needham, MD, PhD, began his pulmonology and critical care residency in Toronto, Canada, in 2005, a group of physicians there began a 5-year longitudinal study to assess long-term outcomes of patients who developed acute respiratory distress syndrome (ARDS). Although ARDS is an acute condition, the investigators found that patients felt effects for years. Younger patients recovered better than older ones, but none of the patients› physical functioning was equivalent to that of age-matched control persons. Even 5 years later, former ICU patients only reached 76% of expected physical functioning, according to results published in the New England Journal of Medicine. The study was a wake-up call.

At a meeting in Chicago in 2010, Needham, now an intensivist at Johns Hopkins Hospital in Baltimore, Maryland, gathered an interdisciplinary group of colleagues, including patients and caregivers, to clarify the phenomena they were seeing. What emerged from that meeting, published in 2012 in Critical Care Medicine, were the diagnostic criteria for PICS: According to the new definition, PICS is characterized by new or worsening physical and neuropsychiatric deficits that range from forgetfulness and loss of motivation to physical weakness and insomnia.

The issue, Needham says, is that although the trouble starts in the ICU, it only becomes clear once patients leave. “ICU doctors aren’t the ones dealing with this,” Needham said. “We need to build stronger bridges between critical care and other professions.” That’s where PICS comes in, a definition that exists explicitly to alert healthcare providers about the constellation of challenges many of these individuals face as they try to reenter “normal” life.
 

Defining the problem

As an ICU nurse at the Mayo Clinic in Rochester, Minnesota, Annie Johnson, ACNP-BC, knew lots about helping hospitalized patients, but she says she didn’t know anything about what to do after discharge – at least not until her own mother became a patient.

On the first day of retirement in October 2014, Johnson’s mother flatlined. Quick-thinking paramedics resuscitated her, and after several days in critical care, she was discharged. Since then, her heart has remained healthy. Johnson’s sister, who spent time worrying over her mother at the hospital, also had lingering effects. Both have since struggled, plagued by nightmares, flashbacks, and insomnia.

Johnson initially believed her mom’s and sister’s neuropsychiatric, post-ICU struggles were unique to her family. It was only a year later, at a seminar she was attending, that she first heard the words “post–intensive care syndrome.” Suddenly, Johnson had a name for her family’s experiences, and she began to create support groups and resources to help other families like hers.

“I thought of all the patients I had treated over the years who had been on ventilators for days and days and days. And if this happened to my mom after 48 hours, what must they be going through?” she asked.

Once physicians formally defined PICS, the Society for Critical Care Medicine helped create programs to educate ICU staff, patients, and families about potential post-discharge challenges. Researchers also began to investigate factors affecting post-ICU functioning. Follow-up studies of patients with delirium (ranging from general confusion about time and place to extreme agitation and violence) showed they had striking cognitive deficits. Problems with short-term memory, flexible thinking, and motivation plagued patients for years after their critical illness, similar to the physical deficiencies seen after ARDS. Delirium was one of the strongest risk factors for neuropsychiatric problems.

“Delirium is basically a stress test for the brain,” said Babar Khan, MD, a critical care specialist at Indiana University’s Regenstrief Institute, in Bloomington. But whether delirium accentuates preexisting cognitive difficulties or creates them afresh isn’t yet clear.

Sophia Wang, MD, a geriatric psychiatrist at Indiana University who works with many critical care patients, says patients who had experienced delirium in the ICU showed significant defects in memory and executive functioning long after their hospital stay. She points to a 2015 study that followed 47 ICU patients for a year post discharge. Among those who experienced delirium, brain volumes, as measured by MRI, were smaller at 3 months, something associated with cognitive problems at 1 year. Many struggled at work, and unemployment was common. Depression and posttraumatic stress compounded these difficulties. Among those with acute respiratory distress, ICU patients who are young, female, and unemployed are most likely to suffer from posttraumatic stress disorder after they are discharge.

Critical care medicine may have given these patients a second chance at life, Wang says, but the life they return to often looks nothing like the one they had before their illness.

Prolonged mechanical ventilation and the heavy sedation that often accompanies it are predictors of PICS severity. Some of these links could be explained by the gravity of the illness that landed someone in critical care, but others are more likely to be iatrogenic, says Gerald Weinhouse, MD, a pulmonology and critical care physician and co-director of the Critical Illness Recovery Program at the Brigham and Women’s Hospital in Boston. The involvement of loved ones at the patient’s bedside, however, improved the entire family’s outcome.

When Weinhouse saw those data, he and his colleagues founded a peer support program for ICU survivors. In a study published in 2019 in Critical Care Medicine, they identified six different models for peer support for those with PICS and their families, including both online and in-person approaches. An ongoing challenge for physicians, Weinhouse says, is getting patients to engage with these programs, given that their calendars are crowded with medical appointments and that they suffer from increased physical and mental disability.

Studies such as these led critical care physicians to form the ICU Liberation Collaborative to rethink critical care medicine. At Vanderbilt, Sevin and Jackson headed up one of the world’s first post-ICU clinics, which uses an interdisciplinary team to help patients maximize their functioning. They redesigned their critical care unit in a way that allows families to spend the night and that encourages patient mobility. Both Needham and Weinhouse continue tracking patient outcomes.

Even before the novel coronavirus struck, the United States — and the world — had begun to realize that graduating from the ICU was only the start of what was often an extensive recovery.
 

The long road back

When COVID-19 patients began flooding intensive care wards around the world, physicians scrambled to meet their complex and desperate acute medical needs. Over the past few months, physicians have focused on keeping these patients alive. “We’ve never seen anything like it ― not even during polio — with the sheer number of patients, all with respiratory distress,” Needham said.

But he and his colleagues know this is only the beginning.

“We’re aware that survivorship issues are coming. There’s going to be a wave of sick people who survived the coronavirus but are going to need more help,” Weinhouse said.

Intensivists have been drawing on PICS research in their fight to help COVID-19 patients. Work from the past few years has shown that although sedation is required during intubation itself, not everyone needs it while on a ventilator. Titrating down sedating medication helps reduce delirium, Wang says. Such medication has been shown to contribute to later cognitive problems. Needham’s studies showing that prolonged bedrest by ICU patients causes muscular atrophy has led him to encourage patients to move as much as possible. With the help of physical therapists, many patients on ventilators can be awake, alert, and moving around the ward.

One of the biggest challenges critical-care coronavirus patients face is prolonged isolation. The constant presence of a familiar face helps orient confused and delirious patients and provides emotional support during a frightening time. But because the immediate need for infection control outweighs these benefits, few hospitals allow visitors, especially for COVID-19 patients.

To address this, some units have been using video technology to allow loved ones to call in. At Johns Hopkins, physicians have also been relying on the expertise of occupational therapists (OTs). Needham says that one OT found that rubbing the hand and back of an agitated, delirious patient helped soothe and calm him better than many medications.

Ronan, who spent 5 days in intensive care, echoes that problem. She says she found the relative lack of human contact to be one of the most challenging parts of being in a bed on a COVID-19 ward. Separated from her husband and daughter, suffering from high fever and severe illness, she lost all track of time.

Her return home was difficult, too. Although her job as a home health nurse had prepared her on some level for the challenges she would face after discharge, Ronan says the hospital provided little practical help.

“Everything is so much harder at home, even little things like going to the bathroom,” she said. “I feel like I’m trying to bail out a sinking ship with a teacup.”

Khan and other physicians, aware of the challenges Ronan and others face once home, aim to create post-ICU clinics specifically for COVID-19 patients. They want to build what Khan calls a “one-stop shop” for all the support patients need to recover. Some of that can be provided via telehealth, which may also help ease the physical burden.

Because there’s so much physicians don’t know about the coronavirus, Johnson says, such clinics are not only a chance to help the sickest COVID-19 patients, they will also help researchers learn more about the virus and improve critical care for other illnesses.

Today, nearly 2 months after discharge, Ronan is back on the job but struggles with a persistent cough — likely due to the lung damage she sustained while ill. She has constant fatigue, as well as ongoing upset stomach from all the medications she took to reduce fever and body aches. When she dons a mask for work, the tangible reminder of her hospital stay sends her into a panic attack. Physically, she’s weaker than before.

Researchers are still trying to understand everything that Ronan and other COVID-19 patients need to move on with their lives after being in the ICU. Mysteries abound, but the ground laid by Sevin, Needham, Weinhouse, and others has provided a solid foundation on which to build.
 

This article first appeared on Medscape.com.

The challenges posed by COVID-19 have crippled health care systems around the globe. By February 2020, the first outbreak in the United States had been set off in Washington State. We quickly became the world’s epicenter of the epidemic, with over 1.8 million patients and over 110,000 deaths.¹ The rapidity of spread and the severity of the disease created a tremendous strain on resources. It blindsided policymakers and hospital administrators, which left little time to react to the challenges placed on hospital operations all over the country.

The necessity of a new care model

Although health systems in the United States are adept in managing complications of common seasonal viral respiratory illnesses, COVID-19 presented an entirely different challenge with its significantly higher mortality rate. A respiratory disease turning into a multiorgan disease that causes debilitating cardiac, renal, neurological, hematological, and psychosocial complications² was not something we had experience managing effectively. Additional challenges included a massive surge of COVID-19 patients, a limited supply of personal protective equipment (PPE), an inadequate number of intensivists for managing the anticipated ventilated patients, and most importantly, the potential of losing some of our workforce if they became infected.

Based on the experiences in China and Italy, and various predictive models, the division of hospital medicine at Baystate Health quickly realized the necessity of a new model of care for COVID-19 patients. We came up with an elaborate plan to manage the disease burden and the strain on resources effectively. The measures we put in place could be broadly divided into three categories following the timeline of the disease: the preparatory phase, the execution phase, and the maintenance phase.
 

The preparatory phase: From “Hospitalists” to “COVIDists”

As in most hospitals around the country, hospitalists are the backbone of inpatient clinical operations at our health system. A focused group of 10 hospitalists who volunteered to take care of COVID-19 patients with a particular interest in the pandemic and experience in critical care were selected, and the term “COVIDists” was coined to refer to them.

COVIDists were trained in various treatment protocols and ongoing clinical trials. They were given refresher training in Advanced Cardiac Life Support (ACLS) and Fundamental Critical Care Support (FCCS) courses and were taught in critical care/ventilator management by the intensivists through rapid indoctrination in the ICU. All of them had their N-95 mask fitting updated and were trained in the safe donning and doffing of all kinds of PPE by PPE coaches. The palliative care team trained them in conducting end-of-life/code status discussions with a focus on being unable to speak with family members at the bedside. COVIDists were also assigned as Code Blue leaders for any “COVID code blue” in the hospital.

In addition to the rapid training course, COVID-related updates were disseminated daily using three different modalities: brief huddles at the start of the day with the COVIDists; a COVID-19 newsletter summarizing daily updates, new treatments, strategies, and policies; and a WhatsApp group for instantly broadcasting information to the COVIDists (Table 1).

The execution phase

All the hospitalized COVID-19 patients were grouped together to COVID units, and the COVIDists were deployed to those units geographically. COVIDists were given lighter than usual patient loads to deal with the extra time needed for donning and doffing of PPE and for coordination with specialists. COVIDists were almost the only clinicians physically visiting the patients in most cases, and they became the “eyes and ears” of specialists since the specialists were advised to minimize exposure and pursue telemedicine consults. The COVIDists were also undertaking the most challenging part of the care – talking to families about end-of-life issues and the futility of aggressive care in certain patients with preexisting conditions.

Some COVIDists were deployed to the ICU to work alongside the intensivists and became an invaluable resource in ICU management when the ICU census skyrocketed during the initial phase of the outbreak. This helped in tiding the health system over during the initial crisis. Within a short time, we shifted away from an early intubation strategy, and most of the ICU patients were managed in the intermediate care units on high flow oxygen along with the awake-proning protocol. The COVIDists exclusively managed these units. They led multidisciplinary rounds two times a day with the ICU, rapid response team (RRT), the palliative care team, and the nursing team. This step drastically decreased the number of intubations, RRT activations, reduced ICU census,³ and helped with hospital capacity and patient flow (Tables 2 and 3).

The maintenance phase

It is already 2 months since the first devising COVIDists. There is no difference in sick callouts between COVIDists and non-COVIDists. One COVIDist and one non-COVIDist contracted the disease, but none of them required hospitalization. Although we initially thought that COVIDists would be needed for only a short period of time, the evolution of the disease is showing signs that it might be prolonged over the next several months. Hence, we are planning to continue COVIDist service for at least the next 6 months and reevaluate the need.

Hospital medicine leadership checked on COVIDists daily in regard to their physical health and, more importantly, their mental well-being. They were offered the chance to be taken off the schedule if they felt burned out, but no one wanted to come off their scheduled service before finishing their shifts. BlueCross MA recognized one of the COVIDists, Raghuveer Rakasi, MD, as a “hero on the front line.”⁴ In Dr. Rakasi’s words, “We took a nosedive into something without knowing its depth, and aware that we could have fatalities among ourselves. We took up new roles, faced new challenges, learned new things every day, evolving every step of the way. We had to change the way we practice medicine, finding new ways to treat patients, and protecting the workforce by limiting patient exposure, prioritizing investigations.” He added that “we have to adapt to a new normal; we should be prepared for this to come in waves. Putting aside our political views, we should stand united 6 feet apart, with a mask covering our brave faces, frequently washing our helping hands to overcome these uncertain times.”
 

Conclusion

The creation of a focused group of hospitalists called COVIDists and providing them with structured and rapid training (in various aspects of clinical care of COVID-19 patients, critical care/ventilator management, efficient and safe use of PPE) and daily information dissemination allowed our health system to prepare for the large volume of COVID-19 patients. It also helped in preserving the larger hospital workforce for a possible future surge.

The rapid development and implementation of the COVIDist strategy succeeded because of the intrinsic motivation of the providers to improve the outcomes of this high-risk patient population and the close collaboration of the stakeholders. Our institution remains successful in managing the pandemic in Western Massachusetts, with reserve capacity remaining even during the peak of the epidemic. A large part of this was because of creating and training a pool of COVIDists.
 

Dr. Medarametla is medical director, clinical operations, in the division of hospital medicine at Baystate Health, and assistant professor at University of Massachusetts, Worcester. Readers can contact him at [email protected]. Dr. Prabhakaran is unit medical director, geriatrics unit, in the division of hospital medicine at Baystate Health and assistant professor at University of Massachusetts. Dr. Bryson is associate program director of the Internal Medicine Residency at Baystate Health and assistant professor at University of Massachusetts. Dr. Umar is medical director, clinical operations, in the division of hospital medicine at Baystate Health. Dr. Natanasabapathy is division chief of hospital medicine at Baystate Health and assistant professor at University of Massachusetts.

References

1. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). Updated Jun 10, 2020. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html.

2. Zhou F et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet. 2020 Mar 28;395(10229):1054-62.

3. Westafer LM et al. A transdisciplinary COVID-19 early respiratory intervention protocol: An implementation story. J Hosp Med. 2020 May 21;15(6):372-374.

4. Miller J. “Heroes on the front line: Dr. Raghuveer Rakasi.” Coverage. May 18, 2020. https://coverage.bluecrossma.com/article/heroes-front-line-dr-raghuveer-rakasi

The challenges posed by COVID-19 have crippled health care systems around the globe. By February 2020, the first outbreak in the United States had been set off in Washington State. We quickly became the world’s epicenter of the epidemic, with over 1.8 million patients and over 110,000 deaths.¹ The rapidity of spread and the severity of the disease created a tremendous strain on resources. It blindsided policymakers and hospital administrators, which left little time to react to the challenges placed on hospital operations all over the country.

The necessity of a new care model

Although health systems in the United States are adept in managing complications of common seasonal viral respiratory illnesses, COVID-19 presented an entirely different challenge with its significantly higher mortality rate. A respiratory disease turning into a multiorgan disease that causes debilitating cardiac, renal, neurological, hematological, and psychosocial complications² was not something we had experience managing effectively. Additional challenges included a massive surge of COVID-19 patients, a limited supply of personal protective equipment (PPE), an inadequate number of intensivists for managing the anticipated ventilated patients, and most importantly, the potential of losing some of our workforce if they became infected.

Based on the experiences in China and Italy, and various predictive models, the division of hospital medicine at Baystate Health quickly realized the necessity of a new model of care for COVID-19 patients. We came up with an elaborate plan to manage the disease burden and the strain on resources effectively. The measures we put in place could be broadly divided into three categories following the timeline of the disease: the preparatory phase, the execution phase, and the maintenance phase.
 

The preparatory phase: From “Hospitalists” to “COVIDists”

As in most hospitals around the country, hospitalists are the backbone of inpatient clinical operations at our health system. A focused group of 10 hospitalists who volunteered to take care of COVID-19 patients with a particular interest in the pandemic and experience in critical care were selected, and the term “COVIDists” was coined to refer to them.

COVIDists were trained in various treatment protocols and ongoing clinical trials. They were given refresher training in Advanced Cardiac Life Support (ACLS) and Fundamental Critical Care Support (FCCS) courses and were taught in critical care/ventilator management by the intensivists through rapid indoctrination in the ICU. All of them had their N-95 mask fitting updated and were trained in the safe donning and doffing of all kinds of PPE by PPE coaches. The palliative care team trained them in conducting end-of-life/code status discussions with a focus on being unable to speak with family members at the bedside. COVIDists were also assigned as Code Blue leaders for any “COVID code blue” in the hospital.

In addition to the rapid training course, COVID-related updates were disseminated daily using three different modalities: brief huddles at the start of the day with the COVIDists; a COVID-19 newsletter summarizing daily updates, new treatments, strategies, and policies; and a WhatsApp group for instantly broadcasting information to the COVIDists (Table 1).

The execution phase

All the hospitalized COVID-19 patients were grouped together to COVID units, and the COVIDists were deployed to those units geographically. COVIDists were given lighter than usual patient loads to deal with the extra time needed for donning and doffing of PPE and for coordination with specialists. COVIDists were almost the only clinicians physically visiting the patients in most cases, and they became the “eyes and ears” of specialists since the specialists were advised to minimize exposure and pursue telemedicine consults. The COVIDists were also undertaking the most challenging part of the care – talking to families about end-of-life issues and the futility of aggressive care in certain patients with preexisting conditions.

Some COVIDists were deployed to the ICU to work alongside the intensivists and became an invaluable resource in ICU management when the ICU census skyrocketed during the initial phase of the outbreak. This helped in tiding the health system over during the initial crisis. Within a short time, we shifted away from an early intubation strategy, and most of the ICU patients were managed in the intermediate care units on high flow oxygen along with the awake-proning protocol. The COVIDists exclusively managed these units. They led multidisciplinary rounds two times a day with the ICU, rapid response team (RRT), the palliative care team, and the nursing team. This step drastically decreased the number of intubations, RRT activations, reduced ICU census,³ and helped with hospital capacity and patient flow (Tables 2 and 3).

The maintenance phase

It is already 2 months since the first devising COVIDists. There is no difference in sick callouts between COVIDists and non-COVIDists. One COVIDist and one non-COVIDist contracted the disease, but none of them required hospitalization. Although we initially thought that COVIDists would be needed for only a short period of time, the evolution of the disease is showing signs that it might be prolonged over the next several months. Hence, we are planning to continue COVIDist service for at least the next 6 months and reevaluate the need.

Hospital medicine leadership checked on COVIDists daily in regard to their physical health and, more importantly, their mental well-being. They were offered the chance to be taken off the schedule if they felt burned out, but no one wanted to come off their scheduled service before finishing their shifts. BlueCross MA recognized one of the COVIDists, Raghuveer Rakasi, MD, as a “hero on the front line.”⁴ In Dr. Rakasi’s words, “We took a nosedive into something without knowing its depth, and aware that we could have fatalities among ourselves. We took up new roles, faced new challenges, learned new things every day, evolving every step of the way. We had to change the way we practice medicine, finding new ways to treat patients, and protecting the workforce by limiting patient exposure, prioritizing investigations.” He added that “we have to adapt to a new normal; we should be prepared for this to come in waves. Putting aside our political views, we should stand united 6 feet apart, with a mask covering our brave faces, frequently washing our helping hands to overcome these uncertain times.”
 

Conclusion

The creation of a focused group of hospitalists called COVIDists and providing them with structured and rapid training (in various aspects of clinical care of COVID-19 patients, critical care/ventilator management, efficient and safe use of PPE) and daily information dissemination allowed our health system to prepare for the large volume of COVID-19 patients. It also helped in preserving the larger hospital workforce for a possible future surge.

The rapid development and implementation of the COVIDist strategy succeeded because of the intrinsic motivation of the providers to improve the outcomes of this high-risk patient population and the close collaboration of the stakeholders. Our institution remains successful in managing the pandemic in Western Massachusetts, with reserve capacity remaining even during the peak of the epidemic. A large part of this was because of creating and training a pool of COVIDists.
 

Dr. Medarametla is medical director, clinical operations, in the division of hospital medicine at Baystate Health, and assistant professor at University of Massachusetts, Worcester. Readers can contact him at [email protected]. Dr. Prabhakaran is unit medical director, geriatrics unit, in the division of hospital medicine at Baystate Health and assistant professor at University of Massachusetts. Dr. Bryson is associate program director of the Internal Medicine Residency at Baystate Health and assistant professor at University of Massachusetts. Dr. Umar is medical director, clinical operations, in the division of hospital medicine at Baystate Health. Dr. Natanasabapathy is division chief of hospital medicine at Baystate Health and assistant professor at University of Massachusetts.

References

1. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). Updated Jun 10, 2020. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html.

2. Zhou F et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet. 2020 Mar 28;395(10229):1054-62.

3. Westafer LM et al. A transdisciplinary COVID-19 early respiratory intervention protocol: An implementation story. J Hosp Med. 2020 May 21;15(6):372-374.

4. Miller J. “Heroes on the front line: Dr. Raghuveer Rakasi.” Coverage. May 18, 2020. https://coverage.bluecrossma.com/article/heroes-front-line-dr-raghuveer-rakasi

The challenges posed by COVID-19 have crippled health care systems around the globe. By February 2020, the first outbreak in the United States had been set off in Washington State. We quickly became the world’s epicenter of the epidemic, with over 1.8 million patients and over 110,000 deaths.¹ The rapidity of spread and the severity of the disease created a tremendous strain on resources. It blindsided policymakers and hospital administrators, which left little time to react to the challenges placed on hospital operations all over the country.

The necessity of a new care model

Although health systems in the United States are adept in managing complications of common seasonal viral respiratory illnesses, COVID-19 presented an entirely different challenge with its significantly higher mortality rate. A respiratory disease turning into a multiorgan disease that causes debilitating cardiac, renal, neurological, hematological, and psychosocial complications² was not something we had experience managing effectively. Additional challenges included a massive surge of COVID-19 patients, a limited supply of personal protective equipment (PPE), an inadequate number of intensivists for managing the anticipated ventilated patients, and most importantly, the potential of losing some of our workforce if they became infected.

Based on the experiences in China and Italy, and various predictive models, the division of hospital medicine at Baystate Health quickly realized the necessity of a new model of care for COVID-19 patients. We came up with an elaborate plan to manage the disease burden and the strain on resources effectively. The measures we put in place could be broadly divided into three categories following the timeline of the disease: the preparatory phase, the execution phase, and the maintenance phase.
 

The preparatory phase: From “Hospitalists” to “COVIDists”

As in most hospitals around the country, hospitalists are the backbone of inpatient clinical operations at our health system. A focused group of 10 hospitalists who volunteered to take care of COVID-19 patients with a particular interest in the pandemic and experience in critical care were selected, and the term “COVIDists” was coined to refer to them.

COVIDists were trained in various treatment protocols and ongoing clinical trials. They were given refresher training in Advanced Cardiac Life Support (ACLS) and Fundamental Critical Care Support (FCCS) courses and were taught in critical care/ventilator management by the intensivists through rapid indoctrination in the ICU. All of them had their N-95 mask fitting updated and were trained in the safe donning and doffing of all kinds of PPE by PPE coaches. The palliative care team trained them in conducting end-of-life/code status discussions with a focus on being unable to speak with family members at the bedside. COVIDists were also assigned as Code Blue leaders for any “COVID code blue” in the hospital.

In addition to the rapid training course, COVID-related updates were disseminated daily using three different modalities: brief huddles at the start of the day with the COVIDists; a COVID-19 newsletter summarizing daily updates, new treatments, strategies, and policies; and a WhatsApp group for instantly broadcasting information to the COVIDists (Table 1).

The execution phase

All the hospitalized COVID-19 patients were grouped together to COVID units, and the COVIDists were deployed to those units geographically. COVIDists were given lighter than usual patient loads to deal with the extra time needed for donning and doffing of PPE and for coordination with specialists. COVIDists were almost the only clinicians physically visiting the patients in most cases, and they became the “eyes and ears” of specialists since the specialists were advised to minimize exposure and pursue telemedicine consults. The COVIDists were also undertaking the most challenging part of the care – talking to families about end-of-life issues and the futility of aggressive care in certain patients with preexisting conditions.

Some COVIDists were deployed to the ICU to work alongside the intensivists and became an invaluable resource in ICU management when the ICU census skyrocketed during the initial phase of the outbreak. This helped in tiding the health system over during the initial crisis. Within a short time, we shifted away from an early intubation strategy, and most of the ICU patients were managed in the intermediate care units on high flow oxygen along with the awake-proning protocol. The COVIDists exclusively managed these units. They led multidisciplinary rounds two times a day with the ICU, rapid response team (RRT), the palliative care team, and the nursing team. This step drastically decreased the number of intubations, RRT activations, reduced ICU census,³ and helped with hospital capacity and patient flow (Tables 2 and 3).

The maintenance phase

It is already 2 months since the first devising COVIDists. There is no difference in sick callouts between COVIDists and non-COVIDists. One COVIDist and one non-COVIDist contracted the disease, but none of them required hospitalization. Although we initially thought that COVIDists would be needed for only a short period of time, the evolution of the disease is showing signs that it might be prolonged over the next several months. Hence, we are planning to continue COVIDist service for at least the next 6 months and reevaluate the need.

Hospital medicine leadership checked on COVIDists daily in regard to their physical health and, more importantly, their mental well-being. They were offered the chance to be taken off the schedule if they felt burned out, but no one wanted to come off their scheduled service before finishing their shifts. BlueCross MA recognized one of the COVIDists, Raghuveer Rakasi, MD, as a “hero on the front line.”⁴ In Dr. Rakasi’s words, “We took a nosedive into something without knowing its depth, and aware that we could have fatalities among ourselves. We took up new roles, faced new challenges, learned new things every day, evolving every step of the way. We had to change the way we practice medicine, finding new ways to treat patients, and protecting the workforce by limiting patient exposure, prioritizing investigations.” He added that “we have to adapt to a new normal; we should be prepared for this to come in waves. Putting aside our political views, we should stand united 6 feet apart, with a mask covering our brave faces, frequently washing our helping hands to overcome these uncertain times.”
 

Conclusion

The creation of a focused group of hospitalists called COVIDists and providing them with structured and rapid training (in various aspects of clinical care of COVID-19 patients, critical care/ventilator management, efficient and safe use of PPE) and daily information dissemination allowed our health system to prepare for the large volume of COVID-19 patients. It also helped in preserving the larger hospital workforce for a possible future surge.

The rapid development and implementation of the COVIDist strategy succeeded because of the intrinsic motivation of the providers to improve the outcomes of this high-risk patient population and the close collaboration of the stakeholders. Our institution remains successful in managing the pandemic in Western Massachusetts, with reserve capacity remaining even during the peak of the epidemic. A large part of this was because of creating and training a pool of COVIDists.
 

Dr. Medarametla is medical director, clinical operations, in the division of hospital medicine at Baystate Health, and assistant professor at University of Massachusetts, Worcester. Readers can contact him at [email protected]. Dr. Prabhakaran is unit medical director, geriatrics unit, in the division of hospital medicine at Baystate Health and assistant professor at University of Massachusetts. Dr. Bryson is associate program director of the Internal Medicine Residency at Baystate Health and assistant professor at University of Massachusetts. Dr. Umar is medical director, clinical operations, in the division of hospital medicine at Baystate Health. Dr. Natanasabapathy is division chief of hospital medicine at Baystate Health and assistant professor at University of Massachusetts.

References

1. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). Updated Jun 10, 2020. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html.

2. Zhou F et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet. 2020 Mar 28;395(10229):1054-62.

3. Westafer LM et al. A transdisciplinary COVID-19 early respiratory intervention protocol: An implementation story. J Hosp Med. 2020 May 21;15(6):372-374.

4. Miller J. “Heroes on the front line: Dr. Raghuveer Rakasi.” Coverage. May 18, 2020. https://coverage.bluecrossma.com/article/heroes-front-line-dr-raghuveer-rakasi

Here are the stories our MDedge editors across specialties think you need to know about today:

Lung ultrasound works well in children with COVID-19

Lung ultrasound has “high concordance” with radiologic findings in children with COVID-19 and offers benefits over other imaging techniques, such as CT. “First, it may reduce the number of radiologic examinations, lowering the radiation exposure of the patients,” wrote Marco Denina, MD, and colleagues from the pediatric infectious diseases unit at Regina Margherita Children’s Hospital in Turin, Italy. “Secondly, when performed at the bedside, [lung ultrasound] allows for the reduction of the patient’s movement within the hospital; thus, it lowers the number of health care workers and medical devices exposed to [SARS-CoV-2].” The findings of the small, observational study were published in Pediatrics. Read more.

New hypertension definitions reveal preclampsia risk

Using the new clinical definitions of hypertension, pregnant women with even modest elevations in blood pressure are at increased risk for preeclampsia, according to results from a large retrospective cohort study. Elizabeth F. Sutton, PhD, of the University of Pittsburgh and colleagues looked at records from 18,162 women who had given birth to a single baby. The authors found preeclampsia risk increased with increasing blood pressure elevation. Among women with normal blood pressure before 20 weeks’ gestation, 5% had preeclampsia, while 7% of those with elevated blood pressure did, as did 12% of women with stage 1 hypertension and 30% of women with stage 2 hypertension. The increase in risk of preeclampsia was because of preterm preeclampsia in the women with elevated blood pressure. Preeclampsia researcher Mark Santillan, MD, PhD, of the University of Iowa in Iowa City, said in an interview that the results “open the door to considering these new blood pressure categories as a prognosticator” for preeclampsia. “This paper furthers the field by applying these new categories to hypertensive diseases in pregnancy, which are not well studied” in comparison to nonpregnant hypertensive states. Read more.

Face mask type matters when sterilizing

When sterilizing face masks, the type of mask and the method of sterilization have a bearing on subsequent filtration efficiency, according to new research published in JAMA Network Open. The greatest reduction in filtration efficiency after sterilization occurred with surgical face masks. With plasma vapor hydrogen peroxide (H2O2) sterilization, filtration efficiency of N95 and KN95 masks was maintained at more than 95%, but for surgical face masks, filtration efficiency was reduced to less than 95%. With chlorine dioxide (ClO2) sterilization, on the other hand, filtration efficiency was maintained at above 95% for N95 masks, but for KN95 and surgical face masks, filtration efficiency was reduced to less than 80%. Read more.

FDA approves first treatment for adult-onset Still’s disease

The Food and Drug Administration has expanded the indications for canakinumab (Ilaris) to include all patients with active Still’s disease older than 2 years, adding adult-onset Still’s disease (AOSD) to a previous approval for juvenile-onset Still’s disease, also known as systemic juvenile idiopathic arthritis (sJIA). That makes Ilaris the first approved treatment for AOSD. The results from a randomized, double-blind, placebo-controlled study of 36 patients with AOSD aged 22-70 years showed that the efficacy and safety data in AOSD were generally consistent with the results of a pooled analysis of sJIA patients, according to Novartis, which markets canakinumab. Read more.

Intranasal DHE shows promise in migraine

An intranasal form of dihydroergotamine (DHE) targeting the upper nasal region is safe and effective for the treatment of migraine, according to results from a phase 3 clinical trial. The new formulation could offer patients an at-home alternative to intramuscular infusions or intravenous injections currently used to deliver DHE. The STOP 301 phase 3 open-label safety and tolerability trial treated over 5,650 migraine attacks in 354 patients who self-administered INP104 for up to 52 weeks. They were provided up to three doses per week (1.45 mg in a dose of two puffs, one per nostril). A total of 66.3% of participants reported pain relief by 2 hours following a dose, and 38% had freedom from pain. Read more.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

Here are the stories our MDedge editors across specialties think you need to know about today:

Lung ultrasound works well in children with COVID-19

Lung ultrasound has “high concordance” with radiologic findings in children with COVID-19 and offers benefits over other imaging techniques, such as CT. “First, it may reduce the number of radiologic examinations, lowering the radiation exposure of the patients,” wrote Marco Denina, MD, and colleagues from the pediatric infectious diseases unit at Regina Margherita Children’s Hospital in Turin, Italy. “Secondly, when performed at the bedside, [lung ultrasound] allows for the reduction of the patient’s movement within the hospital; thus, it lowers the number of health care workers and medical devices exposed to [SARS-CoV-2].” The findings of the small, observational study were published in Pediatrics. Read more.

New hypertension definitions reveal preclampsia risk

Using the new clinical definitions of hypertension, pregnant women with even modest elevations in blood pressure are at increased risk for preeclampsia, according to results from a large retrospective cohort study. Elizabeth F. Sutton, PhD, of the University of Pittsburgh and colleagues looked at records from 18,162 women who had given birth to a single baby. The authors found preeclampsia risk increased with increasing blood pressure elevation. Among women with normal blood pressure before 20 weeks’ gestation, 5% had preeclampsia, while 7% of those with elevated blood pressure did, as did 12% of women with stage 1 hypertension and 30% of women with stage 2 hypertension. The increase in risk of preeclampsia was because of preterm preeclampsia in the women with elevated blood pressure. Preeclampsia researcher Mark Santillan, MD, PhD, of the University of Iowa in Iowa City, said in an interview that the results “open the door to considering these new blood pressure categories as a prognosticator” for preeclampsia. “This paper furthers the field by applying these new categories to hypertensive diseases in pregnancy, which are not well studied” in comparison to nonpregnant hypertensive states. Read more.

Face mask type matters when sterilizing

When sterilizing face masks, the type of mask and the method of sterilization have a bearing on subsequent filtration efficiency, according to new research published in JAMA Network Open. The greatest reduction in filtration efficiency after sterilization occurred with surgical face masks. With plasma vapor hydrogen peroxide (H2O2) sterilization, filtration efficiency of N95 and KN95 masks was maintained at more than 95%, but for surgical face masks, filtration efficiency was reduced to less than 95%. With chlorine dioxide (ClO2) sterilization, on the other hand, filtration efficiency was maintained at above 95% for N95 masks, but for KN95 and surgical face masks, filtration efficiency was reduced to less than 80%. Read more.

FDA approves first treatment for adult-onset Still’s disease

The Food and Drug Administration has expanded the indications for canakinumab (Ilaris) to include all patients with active Still’s disease older than 2 years, adding adult-onset Still’s disease (AOSD) to a previous approval for juvenile-onset Still’s disease, also known as systemic juvenile idiopathic arthritis (sJIA). That makes Ilaris the first approved treatment for AOSD. The results from a randomized, double-blind, placebo-controlled study of 36 patients with AOSD aged 22-70 years showed that the efficacy and safety data in AOSD were generally consistent with the results of a pooled analysis of sJIA patients, according to Novartis, which markets canakinumab. Read more.

Intranasal DHE shows promise in migraine

An intranasal form of dihydroergotamine (DHE) targeting the upper nasal region is safe and effective for the treatment of migraine, according to results from a phase 3 clinical trial. The new formulation could offer patients an at-home alternative to intramuscular infusions or intravenous injections currently used to deliver DHE. The STOP 301 phase 3 open-label safety and tolerability trial treated over 5,650 migraine attacks in 354 patients who self-administered INP104 for up to 52 weeks. They were provided up to three doses per week (1.45 mg in a dose of two puffs, one per nostril). A total of 66.3% of participants reported pain relief by 2 hours following a dose, and 38% had freedom from pain. Read more.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

Here are the stories our MDedge editors across specialties think you need to know about today:

Lung ultrasound works well in children with COVID-19

Lung ultrasound has “high concordance” with radiologic findings in children with COVID-19 and offers benefits over other imaging techniques, such as CT. “First, it may reduce the number of radiologic examinations, lowering the radiation exposure of the patients,” wrote Marco Denina, MD, and colleagues from the pediatric infectious diseases unit at Regina Margherita Children’s Hospital in Turin, Italy. “Secondly, when performed at the bedside, [lung ultrasound] allows for the reduction of the patient’s movement within the hospital; thus, it lowers the number of health care workers and medical devices exposed to [SARS-CoV-2].” The findings of the small, observational study were published in Pediatrics. Read more.

New hypertension definitions reveal preclampsia risk

Using the new clinical definitions of hypertension, pregnant women with even modest elevations in blood pressure are at increased risk for preeclampsia, according to results from a large retrospective cohort study. Elizabeth F. Sutton, PhD, of the University of Pittsburgh and colleagues looked at records from 18,162 women who had given birth to a single baby. The authors found preeclampsia risk increased with increasing blood pressure elevation. Among women with normal blood pressure before 20 weeks’ gestation, 5% had preeclampsia, while 7% of those with elevated blood pressure did, as did 12% of women with stage 1 hypertension and 30% of women with stage 2 hypertension. The increase in risk of preeclampsia was because of preterm preeclampsia in the women with elevated blood pressure. Preeclampsia researcher Mark Santillan, MD, PhD, of the University of Iowa in Iowa City, said in an interview that the results “open the door to considering these new blood pressure categories as a prognosticator” for preeclampsia. “This paper furthers the field by applying these new categories to hypertensive diseases in pregnancy, which are not well studied” in comparison to nonpregnant hypertensive states. Read more.

Face mask type matters when sterilizing

When sterilizing face masks, the type of mask and the method of sterilization have a bearing on subsequent filtration efficiency, according to new research published in JAMA Network Open. The greatest reduction in filtration efficiency after sterilization occurred with surgical face masks. With plasma vapor hydrogen peroxide (H2O2) sterilization, filtration efficiency of N95 and KN95 masks was maintained at more than 95%, but for surgical face masks, filtration efficiency was reduced to less than 95%. With chlorine dioxide (ClO2) sterilization, on the other hand, filtration efficiency was maintained at above 95% for N95 masks, but for KN95 and surgical face masks, filtration efficiency was reduced to less than 80%. Read more.

FDA approves first treatment for adult-onset Still’s disease

The Food and Drug Administration has expanded the indications for canakinumab (Ilaris) to include all patients with active Still’s disease older than 2 years, adding adult-onset Still’s disease (AOSD) to a previous approval for juvenile-onset Still’s disease, also known as systemic juvenile idiopathic arthritis (sJIA). That makes Ilaris the first approved treatment for AOSD. The results from a randomized, double-blind, placebo-controlled study of 36 patients with AOSD aged 22-70 years showed that the efficacy and safety data in AOSD were generally consistent with the results of a pooled analysis of sJIA patients, according to Novartis, which markets canakinumab. Read more.

Intranasal DHE shows promise in migraine

An intranasal form of dihydroergotamine (DHE) targeting the upper nasal region is safe and effective for the treatment of migraine, according to results from a phase 3 clinical trial. The new formulation could offer patients an at-home alternative to intramuscular infusions or intravenous injections currently used to deliver DHE. The STOP 301 phase 3 open-label safety and tolerability trial treated over 5,650 migraine attacks in 354 patients who self-administered INP104 for up to 52 weeks. They were provided up to three doses per week (1.45 mg in a dose of two puffs, one per nostril). A total of 66.3% of participants reported pain relief by 2 hours following a dose, and 38% had freedom from pain. Read more.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

What a privilege it has been over the last several months to participate as staff support along with Jenny Nemkovich and Michelle Kosobucki to CHEST’s new Health Policy and Advocacy Committee (HPAC). The opportunity to serve on a committee of CHEST from the perspective of staff rather than in a volunteer/leadership role has been very enlightening and clearly a learning experience.

Background

As most know, CHEST in the summer of 2019 made the decision to proactively strengthen our position in the areas of public policy, both advocacy and the regulatory space.

This decision will provide CHEST with the mechanism to have greater control over determining and influencing the pulmonary, critical care, and sleep agenda that directly impacts our members and our patients. Adding this piece to the CHEST portfolio is particularly fortuitous in light of the increased advocacy needs in this COVID-19 environment. Having recently completed the acquisition of NAMDRC, CHEST has jump-started our return to this space. While this acquisition does not represent a single source solution, it does represent a key component to a comprehensive approach to policy and advocacy. The rich experience of our new colleagues from NAMDRC brings incredible value and insights to our efforts.
 

Health policy and advocacy committee

The initial composition of the HPAC is made up of equal numbers of members drawn from the NAMDRC leadership pool, as well as members of both the CHEST Foundation Board of Trustees and the Board of Regents of the College. This group represents a very energetic, talented, and diverse group. Experience in the space of policy and advocacy in areas such as home ventilation, oxygen issues, telemedicine, and pulmonary rehab reimbursement is blended with presidential leadership of both the CHEST Foundation and CHEST, as well as talent in areas such as coding and reimbursement, social media applications, and also leadership representing our NetWorks.

Policy priorities

Having had three virtual meetings, the HPAC has initially been focusing on developing and discussing an initial group of policy priorities. These topics are being vetted and held to a rigorous discussion, including what success looks like in these areas, potential barriers or obstacles to making an impact, and who could represent important collaborative partners in these areas. These priorities will be coupled with an effort to define short-term and longer term performance indicators to help try to assess meaningful impact. Once these are better defined, we plan to reach out to our CHEST NetWorks, partners in Industry, sister societies, and friends in patient advocacy groups to get their input and, when appropriate, their collaboration. The BOR will be kept informed and eventually comment and hopefully endorse these policy priorities.

Member engagement

In my opinion, our approach in this area of policy and advocacy is somewhat unique in the associational arena. Rather than policy staff driving the agenda, we are following the example of other committees at CHEST in having volunteers and leadership developing the “what” and staff creating the “how.” At that point, a team of leadership/staff will deliver the product. I feel that this somewhat “bottom up” approach will lead to much more productive and effective member engagement and a growing group of advocacy aware and committed members.

Washington watchline

To complement the work of HPAC and better communicate important issues related to policy and advocacy, our Publications team, led by Nicki Augustyn, has taken over the production of what was NAMDRC’s valuable periodical, the Washington Watchline. Under the editorship for many years of past CHEST President, Jim Mathers, MD, FCCP, this resource has been a valuable and respected source of information for NAMDRC membership. The June edition has recently been published.

Spring meeting, 2021

The HPAC’s Chair and Vice-Chair, Drs. Neil Freedman and Jim Lamberti, are serving as the Program Directors for our first meeting that will blend the NAMDRC perspective and experience in a program around policy and advocacy with the traditional expertise in education delivery of CHEST. This meeting will be in conjunction with our Spring Leadership meetings in Sonoma, California. Save the date, as this promises to be a great meeting, with unique educational opportunities and policy and advocacy insights.

Thanks again to the members of HPAC and to Bob Musacchio for giving me an opportunity to provide staff assistance in this exciting new endeavor for CHEST.

What a privilege it has been over the last several months to participate as staff support along with Jenny Nemkovich and Michelle Kosobucki to CHEST’s new Health Policy and Advocacy Committee (HPAC). The opportunity to serve on a committee of CHEST from the perspective of staff rather than in a volunteer/leadership role has been very enlightening and clearly a learning experience.

Background

As most know, CHEST in the summer of 2019 made the decision to proactively strengthen our position in the areas of public policy, both advocacy and the regulatory space.

This decision will provide CHEST with the mechanism to have greater control over determining and influencing the pulmonary, critical care, and sleep agenda that directly impacts our members and our patients. Adding this piece to the CHEST portfolio is particularly fortuitous in light of the increased advocacy needs in this COVID-19 environment. Having recently completed the acquisition of NAMDRC, CHEST has jump-started our return to this space. While this acquisition does not represent a single source solution, it does represent a key component to a comprehensive approach to policy and advocacy. The rich experience of our new colleagues from NAMDRC brings incredible value and insights to our efforts.
 

Health policy and advocacy committee

The initial composition of the HPAC is made up of equal numbers of members drawn from the NAMDRC leadership pool, as well as members of both the CHEST Foundation Board of Trustees and the Board of Regents of the College. This group represents a very energetic, talented, and diverse group. Experience in the space of policy and advocacy in areas such as home ventilation, oxygen issues, telemedicine, and pulmonary rehab reimbursement is blended with presidential leadership of both the CHEST Foundation and CHEST, as well as talent in areas such as coding and reimbursement, social media applications, and also leadership representing our NetWorks.

Policy priorities

Having had three virtual meetings, the HPAC has initially been focusing on developing and discussing an initial group of policy priorities. These topics are being vetted and held to a rigorous discussion, including what success looks like in these areas, potential barriers or obstacles to making an impact, and who could represent important collaborative partners in these areas. These priorities will be coupled with an effort to define short-term and longer term performance indicators to help try to assess meaningful impact. Once these are better defined, we plan to reach out to our CHEST NetWorks, partners in Industry, sister societies, and friends in patient advocacy groups to get their input and, when appropriate, their collaboration. The BOR will be kept informed and eventually comment and hopefully endorse these policy priorities.

Member engagement

In my opinion, our approach in this area of policy and advocacy is somewhat unique in the associational arena. Rather than policy staff driving the agenda, we are following the example of other committees at CHEST in having volunteers and leadership developing the “what” and staff creating the “how.” At that point, a team of leadership/staff will deliver the product. I feel that this somewhat “bottom up” approach will lead to much more productive and effective member engagement and a growing group of advocacy aware and committed members.

Washington watchline

To complement the work of HPAC and better communicate important issues related to policy and advocacy, our Publications team, led by Nicki Augustyn, has taken over the production of what was NAMDRC’s valuable periodical, the Washington Watchline. Under the editorship for many years of past CHEST President, Jim Mathers, MD, FCCP, this resource has been a valuable and respected source of information for NAMDRC membership. The June edition has recently been published.

Spring meeting, 2021

The HPAC’s Chair and Vice-Chair, Drs. Neil Freedman and Jim Lamberti, are serving as the Program Directors for our first meeting that will blend the NAMDRC perspective and experience in a program around policy and advocacy with the traditional expertise in education delivery of CHEST. This meeting will be in conjunction with our Spring Leadership meetings in Sonoma, California. Save the date, as this promises to be a great meeting, with unique educational opportunities and policy and advocacy insights.

Thanks again to the members of HPAC and to Bob Musacchio for giving me an opportunity to provide staff assistance in this exciting new endeavor for CHEST.

What a privilege it has been over the last several months to participate as staff support along with Jenny Nemkovich and Michelle Kosobucki to CHEST’s new Health Policy and Advocacy Committee (HPAC). The opportunity to serve on a committee of CHEST from the perspective of staff rather than in a volunteer/leadership role has been very enlightening and clearly a learning experience.

Background

As most know, CHEST in the summer of 2019 made the decision to proactively strengthen our position in the areas of public policy, both advocacy and the regulatory space.

This decision will provide CHEST with the mechanism to have greater control over determining and influencing the pulmonary, critical care, and sleep agenda that directly impacts our members and our patients. Adding this piece to the CHEST portfolio is particularly fortuitous in light of the increased advocacy needs in this COVID-19 environment. Having recently completed the acquisition of NAMDRC, CHEST has jump-started our return to this space. While this acquisition does not represent a single source solution, it does represent a key component to a comprehensive approach to policy and advocacy. The rich experience of our new colleagues from NAMDRC brings incredible value and insights to our efforts.
 

Health policy and advocacy committee

The initial composition of the HPAC is made up of equal numbers of members drawn from the NAMDRC leadership pool, as well as members of both the CHEST Foundation Board of Trustees and the Board of Regents of the College. This group represents a very energetic, talented, and diverse group. Experience in the space of policy and advocacy in areas such as home ventilation, oxygen issues, telemedicine, and pulmonary rehab reimbursement is blended with presidential leadership of both the CHEST Foundation and CHEST, as well as talent in areas such as coding and reimbursement, social media applications, and also leadership representing our NetWorks.

Policy priorities

Having had three virtual meetings, the HPAC has initially been focusing on developing and discussing an initial group of policy priorities. These topics are being vetted and held to a rigorous discussion, including what success looks like in these areas, potential barriers or obstacles to making an impact, and who could represent important collaborative partners in these areas. These priorities will be coupled with an effort to define short-term and longer term performance indicators to help try to assess meaningful impact. Once these are better defined, we plan to reach out to our CHEST NetWorks, partners in Industry, sister societies, and friends in patient advocacy groups to get their input and, when appropriate, their collaboration. The BOR will be kept informed and eventually comment and hopefully endorse these policy priorities.

Member engagement

In my opinion, our approach in this area of policy and advocacy is somewhat unique in the associational arena. Rather than policy staff driving the agenda, we are following the example of other committees at CHEST in having volunteers and leadership developing the “what” and staff creating the “how.” At that point, a team of leadership/staff will deliver the product. I feel that this somewhat “bottom up” approach will lead to much more productive and effective member engagement and a growing group of advocacy aware and committed members.

Washington watchline

To complement the work of HPAC and better communicate important issues related to policy and advocacy, our Publications team, led by Nicki Augustyn, has taken over the production of what was NAMDRC’s valuable periodical, the Washington Watchline. Under the editorship for many years of past CHEST President, Jim Mathers, MD, FCCP, this resource has been a valuable and respected source of information for NAMDRC membership. The June edition has recently been published.

Spring meeting, 2021

The HPAC’s Chair and Vice-Chair, Drs. Neil Freedman and Jim Lamberti, are serving as the Program Directors for our first meeting that will blend the NAMDRC perspective and experience in a program around policy and advocacy with the traditional expertise in education delivery of CHEST. This meeting will be in conjunction with our Spring Leadership meetings in Sonoma, California. Save the date, as this promises to be a great meeting, with unique educational opportunities and policy and advocacy insights.

Thanks again to the members of HPAC and to Bob Musacchio for giving me an opportunity to provide staff assistance in this exciting new endeavor for CHEST.

On March 17, 2020, I entered my patients electronic medical record and hit the “Connect with Zoom” button in her Epic (Epic Systems Corporation) chart. About 20 seconds later, the face of my 28-year-old patient with advanced spinal muscular atrophy type 2 (SMA-2) appeared virtually and not live for the first time since I had met her some 10 years previously. She appeared well and her history supported that. We spent most of the time reviewing recent events and surveying her home ventilation equipment. She felt well and sleep was of good quality. She was performing her normal activities without dyspnea. Her mechanical insufflator-exsufflator was working fine, although she used it only as needed, and she was performing lung volume recruitment maneuvers with a resuscitator bag three times a day with assistance. Her mask for nocturnal NPPV was getting old, and she showed me where the straps were fraying. We noted that her bilevel device was now 8 years old and that she needed a new one. We concluded our conversation in 20 minutes and she blurted out: “Wow, that was easy. Thanks, Dr. Benditt.” I got off the phone and put in the order for a new mask and bilevel device with our clinic respiratory therapist. She received the equipment 48 hours later and sent an electronic message through her chart to let me know it had arrived. A total of five in-person visits including me and other providers had been cancelled and replaced by virtual visits. She has made one visit to the hospital in the last 3 months for an intrathecal nusinersen (Spinraza) injection that was done with a COVID-19 prescreening and full PPE.

One week prior to our virtual visit, my university hospital had reduced in-person clinic visits to those deemed absolutely necessary due to the COVID-19 pandemic. Visits considered absolutely necessary included such patients as postoperative transplant visits and preoperative evaluations for urgent surgeries. All other patient visits were canceled with plans to reschedule them once the COVID-19 pandemic was controlled. As the breadth and depth of the pandemic became apparent, a very rapid ramp-up of “virtual visits” via telemedicine capacity was rolled out. I had not previously used telemedicine, and the learning curve was steep, although once in place, the technology was straightforward from the provider perspective. The telemedicine visits for our hospital for the entire year of 2019 totaled about 800. In the month of April of 2020 we engaged in 40,000 telemedicine visits. This explosive growth of telemedicine implementation has occurred around the country and world during the COVID-19 pandemic (Olayiwola JN, et al. JMIR Public Health Surveill. 2020, May 29. doi: 10.2196/19045). This recent growth of telemedicine in the US has been fueled by the need for social distancing and quarantine, the lack of universal testing and COVID-19 case tracking, and the realization by CMS that coverage of telemedicine services had to be expanded rapidly to allow for continued patient care in the setting of stay-at-home orders. A rapid role out of application technology support and online training classes for health-care providers was undertaken. Privileges for telemedicine virtual visits were approved when providers completed the informational online modules and set up their HIPPA compliant Zoom accounts (Zoom Video Communications, San Jose, CA). All of us had minor stumbles initially with the equipment, software, and getting the patients connected online. After four or five visits, the process started to click and has become rather routine. Many providers and patients found this quite a positive development in terms of patient-provider visits but a question arose almost immediately: “Will this continue to be supported by insurers and allow us to integrate this practice into our outpatient clinic setting once the pandemic was controlled?” Time with tell, but an opportunity has presented itself.

For patients with neuromuscular disease and respiratory failure, telemedicine is a technology that may be particularly attractive for a number of reasons. First, patients with neuromuscular respiratory failure are likely at a particularly high risk of death if they develop full-blown COVID-19 infection. Development of acute respiratory distress syndrome (ARDS) on top of underlying neuromuscular respiratory failure is likely to be particularly deadly, although, very fortunately, there are no published reports of widespread infections in patients with neuromuscular respiratory disease. We have known for many decades that pneumonia is the leading cause of death for these patients. Second, patients with neuromuscular respiratory failure often find it quite difficult to come to the hospital for clinic visits. Mobilizing equipment, caregivers, and transportation can take days to arrange. For this reason, many neuromuscular clinics provide a multidisciplinary/multi-provider half-day visit to reduce the need to come into the hospital for multiple separate visits. Lastly, there are relatively few respiratory health-care providers in the United States and around the world who focus on patients with neuromuscular respiratory disease. Many neuromuscular clinics and providers will, therefore, have a very wide patient catchment area. For instance, my practice, based in Seattle, Washington, includes patients from Alaska, Montana, Idaho, and Wyoming. In-person hospital visits more than once per year may be virtually impossible.

Telemedicine is a methodology that has long been considered helpful in the arena of home ventilation and, in fact, we have been using some telemedicine technologies for some time (Casavant DW, et al. J Telemed Telecare. 2014;20[8]:441). Telemedicine (telehealth) includes the use of electronic information and communications technologies to provide and support health care when distance separates the participants. For instance, monitoring of nocturnal ventilation via downloads from Internet-connected noninvasive or invasive ventilation devices, overnight oximetry, and even phone calls from durable medical equipment providers during a home visit would be considered telemedicine. Many of us have been using these methods for many years. It is really the face-to-face “virtual visit” frequency that the COVID-19 pandemic has accelerated. This is a crucial advance in the process of telehealth because we may be able to reduce visits to our clinics from once every 3 to 6 months to perhaps once per year if support for virtual visits by insurers continues and if home monitoring can expand to include accurate home measurement of patient CO₂ levels by either end-tidal CO₂, transcutaneous CO₂, or point of care arterial or capillary blood gases, as well as home pulmonary function monitoring. Measurement of CO² levels and pulmonary function has generally been done at the hospital or in the clinic although there is no reason that with home visit support from appropriate services (that might even include durable medical equipment companies) that this could not be accomplished. This is not to say that there are not hurdles to the application of telehealth in the neuromuscular disease and home ventilation population. Not all patients have the equipment or technology savvy to participate in virtual visits, and not all insurers cover these visits even now during COVID-19. However, I imagine a future where a significant number of visits for patients with neuromuscular respiratory disease and home ventilation needs could be performed virtually. I envision that this would reduce patient and home caregiver travel burdens, make more efficient use of health-care provider time, expand the number of patients that a neuromuscular respiratory disease practitioner could serve, and perhaps reduce health-care expenditures per patient. This may be a real health-care bright spot in the huge difficulties of COVID-19. Fingers crossed.
 

Dr. Benditt is Medical Director of Respiratory Care Services and Professor of Medicine, University of Washington Medical Center, Seattle, Washington.

On March 17, 2020, I entered my patients electronic medical record and hit the “Connect with Zoom” button in her Epic (Epic Systems Corporation) chart. About 20 seconds later, the face of my 28-year-old patient with advanced spinal muscular atrophy type 2 (SMA-2) appeared virtually and not live for the first time since I had met her some 10 years previously. She appeared well and her history supported that. We spent most of the time reviewing recent events and surveying her home ventilation equipment. She felt well and sleep was of good quality. She was performing her normal activities without dyspnea. Her mechanical insufflator-exsufflator was working fine, although she used it only as needed, and she was performing lung volume recruitment maneuvers with a resuscitator bag three times a day with assistance. Her mask for nocturnal NPPV was getting old, and she showed me where the straps were fraying. We noted that her bilevel device was now 8 years old and that she needed a new one. We concluded our conversation in 20 minutes and she blurted out: “Wow, that was easy. Thanks, Dr. Benditt.” I got off the phone and put in the order for a new mask and bilevel device with our clinic respiratory therapist. She received the equipment 48 hours later and sent an electronic message through her chart to let me know it had arrived. A total of five in-person visits including me and other providers had been cancelled and replaced by virtual visits. She has made one visit to the hospital in the last 3 months for an intrathecal nusinersen (Spinraza) injection that was done with a COVID-19 prescreening and full PPE.

One week prior to our virtual visit, my university hospital had reduced in-person clinic visits to those deemed absolutely necessary due to the COVID-19 pandemic. Visits considered absolutely necessary included such patients as postoperative transplant visits and preoperative evaluations for urgent surgeries. All other patient visits were canceled with plans to reschedule them once the COVID-19 pandemic was controlled. As the breadth and depth of the pandemic became apparent, a very rapid ramp-up of “virtual visits” via telemedicine capacity was rolled out. I had not previously used telemedicine, and the learning curve was steep, although once in place, the technology was straightforward from the provider perspective. The telemedicine visits for our hospital for the entire year of 2019 totaled about 800. In the month of April of 2020 we engaged in 40,000 telemedicine visits. This explosive growth of telemedicine implementation has occurred around the country and world during the COVID-19 pandemic (Olayiwola JN, et al. JMIR Public Health Surveill. 2020, May 29. doi: 10.2196/19045). This recent growth of telemedicine in the US has been fueled by the need for social distancing and quarantine, the lack of universal testing and COVID-19 case tracking, and the realization by CMS that coverage of telemedicine services had to be expanded rapidly to allow for continued patient care in the setting of stay-at-home orders. A rapid role out of application technology support and online training classes for health-care providers was undertaken. Privileges for telemedicine virtual visits were approved when providers completed the informational online modules and set up their HIPPA compliant Zoom accounts (Zoom Video Communications, San Jose, CA). All of us had minor stumbles initially with the equipment, software, and getting the patients connected online. After four or five visits, the process started to click and has become rather routine. Many providers and patients found this quite a positive development in terms of patient-provider visits but a question arose almost immediately: “Will this continue to be supported by insurers and allow us to integrate this practice into our outpatient clinic setting once the pandemic was controlled?” Time with tell, but an opportunity has presented itself.

For patients with neuromuscular disease and respiratory failure, telemedicine is a technology that may be particularly attractive for a number of reasons. First, patients with neuromuscular respiratory failure are likely at a particularly high risk of death if they develop full-blown COVID-19 infection. Development of acute respiratory distress syndrome (ARDS) on top of underlying neuromuscular respiratory failure is likely to be particularly deadly, although, very fortunately, there are no published reports of widespread infections in patients with neuromuscular respiratory disease. We have known for many decades that pneumonia is the leading cause of death for these patients. Second, patients with neuromuscular respiratory failure often find it quite difficult to come to the hospital for clinic visits. Mobilizing equipment, caregivers, and transportation can take days to arrange. For this reason, many neuromuscular clinics provide a multidisciplinary/multi-provider half-day visit to reduce the need to come into the hospital for multiple separate visits. Lastly, there are relatively few respiratory health-care providers in the United States and around the world who focus on patients with neuromuscular respiratory disease. Many neuromuscular clinics and providers will, therefore, have a very wide patient catchment area. For instance, my practice, based in Seattle, Washington, includes patients from Alaska, Montana, Idaho, and Wyoming. In-person hospital visits more than once per year may be virtually impossible.

Telemedicine is a methodology that has long been considered helpful in the arena of home ventilation and, in fact, we have been using some telemedicine technologies for some time (Casavant DW, et al. J Telemed Telecare. 2014;20[8]:441). Telemedicine (telehealth) includes the use of electronic information and communications technologies to provide and support health care when distance separates the participants. For instance, monitoring of nocturnal ventilation via downloads from Internet-connected noninvasive or invasive ventilation devices, overnight oximetry, and even phone calls from durable medical equipment providers during a home visit would be considered telemedicine. Many of us have been using these methods for many years. It is really the face-to-face “virtual visit” frequency that the COVID-19 pandemic has accelerated. This is a crucial advance in the process of telehealth because we may be able to reduce visits to our clinics from once every 3 to 6 months to perhaps once per year if support for virtual visits by insurers continues and if home monitoring can expand to include accurate home measurement of patient CO₂ levels by either end-tidal CO₂, transcutaneous CO₂, or point of care arterial or capillary blood gases, as well as home pulmonary function monitoring. Measurement of CO² levels and pulmonary function has generally been done at the hospital or in the clinic although there is no reason that with home visit support from appropriate services (that might even include durable medical equipment companies) that this could not be accomplished. This is not to say that there are not hurdles to the application of telehealth in the neuromuscular disease and home ventilation population. Not all patients have the equipment or technology savvy to participate in virtual visits, and not all insurers cover these visits even now during COVID-19. However, I imagine a future where a significant number of visits for patients with neuromuscular respiratory disease and home ventilation needs could be performed virtually. I envision that this would reduce patient and home caregiver travel burdens, make more efficient use of health-care provider time, expand the number of patients that a neuromuscular respiratory disease practitioner could serve, and perhaps reduce health-care expenditures per patient. This may be a real health-care bright spot in the huge difficulties of COVID-19. Fingers crossed.
 

Dr. Benditt is Medical Director of Respiratory Care Services and Professor of Medicine, University of Washington Medical Center, Seattle, Washington.

On March 17, 2020, I entered my patients electronic medical record and hit the “Connect with Zoom” button in her Epic (Epic Systems Corporation) chart. About 20 seconds later, the face of my 28-year-old patient with advanced spinal muscular atrophy type 2 (SMA-2) appeared virtually and not live for the first time since I had met her some 10 years previously. She appeared well and her history supported that. We spent most of the time reviewing recent events and surveying her home ventilation equipment. She felt well and sleep was of good quality. She was performing her normal activities without dyspnea. Her mechanical insufflator-exsufflator was working fine, although she used it only as needed, and she was performing lung volume recruitment maneuvers with a resuscitator bag three times a day with assistance. Her mask for nocturnal NPPV was getting old, and she showed me where the straps were fraying. We noted that her bilevel device was now 8 years old and that she needed a new one. We concluded our conversation in 20 minutes and she blurted out: “Wow, that was easy. Thanks, Dr. Benditt.” I got off the phone and put in the order for a new mask and bilevel device with our clinic respiratory therapist. She received the equipment 48 hours later and sent an electronic message through her chart to let me know it had arrived. A total of five in-person visits including me and other providers had been cancelled and replaced by virtual visits. She has made one visit to the hospital in the last 3 months for an intrathecal nusinersen (Spinraza) injection that was done with a COVID-19 prescreening and full PPE.

One week prior to our virtual visit, my university hospital had reduced in-person clinic visits to those deemed absolutely necessary due to the COVID-19 pandemic. Visits considered absolutely necessary included such patients as postoperative transplant visits and preoperative evaluations for urgent surgeries. All other patient visits were canceled with plans to reschedule them once the COVID-19 pandemic was controlled. As the breadth and depth of the pandemic became apparent, a very rapid ramp-up of “virtual visits” via telemedicine capacity was rolled out. I had not previously used telemedicine, and the learning curve was steep, although once in place, the technology was straightforward from the provider perspective. The telemedicine visits for our hospital for the entire year of 2019 totaled about 800. In the month of April of 2020 we engaged in 40,000 telemedicine visits. This explosive growth of telemedicine implementation has occurred around the country and world during the COVID-19 pandemic (Olayiwola JN, et al. JMIR Public Health Surveill. 2020, May 29. doi: 10.2196/19045). This recent growth of telemedicine in the US has been fueled by the need for social distancing and quarantine, the lack of universal testing and COVID-19 case tracking, and the realization by CMS that coverage of telemedicine services had to be expanded rapidly to allow for continued patient care in the setting of stay-at-home orders. A rapid role out of application technology support and online training classes for health-care providers was undertaken. Privileges for telemedicine virtual visits were approved when providers completed the informational online modules and set up their HIPPA compliant Zoom accounts (Zoom Video Communications, San Jose, CA). All of us had minor stumbles initially with the equipment, software, and getting the patients connected online. After four or five visits, the process started to click and has become rather routine. Many providers and patients found this quite a positive development in terms of patient-provider visits but a question arose almost immediately: “Will this continue to be supported by insurers and allow us to integrate this practice into our outpatient clinic setting once the pandemic was controlled?” Time with tell, but an opportunity has presented itself.

For patients with neuromuscular disease and respiratory failure, telemedicine is a technology that may be particularly attractive for a number of reasons. First, patients with neuromuscular respiratory failure are likely at a particularly high risk of death if they develop full-blown COVID-19 infection. Development of acute respiratory distress syndrome (ARDS) on top of underlying neuromuscular respiratory failure is likely to be particularly deadly, although, very fortunately, there are no published reports of widespread infections in patients with neuromuscular respiratory disease. We have known for many decades that pneumonia is the leading cause of death for these patients. Second, patients with neuromuscular respiratory failure often find it quite difficult to come to the hospital for clinic visits. Mobilizing equipment, caregivers, and transportation can take days to arrange. For this reason, many neuromuscular clinics provide a multidisciplinary/multi-provider half-day visit to reduce the need to come into the hospital for multiple separate visits. Lastly, there are relatively few respiratory health-care providers in the United States and around the world who focus on patients with neuromuscular respiratory disease. Many neuromuscular clinics and providers will, therefore, have a very wide patient catchment area. For instance, my practice, based in Seattle, Washington, includes patients from Alaska, Montana, Idaho, and Wyoming. In-person hospital visits more than once per year may be virtually impossible.

Telemedicine is a methodology that has long been considered helpful in the arena of home ventilation and, in fact, we have been using some telemedicine technologies for some time (Casavant DW, et al. J Telemed Telecare. 2014;20[8]:441). Telemedicine (telehealth) includes the use of electronic information and communications technologies to provide and support health care when distance separates the participants. For instance, monitoring of nocturnal ventilation via downloads from Internet-connected noninvasive or invasive ventilation devices, overnight oximetry, and even phone calls from durable medical equipment providers during a home visit would be considered telemedicine. Many of us have been using these methods for many years. It is really the face-to-face “virtual visit” frequency that the COVID-19 pandemic has accelerated. This is a crucial advance in the process of telehealth because we may be able to reduce visits to our clinics from once every 3 to 6 months to perhaps once per year if support for virtual visits by insurers continues and if home monitoring can expand to include accurate home measurement of patient CO₂ levels by either end-tidal CO₂, transcutaneous CO₂, or point of care arterial or capillary blood gases, as well as home pulmonary function monitoring. Measurement of CO² levels and pulmonary function has generally been done at the hospital or in the clinic although there is no reason that with home visit support from appropriate services (that might even include durable medical equipment companies) that this could not be accomplished. This is not to say that there are not hurdles to the application of telehealth in the neuromuscular disease and home ventilation population. Not all patients have the equipment or technology savvy to participate in virtual visits, and not all insurers cover these visits even now during COVID-19. However, I imagine a future where a significant number of visits for patients with neuromuscular respiratory disease and home ventilation needs could be performed virtually. I envision that this would reduce patient and home caregiver travel burdens, make more efficient use of health-care provider time, expand the number of patients that a neuromuscular respiratory disease practitioner could serve, and perhaps reduce health-care expenditures per patient. This may be a real health-care bright spot in the huge difficulties of COVID-19. Fingers crossed.
 

Dr. Benditt is Medical Director of Respiratory Care Services and Professor of Medicine, University of Washington Medical Center, Seattle, Washington.

Lung ultrasound has “high concordance” with radiologic findings in children with COVID-19, researchers wrote in Pediatrics.

They also noted the benefits that modality provides over other imaging techniques.

Marco Denina, MD, and colleagues from the pediatric infectious diseases unit at Regina Margherita Children’s Hospital in Turin, Italy, performed an observational study of eight children aged 0-17 years who were admitted to the hospital for COVID-19 between March 8 and 26, 2020. In seven of eight patients, the findings were concordant between imaging modalities; in the remaining patient, lung ultrasound (LUS) found an interstitial B-lines pattern that was not seen on radiography. In seven patients with pathologic ultrasound findings at baseline, the improvement or resolution of the subpleural consolidations or interstitial patterns was consistent with concomitant radiologic findings.

The authors cited the benefits of using point-of-care ultrasound instead of other modalities, such as CT. “First, it may reduce the number of radiologic examinations, lowering the radiation exposure of the patients,” they wrote. “Secondly, when performed at the bedside, LUS allows for the reduction of the patient’s movement within the hospital; thus, it lowers the number of health care workers and medical devices exposed to [SARS-CoV-2].”

One limitation of the study is the small sample size; however, the researchers felt the high concordance still suggests LUS is a reasonable method for COVID-19 patients.

There was no external funding for this study and the investigators had no relevant financial disclosures.

[email protected]

SOURCE: Denina M et al. Pediatrics. 2020 Jun. doi: 10.1542/peds.2020-1157.

Lung ultrasound has “high concordance” with radiologic findings in children with COVID-19, researchers wrote in Pediatrics.

They also noted the benefits that modality provides over other imaging techniques.

Marco Denina, MD, and colleagues from the pediatric infectious diseases unit at Regina Margherita Children’s Hospital in Turin, Italy, performed an observational study of eight children aged 0-17 years who were admitted to the hospital for COVID-19 between March 8 and 26, 2020. In seven of eight patients, the findings were concordant between imaging modalities; in the remaining patient, lung ultrasound (LUS) found an interstitial B-lines pattern that was not seen on radiography. In seven patients with pathologic ultrasound findings at baseline, the improvement or resolution of the subpleural consolidations or interstitial patterns was consistent with concomitant radiologic findings.

The authors cited the benefits of using point-of-care ultrasound instead of other modalities, such as CT. “First, it may reduce the number of radiologic examinations, lowering the radiation exposure of the patients,” they wrote. “Secondly, when performed at the bedside, LUS allows for the reduction of the patient’s movement within the hospital; thus, it lowers the number of health care workers and medical devices exposed to [SARS-CoV-2].”

One limitation of the study is the small sample size; however, the researchers felt the high concordance still suggests LUS is a reasonable method for COVID-19 patients.

There was no external funding for this study and the investigators had no relevant financial disclosures.

[email protected]

SOURCE: Denina M et al. Pediatrics. 2020 Jun. doi: 10.1542/peds.2020-1157.

Lung ultrasound has “high concordance” with radiologic findings in children with COVID-19, researchers wrote in Pediatrics.

They also noted the benefits that modality provides over other imaging techniques.

Marco Denina, MD, and colleagues from the pediatric infectious diseases unit at Regina Margherita Children’s Hospital in Turin, Italy, performed an observational study of eight children aged 0-17 years who were admitted to the hospital for COVID-19 between March 8 and 26, 2020. In seven of eight patients, the findings were concordant between imaging modalities; in the remaining patient, lung ultrasound (LUS) found an interstitial B-lines pattern that was not seen on radiography. In seven patients with pathologic ultrasound findings at baseline, the improvement or resolution of the subpleural consolidations or interstitial patterns was consistent with concomitant radiologic findings.

The authors cited the benefits of using point-of-care ultrasound instead of other modalities, such as CT. “First, it may reduce the number of radiologic examinations, lowering the radiation exposure of the patients,” they wrote. “Secondly, when performed at the bedside, LUS allows for the reduction of the patient’s movement within the hospital; thus, it lowers the number of health care workers and medical devices exposed to [SARS-CoV-2].”

One limitation of the study is the small sample size; however, the researchers felt the high concordance still suggests LUS is a reasonable method for COVID-19 patients.

There was no external funding for this study and the investigators had no relevant financial disclosures.

[email protected]

SOURCE: Denina M et al. Pediatrics. 2020 Jun. doi: 10.1542/peds.2020-1157.

When sterilizing face masks, the type of face mask and the method of sterilization have a bearing on subsequent filtration efficiency, according to researchers. The greatest reduction in filtration efficiency after sterilization occurred with surgical face masks.

With plasma vapor hydrogen peroxide (H₂O₂) sterilization, filtration efficiency of N95 and KN95 masks was maintained at more than 95%, but for surgical face masks, filtration efficiency was reduced to less than 95%. With chlorine dioxide (ClO₂) sterilization, on the other hand, filtration efficiency was maintained at above 95% for N95 masks, but for KN95 and surgical face masks, filtration efficiency was reduced to less than 80%.

In a research letter published online June 15 in JAMA Network Open, researchers from the University of Oklahoma Health Sciences Center, Oklahoma City, report the results of a study of the two sterilization techniques on the pressure drop and filtration efficiency of N95, KN95, and surgical face masks.

“The H₂O₂ treatment showed a small effect on the overall filtration efficiency of the tested masks, but the ClO₂ treatment showed marked reduction in the overall filtration efficiency of the KN95s and surgical face masks. All pressure drop changes were within the acceptable range,” the researchers write.

The study did not evaluate the effect of repeated sterilizations on face masks.

Five masks of each type were sterilized with either H₂O₂ or ClO₂. Masks were then placed in a test chamber, and a salt aerosol was nebulized to assess both upstream and downstream filtration as well as pressure drop. The researchers used a mobility particle sizer to measure particle number concentration from 16.8 nm to 514 nm. An acceptable pressure drop was defined as a drop of less than 1.38 inches of water (35 mm) for inhalation.

Although pressure drop changes were within the acceptable range for all three mask types following sterilization with either method, H₂O₂ sterilization yielded the least reduction in filtration efficacy in all cases. After sterilization with H₂O₂, filtration efficiencies were 96.6%, 97.1%, and 91.6% for the N95s, KN95s, and the surgical face masks, respectively. In contrast, filtration efficiencies after ClO₂ sterilization were 95.1%, 76.2%, and 77.9%, respectively.

The researchers note that, although overall filtration efficiency was maintained with ClO₂ sterilization, there was a significant drop in efficiency with respect to particles of approximately 300 nm (0.3 microns) in size. For particles of that size, mean filtration efficiency decreased to 86.2% for N95s, 40.8% for KN95s, and 47.1% for surgical face masks.

The testing described in the report is “quite affordable at $350 per mask type, so it is hard to imagine any health care provider cannot set aside a small budget to conduct such an important test,” author Evan Floyd, PhD, told Medscape Medical News.

Given the high demand for effective face masks and the current risk for counterfeit products, Floyd suggested that individual facilities test all masks intended for use by healthcare workers before and after sterilization procedures.

“However, if for some reason testing is not an option, we would recommend sticking to established brands and suppliers, perhaps reach out to your state health department or a local representative of the strategic stockpile of PPE,” he noted.

The authors acknowledge that further studies using a larger sample size and a greater variety of masks, as well as studies to evaluate different sterilization techniques, are required. Further, “measuring the respirator’s filtration efficiency by aerosol size instead of only measuring the overall filtration efficiency” should also be considered. Such an approach would enable researchers to evaluate the degree to which masks protect against specific infectious agents.

This article first appeared on Medscape.com.

When sterilizing face masks, the type of face mask and the method of sterilization have a bearing on subsequent filtration efficiency, according to researchers. The greatest reduction in filtration efficiency after sterilization occurred with surgical face masks.

With plasma vapor hydrogen peroxide (H₂O₂) sterilization, filtration efficiency of N95 and KN95 masks was maintained at more than 95%, but for surgical face masks, filtration efficiency was reduced to less than 95%. With chlorine dioxide (ClO₂) sterilization, on the other hand, filtration efficiency was maintained at above 95% for N95 masks, but for KN95 and surgical face masks, filtration efficiency was reduced to less than 80%.

In a research letter published online June 15 in JAMA Network Open, researchers from the University of Oklahoma Health Sciences Center, Oklahoma City, report the results of a study of the two sterilization techniques on the pressure drop and filtration efficiency of N95, KN95, and surgical face masks.

“The H₂O₂ treatment showed a small effect on the overall filtration efficiency of the tested masks, but the ClO₂ treatment showed marked reduction in the overall filtration efficiency of the KN95s and surgical face masks. All pressure drop changes were within the acceptable range,” the researchers write.

The study did not evaluate the effect of repeated sterilizations on face masks.

Five masks of each type were sterilized with either H₂O₂ or ClO₂. Masks were then placed in a test chamber, and a salt aerosol was nebulized to assess both upstream and downstream filtration as well as pressure drop. The researchers used a mobility particle sizer to measure particle number concentration from 16.8 nm to 514 nm. An acceptable pressure drop was defined as a drop of less than 1.38 inches of water (35 mm) for inhalation.

Although pressure drop changes were within the acceptable range for all three mask types following sterilization with either method, H₂O₂ sterilization yielded the least reduction in filtration efficacy in all cases. After sterilization with H₂O₂, filtration efficiencies were 96.6%, 97.1%, and 91.6% for the N95s, KN95s, and the surgical face masks, respectively. In contrast, filtration efficiencies after ClO₂ sterilization were 95.1%, 76.2%, and 77.9%, respectively.

The researchers note that, although overall filtration efficiency was maintained with ClO₂ sterilization, there was a significant drop in efficiency with respect to particles of approximately 300 nm (0.3 microns) in size. For particles of that size, mean filtration efficiency decreased to 86.2% for N95s, 40.8% for KN95s, and 47.1% for surgical face masks.

The testing described in the report is “quite affordable at $350 per mask type, so it is hard to imagine any health care provider cannot set aside a small budget to conduct such an important test,” author Evan Floyd, PhD, told Medscape Medical News.

Given the high demand for effective face masks and the current risk for counterfeit products, Floyd suggested that individual facilities test all masks intended for use by healthcare workers before and after sterilization procedures.

“However, if for some reason testing is not an option, we would recommend sticking to established brands and suppliers, perhaps reach out to your state health department or a local representative of the strategic stockpile of PPE,” he noted.

The authors acknowledge that further studies using a larger sample size and a greater variety of masks, as well as studies to evaluate different sterilization techniques, are required. Further, “measuring the respirator’s filtration efficiency by aerosol size instead of only measuring the overall filtration efficiency” should also be considered. Such an approach would enable researchers to evaluate the degree to which masks protect against specific infectious agents.

This article first appeared on Medscape.com.

When sterilizing face masks, the type of face mask and the method of sterilization have a bearing on subsequent filtration efficiency, according to researchers. The greatest reduction in filtration efficiency after sterilization occurred with surgical face masks.

With plasma vapor hydrogen peroxide (H₂O₂) sterilization, filtration efficiency of N95 and KN95 masks was maintained at more than 95%, but for surgical face masks, filtration efficiency was reduced to less than 95%. With chlorine dioxide (ClO₂) sterilization, on the other hand, filtration efficiency was maintained at above 95% for N95 masks, but for KN95 and surgical face masks, filtration efficiency was reduced to less than 80%.

In a research letter published online June 15 in JAMA Network Open, researchers from the University of Oklahoma Health Sciences Center, Oklahoma City, report the results of a study of the two sterilization techniques on the pressure drop and filtration efficiency of N95, KN95, and surgical face masks.

“The H₂O₂ treatment showed a small effect on the overall filtration efficiency of the tested masks, but the ClO₂ treatment showed marked reduction in the overall filtration efficiency of the KN95s and surgical face masks. All pressure drop changes were within the acceptable range,” the researchers write.

The study did not evaluate the effect of repeated sterilizations on face masks.

Five masks of each type were sterilized with either H₂O₂ or ClO₂. Masks were then placed in a test chamber, and a salt aerosol was nebulized to assess both upstream and downstream filtration as well as pressure drop. The researchers used a mobility particle sizer to measure particle number concentration from 16.8 nm to 514 nm. An acceptable pressure drop was defined as a drop of less than 1.38 inches of water (35 mm) for inhalation.

Although pressure drop changes were within the acceptable range for all three mask types following sterilization with either method, H₂O₂ sterilization yielded the least reduction in filtration efficacy in all cases. After sterilization with H₂O₂, filtration efficiencies were 96.6%, 97.1%, and 91.6% for the N95s, KN95s, and the surgical face masks, respectively. In contrast, filtration efficiencies after ClO₂ sterilization were 95.1%, 76.2%, and 77.9%, respectively.

The researchers note that, although overall filtration efficiency was maintained with ClO₂ sterilization, there was a significant drop in efficiency with respect to particles of approximately 300 nm (0.3 microns) in size. For particles of that size, mean filtration efficiency decreased to 86.2% for N95s, 40.8% for KN95s, and 47.1% for surgical face masks.

The testing described in the report is “quite affordable at $350 per mask type, so it is hard to imagine any health care provider cannot set aside a small budget to conduct such an important test,” author Evan Floyd, PhD, told Medscape Medical News.

Given the high demand for effective face masks and the current risk for counterfeit products, Floyd suggested that individual facilities test all masks intended for use by healthcare workers before and after sterilization procedures.

“However, if for some reason testing is not an option, we would recommend sticking to established brands and suppliers, perhaps reach out to your state health department or a local representative of the strategic stockpile of PPE,” he noted.

The authors acknowledge that further studies using a larger sample size and a greater variety of masks, as well as studies to evaluate different sterilization techniques, are required. Further, “measuring the respirator’s filtration efficiency by aerosol size instead of only measuring the overall filtration efficiency” should also be considered. Such an approach would enable researchers to evaluate the degree to which masks protect against specific infectious agents.

This article first appeared on Medscape.com.

The global COVID-19 pandemic has escalated everyone’s stress levels, especially clinicians caring for hospitalized patients. New pressures have added to everyday stress, new studies have revised prior patient care recommendations, and the world generally seems upside down. What can a busy hospitalist do to maintain a modicum of sanity in all the craziness?

The stressors facing hospitalists

Uncertainty

Of all the burdens COVID-19 has unleashed, the biggest may be uncertainty. Not only is there unease about the virus itself, there also is legitimate concern about the future of medicine, said Elizabeth Harry, MD, SFHM, a hospitalist and senior director of clinical affairs at the University of Colorado Hospital in Aurora.

“What does it look like after an event like this, particularly in areas like academic medicine and teaching our next generation and getting funding for research? And how do we continue to produce physicians that can provide excellent care?” she asked.

There is also uncertainty in the best way to care for patients, said Eileen Barrett, MD, MPH, SFHM, a hospitalist at the University of New Mexico, Albuquerque.

“There are some models that are emerging to predict who will have a worse outcome, but they’re still not great models, so we have uncertainty for a given patient.” And, she noted, as the science continues to evolve, there exists a constant worry that “you might have inadvertently caused someone harm.”

The financial implications of the pandemic are creating uncertainty too. “When you fund a health care system with elective procedures and you can’t do those, and instead have to shift to the most essential services, a lot of places are seeing a massive deficit, which is going to affect staff morale and some physician offices are going to close,” said Elisabeth Poorman, MD, MPH, a primary care and internal medicine physician and chair of the King County Medical Society Physician Wellness Committee in Seattle.
 

Fear

When the pandemic began in the United States, “fear of the unknown was perhaps the scariest part, particularly as it pertained to personal protective equipment,” said Mark Rudolph, MD, SFHM, chief experience officer and vice president of patient experience and physician development at Sound Physicians in Tacoma, Wash. “For most clinicians, this is the first time that they are themselves in harm’s way while they do their jobs. And worse, they risk bringing the virus home to their families. That is the concern I hear most.”

Anxiety

Worrying about being able to provide excellent patient care is a big stressor, especially since this is the heart and soul of why most hospitalists have gone into their line of work.

“Part of providing excellent care to your patients is providing excellent supportive care to their families,” Dr. Harry said. “There’s some dissonance there in not being able to allow the family to come visit, but wanting to keep them safe, and it feels really hard to support your patients and support their families in the best way. It can feel like you’re just watching and waiting to see what will happen, and that we don’t have a lot of agency over which direction things take.”

There is concern for health care team members as well, Dr. Harry added. “Physicians care a lot about their teams and how they’re doing. I think there’s a sense of esprit de corps among folks and worry for each other there.”
 

Guilt

Although you may be at the hospital all day, you may feel guilty when you are not providing direct patient care. Or maybe you or someone on your team has an immunodeficiency and can’t be on the front line. Perhaps one of your team members contracted COVID-19 and you did not. Whatever the case, guilt is another emotion that is rampant among hospitalists right now, Dr. Barrett said.

Burnout

Unfortunately, burnout is a potential reality in times of high stress. “Burnout is dynamic,” said Dr. Poorman. “It’s a process by which your emotional and cognitive reserves are exhausted. The people with the highest burnout are the ones who are still trying to provide the standard of care, or above the standard of care in dysfunctional systems.”

Dr. Harry noted that burnout presents in different ways for different people, but Dr. Rudolph added that it’s crucial for hospitalist team members to watch for signs of burnout so they can intervene and/or get help for their colleagues.

Warning signs in yourself or others that burnout could be on the horizon include:

• Fatigue/exhaustion – Whether emotional or physical (or both), this can become a problem if it “just doesn’t seem to go away despite rest and time away from work,” said Dr. Rudolph.
• Behavioral changes – Any behavior that’s out of the ordinary may be a red flag, like lashing out at someone at work.
• Overwork – Working too much can be caused by an inability to let go of patient care, Dr. Barrett said.
• Not working enough – This may include avoiding tasks and having difficulty meeting deadlines.
• Maladaptive coping behaviors – Excessive consumption of alcohol or drugs is a common coping mechanism. “Even excessive consumption of news is something that people are using to numb out a little bit,” said Dr. Harry.
• Depersonalization – “This is where you start to look at patients, colleagues, or administrators as ‘them’ and you can’t connect as deeply,” Dr. Harry said. “Part of that’s protective and a normal thing to do during a big trauma like this, but it’s also incredibly distancing. Any language that people start using that feels like ‘us’ or ‘them’ is a warning sign.”
• Disengagement – Many people disengage from their work, but Dr. Poorman said physicians tend to disengage from other parts of their lives, such as exercise and family interaction.

Protecting yourself while supporting others

Like the illustration of putting the oxygen mask on yourself first so you can help others, it’s important to protect your own mental and physical health as you support your fellow physicians. Here’s what the experts suggest.

Focus on basic needs

“When you’re in the midst of a trauma, which we are, you don’t want to open all of that up and go to the depths of your thoughts about the grief of all of it because it can actually make the trauma worse,” said Dr. Harry. “There’s a lot of literature that debriefing is really helpful after the event, but if you do it during the event, it can be really dangerous.”

Instead, she said, the goal should be focusing on your basic needs and what you need to do to get through each day, like keeping you and your family in good health. “What is your purpose? Staying connected to why you do this and staying focused on the present is really important,” Dr. Harry noted.

Do your best to get a good night’s sleep, exercise as much as you can, talk to others, and see a mental health provider if your anxiety is too high, advises Dr. Barrett. “Even avoiding blue light from phones and screens within 2 hours of bedtime, parking further away from the hospital and walking, and taking the stairs are things that add up in a big way.”
 

Keep up your normal routine

“Right now, it’s really critical for clinicians to keep up components of their routine that feel ‘normal,’ ” Dr. Rudolph said. “Whether it’s exercise, playing board games with their kids, or spending time on a hobby, it’s critical to allow yourself these comfortable, predictable, and rewarding detours.”

Set limits

People under stress tend to find unhealthy ways to cope. Instead, try being intentional about what you are consuming by putting limits on things like your news, alcohol consumption, and the number of hours you work, said Dr. Harry.

Implement a culture of wellness

Dr. Barrett believes in creating the work culture we want to be in, one that ensures people have psychological safety, allows them to ask for help, encourages them to disconnect completely from work, and makes them feel valued and listened to. She likes the example of “the pause,” which is called by a team member right after a patient expires.

“It’s a 30-second moment of silence where we reflect on the patient, their loved ones, and every member of the health care team who helped support and treat them,” said Dr. Barrett. “At the conclusion, you say: ‘Thank you. Is there anything you need to be able to go back to the care of other patients?’ Because it’s unnatural to have this terrible thing that happened and then just act like nothing happened.”
 

Target resources

Be proactive and know where to find resources before you need them, advised Dr. Harry. “Most institutions have free mental health resources, either through their employee assistance programs or HR, plus there’s lots of national organizations that are offering free resources to health care providers.”

Focus on what you can control

Separating what is under your control from what is not is a struggle for everyone, Dr. Poorman said, but it’s helpful to think about the ways you can have an impact and what you’re able to control.

“There was a woman who was diagnosed with early-onset Parkinson’s that I heard giving an interview at the beginning of this pandemic,” she said. “It was the most helpful advice I got, which was: ‘Think of the next good thing you can do.’ You can’t fix everything, so what’s the next good thing you can do?”
 

Maintain connectivity

Make sure you are utilizing your support circle and staying connected. “That sense of connection is incredibly protective on multiple fronts for depression, for burnout, for suicide ideation, etc.,” Dr. Harry said.

“It doesn’t matter if it’s your teammates at work, your family at home, your best friend from medical school – whomever you can debrief with, vent with, and just share your thoughts and feelings with, these outlets are critical for all of us to process our emotions and diffuse stress and anxiety,” said Dr. Rudolph.

Dr. Poorman is concerned that there could be a spike in physician suicides caused by increased stress, so she also encourages talking openly about what is going on and about getting help when it’s necessary. “Many of us are afraid to seek care because we can actually have our ability to practice medicine questioned, but now is not the time for heroes. Now is the time for people who are willing to recognize their own strengths and limitations to take care of one another.”
 

Be compassionate toward others

Keep in mind that everyone is stressed out and offer empathy and compassion. “I think everybody’s struggling to try to figure this out and the more that we can give each other the benefit of the doubt and a little grace, the more protective that is,” said Dr. Harry.

Listening is meaningful too. “Recognizing opportunities to validate and acknowledge the feelings that are being shared with you by your colleagues is critical,” Dr. Rudolph said. “We all need to know that we’re not alone, that our thoughts and feelings are okay, and when we share a difficult story, the value of someone saying something as simple as, ‘wow, that sounds like it was really hard,’ is immense.”
 

Be compassionate toward yourself

Try to give yourself a break and be as compassionate with yourself as you would with others. It’s okay that you’re not getting in shape, publishing prolifically, or redesigning your house right now.

“There’s a lot of data linking lack of self-compassion to burnout,” said Dr. Harry. She says there are courses on self-compassion available that help you work on being kinder to yourself.
 

Get a “battle buddy”

The American Medical Association has a free “buddy system” program called PeerRx to help physicians cope during the pandemic. Dr. Rudolph said that now is a great time to use this military-developed intervention in which each team member checks in with a chosen partner at agreed-upon intervals.

For example, “You can tell that person: ‘If I don’t call my family for a week that’s a red flag for me.’ And then you hold each other accountable to those things,” Dr. Harry said.

The buddy system is another way to harness that sense of connection that is so vital to our health and well-being.

“The simple act of showing that you care … can make all the difference when you’re doing this kind of work that is both challenging and dangerous,” said Dr. Rudolph.

The global COVID-19 pandemic has escalated everyone’s stress levels, especially clinicians caring for hospitalized patients. New pressures have added to everyday stress, new studies have revised prior patient care recommendations, and the world generally seems upside down. What can a busy hospitalist do to maintain a modicum of sanity in all the craziness?

The stressors facing hospitalists

Uncertainty

Of all the burdens COVID-19 has unleashed, the biggest may be uncertainty. Not only is there unease about the virus itself, there also is legitimate concern about the future of medicine, said Elizabeth Harry, MD, SFHM, a hospitalist and senior director of clinical affairs at the University of Colorado Hospital in Aurora.

“What does it look like after an event like this, particularly in areas like academic medicine and teaching our next generation and getting funding for research? And how do we continue to produce physicians that can provide excellent care?” she asked.

There is also uncertainty in the best way to care for patients, said Eileen Barrett, MD, MPH, SFHM, a hospitalist at the University of New Mexico, Albuquerque.

“There are some models that are emerging to predict who will have a worse outcome, but they’re still not great models, so we have uncertainty for a given patient.” And, she noted, as the science continues to evolve, there exists a constant worry that “you might have inadvertently caused someone harm.”

The financial implications of the pandemic are creating uncertainty too. “When you fund a health care system with elective procedures and you can’t do those, and instead have to shift to the most essential services, a lot of places are seeing a massive deficit, which is going to affect staff morale and some physician offices are going to close,” said Elisabeth Poorman, MD, MPH, a primary care and internal medicine physician and chair of the King County Medical Society Physician Wellness Committee in Seattle.
 

Fear

When the pandemic began in the United States, “fear of the unknown was perhaps the scariest part, particularly as it pertained to personal protective equipment,” said Mark Rudolph, MD, SFHM, chief experience officer and vice president of patient experience and physician development at Sound Physicians in Tacoma, Wash. “For most clinicians, this is the first time that they are themselves in harm’s way while they do their jobs. And worse, they risk bringing the virus home to their families. That is the concern I hear most.”

Anxiety

Worrying about being able to provide excellent patient care is a big stressor, especially since this is the heart and soul of why most hospitalists have gone into their line of work.

“Part of providing excellent care to your patients is providing excellent supportive care to their families,” Dr. Harry said. “There’s some dissonance there in not being able to allow the family to come visit, but wanting to keep them safe, and it feels really hard to support your patients and support their families in the best way. It can feel like you’re just watching and waiting to see what will happen, and that we don’t have a lot of agency over which direction things take.”

There is concern for health care team members as well, Dr. Harry added. “Physicians care a lot about their teams and how they’re doing. I think there’s a sense of esprit de corps among folks and worry for each other there.”
 

Guilt

Although you may be at the hospital all day, you may feel guilty when you are not providing direct patient care. Or maybe you or someone on your team has an immunodeficiency and can’t be on the front line. Perhaps one of your team members contracted COVID-19 and you did not. Whatever the case, guilt is another emotion that is rampant among hospitalists right now, Dr. Barrett said.

Burnout

Unfortunately, burnout is a potential reality in times of high stress. “Burnout is dynamic,” said Dr. Poorman. “It’s a process by which your emotional and cognitive reserves are exhausted. The people with the highest burnout are the ones who are still trying to provide the standard of care, or above the standard of care in dysfunctional systems.”

Dr. Harry noted that burnout presents in different ways for different people, but Dr. Rudolph added that it’s crucial for hospitalist team members to watch for signs of burnout so they can intervene and/or get help for their colleagues.

Warning signs in yourself or others that burnout could be on the horizon include:

• Fatigue/exhaustion – Whether emotional or physical (or both), this can become a problem if it “just doesn’t seem to go away despite rest and time away from work,” said Dr. Rudolph.
• Behavioral changes – Any behavior that’s out of the ordinary may be a red flag, like lashing out at someone at work.
• Overwork – Working too much can be caused by an inability to let go of patient care, Dr. Barrett said.
• Not working enough – This may include avoiding tasks and having difficulty meeting deadlines.
• Maladaptive coping behaviors – Excessive consumption of alcohol or drugs is a common coping mechanism. “Even excessive consumption of news is something that people are using to numb out a little bit,” said Dr. Harry.
• Depersonalization – “This is where you start to look at patients, colleagues, or administrators as ‘them’ and you can’t connect as deeply,” Dr. Harry said. “Part of that’s protective and a normal thing to do during a big trauma like this, but it’s also incredibly distancing. Any language that people start using that feels like ‘us’ or ‘them’ is a warning sign.”
• Disengagement – Many people disengage from their work, but Dr. Poorman said physicians tend to disengage from other parts of their lives, such as exercise and family interaction.

Protecting yourself while supporting others

Like the illustration of putting the oxygen mask on yourself first so you can help others, it’s important to protect your own mental and physical health as you support your fellow physicians. Here’s what the experts suggest.

Focus on basic needs

“When you’re in the midst of a trauma, which we are, you don’t want to open all of that up and go to the depths of your thoughts about the grief of all of it because it can actually make the trauma worse,” said Dr. Harry. “There’s a lot of literature that debriefing is really helpful after the event, but if you do it during the event, it can be really dangerous.”

Instead, she said, the goal should be focusing on your basic needs and what you need to do to get through each day, like keeping you and your family in good health. “What is your purpose? Staying connected to why you do this and staying focused on the present is really important,” Dr. Harry noted.

Do your best to get a good night’s sleep, exercise as much as you can, talk to others, and see a mental health provider if your anxiety is too high, advises Dr. Barrett. “Even avoiding blue light from phones and screens within 2 hours of bedtime, parking further away from the hospital and walking, and taking the stairs are things that add up in a big way.”
 

Keep up your normal routine

“Right now, it’s really critical for clinicians to keep up components of their routine that feel ‘normal,’ ” Dr. Rudolph said. “Whether it’s exercise, playing board games with their kids, or spending time on a hobby, it’s critical to allow yourself these comfortable, predictable, and rewarding detours.”

Set limits

People under stress tend to find unhealthy ways to cope. Instead, try being intentional about what you are consuming by putting limits on things like your news, alcohol consumption, and the number of hours you work, said Dr. Harry.

Implement a culture of wellness

Dr. Barrett believes in creating the work culture we want to be in, one that ensures people have psychological safety, allows them to ask for help, encourages them to disconnect completely from work, and makes them feel valued and listened to. She likes the example of “the pause,” which is called by a team member right after a patient expires.

“It’s a 30-second moment of silence where we reflect on the patient, their loved ones, and every member of the health care team who helped support and treat them,” said Dr. Barrett. “At the conclusion, you say: ‘Thank you. Is there anything you need to be able to go back to the care of other patients?’ Because it’s unnatural to have this terrible thing that happened and then just act like nothing happened.”
 

Target resources

Be proactive and know where to find resources before you need them, advised Dr. Harry. “Most institutions have free mental health resources, either through their employee assistance programs or HR, plus there’s lots of national organizations that are offering free resources to health care providers.”

Focus on what you can control

Separating what is under your control from what is not is a struggle for everyone, Dr. Poorman said, but it’s helpful to think about the ways you can have an impact and what you’re able to control.

“There was a woman who was diagnosed with early-onset Parkinson’s that I heard giving an interview at the beginning of this pandemic,” she said. “It was the most helpful advice I got, which was: ‘Think of the next good thing you can do.’ You can’t fix everything, so what’s the next good thing you can do?”
 

Maintain connectivity

Make sure you are utilizing your support circle and staying connected. “That sense of connection is incredibly protective on multiple fronts for depression, for burnout, for suicide ideation, etc.,” Dr. Harry said.

“It doesn’t matter if it’s your teammates at work, your family at home, your best friend from medical school – whomever you can debrief with, vent with, and just share your thoughts and feelings with, these outlets are critical for all of us to process our emotions and diffuse stress and anxiety,” said Dr. Rudolph.

Dr. Poorman is concerned that there could be a spike in physician suicides caused by increased stress, so she also encourages talking openly about what is going on and about getting help when it’s necessary. “Many of us are afraid to seek care because we can actually have our ability to practice medicine questioned, but now is not the time for heroes. Now is the time for people who are willing to recognize their own strengths and limitations to take care of one another.”
 

Be compassionate toward others

Keep in mind that everyone is stressed out and offer empathy and compassion. “I think everybody’s struggling to try to figure this out and the more that we can give each other the benefit of the doubt and a little grace, the more protective that is,” said Dr. Harry.

Listening is meaningful too. “Recognizing opportunities to validate and acknowledge the feelings that are being shared with you by your colleagues is critical,” Dr. Rudolph said. “We all need to know that we’re not alone, that our thoughts and feelings are okay, and when we share a difficult story, the value of someone saying something as simple as, ‘wow, that sounds like it was really hard,’ is immense.”
 

Be compassionate toward yourself

Try to give yourself a break and be as compassionate with yourself as you would with others. It’s okay that you’re not getting in shape, publishing prolifically, or redesigning your house right now.

“There’s a lot of data linking lack of self-compassion to burnout,” said Dr. Harry. She says there are courses on self-compassion available that help you work on being kinder to yourself.
 

Get a “battle buddy”

The American Medical Association has a free “buddy system” program called PeerRx to help physicians cope during the pandemic. Dr. Rudolph said that now is a great time to use this military-developed intervention in which each team member checks in with a chosen partner at agreed-upon intervals.

For example, “You can tell that person: ‘If I don’t call my family for a week that’s a red flag for me.’ And then you hold each other accountable to those things,” Dr. Harry said.

The buddy system is another way to harness that sense of connection that is so vital to our health and well-being.

“The simple act of showing that you care … can make all the difference when you’re doing this kind of work that is both challenging and dangerous,” said Dr. Rudolph.

The global COVID-19 pandemic has escalated everyone’s stress levels, especially clinicians caring for hospitalized patients. New pressures have added to everyday stress, new studies have revised prior patient care recommendations, and the world generally seems upside down. What can a busy hospitalist do to maintain a modicum of sanity in all the craziness?

The stressors facing hospitalists

Uncertainty

Of all the burdens COVID-19 has unleashed, the biggest may be uncertainty. Not only is there unease about the virus itself, there also is legitimate concern about the future of medicine, said Elizabeth Harry, MD, SFHM, a hospitalist and senior director of clinical affairs at the University of Colorado Hospital in Aurora.

“What does it look like after an event like this, particularly in areas like academic medicine and teaching our next generation and getting funding for research? And how do we continue to produce physicians that can provide excellent care?” she asked.

There is also uncertainty in the best way to care for patients, said Eileen Barrett, MD, MPH, SFHM, a hospitalist at the University of New Mexico, Albuquerque.

“There are some models that are emerging to predict who will have a worse outcome, but they’re still not great models, so we have uncertainty for a given patient.” And, she noted, as the science continues to evolve, there exists a constant worry that “you might have inadvertently caused someone harm.”

The financial implications of the pandemic are creating uncertainty too. “When you fund a health care system with elective procedures and you can’t do those, and instead have to shift to the most essential services, a lot of places are seeing a massive deficit, which is going to affect staff morale and some physician offices are going to close,” said Elisabeth Poorman, MD, MPH, a primary care and internal medicine physician and chair of the King County Medical Society Physician Wellness Committee in Seattle.
 

Fear

When the pandemic began in the United States, “fear of the unknown was perhaps the scariest part, particularly as it pertained to personal protective equipment,” said Mark Rudolph, MD, SFHM, chief experience officer and vice president of patient experience and physician development at Sound Physicians in Tacoma, Wash. “For most clinicians, this is the first time that they are themselves in harm’s way while they do their jobs. And worse, they risk bringing the virus home to their families. That is the concern I hear most.”

Anxiety

Worrying about being able to provide excellent patient care is a big stressor, especially since this is the heart and soul of why most hospitalists have gone into their line of work.

“Part of providing excellent care to your patients is providing excellent supportive care to their families,” Dr. Harry said. “There’s some dissonance there in not being able to allow the family to come visit, but wanting to keep them safe, and it feels really hard to support your patients and support their families in the best way. It can feel like you’re just watching and waiting to see what will happen, and that we don’t have a lot of agency over which direction things take.”

There is concern for health care team members as well, Dr. Harry added. “Physicians care a lot about their teams and how they’re doing. I think there’s a sense of esprit de corps among folks and worry for each other there.”
 

Guilt

Although you may be at the hospital all day, you may feel guilty when you are not providing direct patient care. Or maybe you or someone on your team has an immunodeficiency and can’t be on the front line. Perhaps one of your team members contracted COVID-19 and you did not. Whatever the case, guilt is another emotion that is rampant among hospitalists right now, Dr. Barrett said.

Burnout

Unfortunately, burnout is a potential reality in times of high stress. “Burnout is dynamic,” said Dr. Poorman. “It’s a process by which your emotional and cognitive reserves are exhausted. The people with the highest burnout are the ones who are still trying to provide the standard of care, or above the standard of care in dysfunctional systems.”

Dr. Harry noted that burnout presents in different ways for different people, but Dr. Rudolph added that it’s crucial for hospitalist team members to watch for signs of burnout so they can intervene and/or get help for their colleagues.

Warning signs in yourself or others that burnout could be on the horizon include:

• Fatigue/exhaustion – Whether emotional or physical (or both), this can become a problem if it “just doesn’t seem to go away despite rest and time away from work,” said Dr. Rudolph.
• Behavioral changes – Any behavior that’s out of the ordinary may be a red flag, like lashing out at someone at work.
• Overwork – Working too much can be caused by an inability to let go of patient care, Dr. Barrett said.
• Not working enough – This may include avoiding tasks and having difficulty meeting deadlines.
• Maladaptive coping behaviors – Excessive consumption of alcohol or drugs is a common coping mechanism. “Even excessive consumption of news is something that people are using to numb out a little bit,” said Dr. Harry.
• Depersonalization – “This is where you start to look at patients, colleagues, or administrators as ‘them’ and you can’t connect as deeply,” Dr. Harry said. “Part of that’s protective and a normal thing to do during a big trauma like this, but it’s also incredibly distancing. Any language that people start using that feels like ‘us’ or ‘them’ is a warning sign.”
• Disengagement – Many people disengage from their work, but Dr. Poorman said physicians tend to disengage from other parts of their lives, such as exercise and family interaction.

Protecting yourself while supporting others

Like the illustration of putting the oxygen mask on yourself first so you can help others, it’s important to protect your own mental and physical health as you support your fellow physicians. Here’s what the experts suggest.

Focus on basic needs

“When you’re in the midst of a trauma, which we are, you don’t want to open all of that up and go to the depths of your thoughts about the grief of all of it because it can actually make the trauma worse,” said Dr. Harry. “There’s a lot of literature that debriefing is really helpful after the event, but if you do it during the event, it can be really dangerous.”

Instead, she said, the goal should be focusing on your basic needs and what you need to do to get through each day, like keeping you and your family in good health. “What is your purpose? Staying connected to why you do this and staying focused on the present is really important,” Dr. Harry noted.

Do your best to get a good night’s sleep, exercise as much as you can, talk to others, and see a mental health provider if your anxiety is too high, advises Dr. Barrett. “Even avoiding blue light from phones and screens within 2 hours of bedtime, parking further away from the hospital and walking, and taking the stairs are things that add up in a big way.”
 

Keep up your normal routine

“Right now, it’s really critical for clinicians to keep up components of their routine that feel ‘normal,’ ” Dr. Rudolph said. “Whether it’s exercise, playing board games with their kids, or spending time on a hobby, it’s critical to allow yourself these comfortable, predictable, and rewarding detours.”

Set limits

People under stress tend to find unhealthy ways to cope. Instead, try being intentional about what you are consuming by putting limits on things like your news, alcohol consumption, and the number of hours you work, said Dr. Harry.

Implement a culture of wellness

Dr. Barrett believes in creating the work culture we want to be in, one that ensures people have psychological safety, allows them to ask for help, encourages them to disconnect completely from work, and makes them feel valued and listened to. She likes the example of “the pause,” which is called by a team member right after a patient expires.

“It’s a 30-second moment of silence where we reflect on the patient, their loved ones, and every member of the health care team who helped support and treat them,” said Dr. Barrett. “At the conclusion, you say: ‘Thank you. Is there anything you need to be able to go back to the care of other patients?’ Because it’s unnatural to have this terrible thing that happened and then just act like nothing happened.”
 

Target resources

Be proactive and know where to find resources before you need them, advised Dr. Harry. “Most institutions have free mental health resources, either through their employee assistance programs or HR, plus there’s lots of national organizations that are offering free resources to health care providers.”

Focus on what you can control

Separating what is under your control from what is not is a struggle for everyone, Dr. Poorman said, but it’s helpful to think about the ways you can have an impact and what you’re able to control.

“There was a woman who was diagnosed with early-onset Parkinson’s that I heard giving an interview at the beginning of this pandemic,” she said. “It was the most helpful advice I got, which was: ‘Think of the next good thing you can do.’ You can’t fix everything, so what’s the next good thing you can do?”
 

Maintain connectivity

Make sure you are utilizing your support circle and staying connected. “That sense of connection is incredibly protective on multiple fronts for depression, for burnout, for suicide ideation, etc.,” Dr. Harry said.

“It doesn’t matter if it’s your teammates at work, your family at home, your best friend from medical school – whomever you can debrief with, vent with, and just share your thoughts and feelings with, these outlets are critical for all of us to process our emotions and diffuse stress and anxiety,” said Dr. Rudolph.

Dr. Poorman is concerned that there could be a spike in physician suicides caused by increased stress, so she also encourages talking openly about what is going on and about getting help when it’s necessary. “Many of us are afraid to seek care because we can actually have our ability to practice medicine questioned, but now is not the time for heroes. Now is the time for people who are willing to recognize their own strengths and limitations to take care of one another.”
 

Be compassionate toward others

Keep in mind that everyone is stressed out and offer empathy and compassion. “I think everybody’s struggling to try to figure this out and the more that we can give each other the benefit of the doubt and a little grace, the more protective that is,” said Dr. Harry.

Listening is meaningful too. “Recognizing opportunities to validate and acknowledge the feelings that are being shared with you by your colleagues is critical,” Dr. Rudolph said. “We all need to know that we’re not alone, that our thoughts and feelings are okay, and when we share a difficult story, the value of someone saying something as simple as, ‘wow, that sounds like it was really hard,’ is immense.”
 

Be compassionate toward yourself

Try to give yourself a break and be as compassionate with yourself as you would with others. It’s okay that you’re not getting in shape, publishing prolifically, or redesigning your house right now.

“There’s a lot of data linking lack of self-compassion to burnout,” said Dr. Harry. She says there are courses on self-compassion available that help you work on being kinder to yourself.
 

Get a “battle buddy”

The American Medical Association has a free “buddy system” program called PeerRx to help physicians cope during the pandemic. Dr. Rudolph said that now is a great time to use this military-developed intervention in which each team member checks in with a chosen partner at agreed-upon intervals.

For example, “You can tell that person: ‘If I don’t call my family for a week that’s a red flag for me.’ And then you hold each other accountable to those things,” Dr. Harry said.

The buddy system is another way to harness that sense of connection that is so vital to our health and well-being.

“The simple act of showing that you care … can make all the difference when you’re doing this kind of work that is both challenging and dangerous,” said Dr. Rudolph.