Opinion

There is apparently some debate about which of our ancestors was the first to use tools. It probably was Homo habilis, the “handy man.” But it could have been a relative of Lucy, of the Australopithecus afarensis tribe. Regardless of which pile of chipped rocks looks more tool-like to you, it is generally agreed that our ability to make and use tools is one of the key ingredients to our evolutionary success.

MichaelJung/Thinkstock

I have always enjoyed the feel of good quality knife when I am woodcarving, and the tool collection hanging on the wall over my work bench is one of my most prized possessions. But when I was practicing general pediatrics, I could never really warm up to the screening tools that were being touted as must-haves for detecting developmental delays.

It turns out I was not alone. A recent study published in Pediatrics found that the number of pediatricians who reported using developmental screening tools increased from 21% to 63% between 2002 and 2016. (Pediatrics. 2020 Apr. doi: 10.1542/peds.2019-0851). However, this means that, despite a significant increase in usage, more than a third of pediatricians still are not employing screening tools. Does this suggest that one out of every three pediatricians, including me and maybe you, is a knuckle-dragging pre–Homo sapiens practicing in blissful and clueless ignorance?

Mei Elansary MD, MPhil, and Michael Silverstein, MD, MPH, who wrote a companion commentary in the same journal, suggested that maybe those of us who have resisted the call to be tool users aren’t prehistoric ignoramuses (Pediatrics. 2020 Apr. doi: 10.1542/peds.2020-0164). They observed that, regardless of whether the pediatricians were using screening tools, more than 40% of the those surveyed did not refer patients for early intervention.

The commentators pointed out that the decision of when, whom, and how to screen must be viewed as part of a “complicated web of changing epidemiology, time and reimbursement constraints, and service availability.” They observe that pediatricians facing this landscape in upheaval “default to what they know best: clinical judgment.” Citing one study of the management of febrile infants, the authors point out that relying on guidelines doesn’t always result in improved clinical care.

My decision of when to refer a patient for early intervention was based on what I had observed over a series of visits and whether I thought that the early intervention resources available in my community would have a significant benefit for any particular child. Because I crafted my practice around a model that put a strong emphasis on continuity, my patients almost never saw another provider for a health maintenance visit and usually saw me for their sick visits, including ear rechecks.

I guess you could argue that there are situations in which seeing a variety of providers, each with a slightly different perspective, might benefit the patient. But when we are talking about a domain like development that is defined by change, or lack of change, over time, multiple observations by a single observer usually can be more valuable.

If I were practicing in a situation in which I didn’t have the luxury of continuity, I think I would be more likely to use a screening tool. Although I have found screening guidelines can be helpful as mnemonics in some situations, they aren’t equally applicable in all clinical settings.

While I may be asking for trouble by questioning anything even remotely related to the concept of early intervention, I must say that I wholeheartedly agree with Dr. Elansary and Dr. Silverstein when they wrote “the pediatrics community may have something to learn from the significant minority of pediatricians who do not practice formalized screening.”
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

There is apparently some debate about which of our ancestors was the first to use tools. It probably was Homo habilis, the “handy man.” But it could have been a relative of Lucy, of the Australopithecus afarensis tribe. Regardless of which pile of chipped rocks looks more tool-like to you, it is generally agreed that our ability to make and use tools is one of the key ingredients to our evolutionary success.

MichaelJung/Thinkstock

I have always enjoyed the feel of good quality knife when I am woodcarving, and the tool collection hanging on the wall over my work bench is one of my most prized possessions. But when I was practicing general pediatrics, I could never really warm up to the screening tools that were being touted as must-haves for detecting developmental delays.

It turns out I was not alone. A recent study published in Pediatrics found that the number of pediatricians who reported using developmental screening tools increased from 21% to 63% between 2002 and 2016. (Pediatrics. 2020 Apr. doi: 10.1542/peds.2019-0851). However, this means that, despite a significant increase in usage, more than a third of pediatricians still are not employing screening tools. Does this suggest that one out of every three pediatricians, including me and maybe you, is a knuckle-dragging pre–Homo sapiens practicing in blissful and clueless ignorance?

Mei Elansary MD, MPhil, and Michael Silverstein, MD, MPH, who wrote a companion commentary in the same journal, suggested that maybe those of us who have resisted the call to be tool users aren’t prehistoric ignoramuses (Pediatrics. 2020 Apr. doi: 10.1542/peds.2020-0164). They observed that, regardless of whether the pediatricians were using screening tools, more than 40% of the those surveyed did not refer patients for early intervention.

The commentators pointed out that the decision of when, whom, and how to screen must be viewed as part of a “complicated web of changing epidemiology, time and reimbursement constraints, and service availability.” They observe that pediatricians facing this landscape in upheaval “default to what they know best: clinical judgment.” Citing one study of the management of febrile infants, the authors point out that relying on guidelines doesn’t always result in improved clinical care.

My decision of when to refer a patient for early intervention was based on what I had observed over a series of visits and whether I thought that the early intervention resources available in my community would have a significant benefit for any particular child. Because I crafted my practice around a model that put a strong emphasis on continuity, my patients almost never saw another provider for a health maintenance visit and usually saw me for their sick visits, including ear rechecks.

I guess you could argue that there are situations in which seeing a variety of providers, each with a slightly different perspective, might benefit the patient. But when we are talking about a domain like development that is defined by change, or lack of change, over time, multiple observations by a single observer usually can be more valuable.

If I were practicing in a situation in which I didn’t have the luxury of continuity, I think I would be more likely to use a screening tool. Although I have found screening guidelines can be helpful as mnemonics in some situations, they aren’t equally applicable in all clinical settings.

While I may be asking for trouble by questioning anything even remotely related to the concept of early intervention, I must say that I wholeheartedly agree with Dr. Elansary and Dr. Silverstein when they wrote “the pediatrics community may have something to learn from the significant minority of pediatricians who do not practice formalized screening.”
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

There is apparently some debate about which of our ancestors was the first to use tools. It probably was Homo habilis, the “handy man.” But it could have been a relative of Lucy, of the Australopithecus afarensis tribe. Regardless of which pile of chipped rocks looks more tool-like to you, it is generally agreed that our ability to make and use tools is one of the key ingredients to our evolutionary success.

MichaelJung/Thinkstock

I have always enjoyed the feel of good quality knife when I am woodcarving, and the tool collection hanging on the wall over my work bench is one of my most prized possessions. But when I was practicing general pediatrics, I could never really warm up to the screening tools that were being touted as must-haves for detecting developmental delays.

It turns out I was not alone. A recent study published in Pediatrics found that the number of pediatricians who reported using developmental screening tools increased from 21% to 63% between 2002 and 2016. (Pediatrics. 2020 Apr. doi: 10.1542/peds.2019-0851). However, this means that, despite a significant increase in usage, more than a third of pediatricians still are not employing screening tools. Does this suggest that one out of every three pediatricians, including me and maybe you, is a knuckle-dragging pre–Homo sapiens practicing in blissful and clueless ignorance?

Mei Elansary MD, MPhil, and Michael Silverstein, MD, MPH, who wrote a companion commentary in the same journal, suggested that maybe those of us who have resisted the call to be tool users aren’t prehistoric ignoramuses (Pediatrics. 2020 Apr. doi: 10.1542/peds.2020-0164). They observed that, regardless of whether the pediatricians were using screening tools, more than 40% of the those surveyed did not refer patients for early intervention.

The commentators pointed out that the decision of when, whom, and how to screen must be viewed as part of a “complicated web of changing epidemiology, time and reimbursement constraints, and service availability.” They observe that pediatricians facing this landscape in upheaval “default to what they know best: clinical judgment.” Citing one study of the management of febrile infants, the authors point out that relying on guidelines doesn’t always result in improved clinical care.

My decision of when to refer a patient for early intervention was based on what I had observed over a series of visits and whether I thought that the early intervention resources available in my community would have a significant benefit for any particular child. Because I crafted my practice around a model that put a strong emphasis on continuity, my patients almost never saw another provider for a health maintenance visit and usually saw me for their sick visits, including ear rechecks.

I guess you could argue that there are situations in which seeing a variety of providers, each with a slightly different perspective, might benefit the patient. But when we are talking about a domain like development that is defined by change, or lack of change, over time, multiple observations by a single observer usually can be more valuable.

If I were practicing in a situation in which I didn’t have the luxury of continuity, I think I would be more likely to use a screening tool. Although I have found screening guidelines can be helpful as mnemonics in some situations, they aren’t equally applicable in all clinical settings.

While I may be asking for trouble by questioning anything even remotely related to the concept of early intervention, I must say that I wholeheartedly agree with Dr. Elansary and Dr. Silverstein when they wrote “the pediatrics community may have something to learn from the significant minority of pediatricians who do not practice formalized screening.”
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Real epidemiologists are out knocking on doors, chasing down contacts, or hunched over their computers trying to make sense out of screens full of data and maps. A few are trying valiantly to talk some sense into our elected officials.

konradlew/Thinkstock

This leaves the rest of us with time on our hands to fabricate our own less-than-scientific explanations for the behavior of the SARS-CoV-2 virus. So I have decided to put on hold my current mental challenge of choosing which pasta shape to pair with the sauce I’ve prepared from an online recipe. Here is my educated guess based on what I can glean from media sources that may have been filtered through a variety politically biased lenses. Remember, I did go to medical school; however, when I was in college the DNA helix was still just theoretical.

From those halcyon days of mid-February when our attention was focused on the Diamond Princess quarantined in Yokohama Harbor, it didn’t take a board-certified epidemiologist to suspect that the virus was spreading through the ventilating system in the ship’s tight quarters. Subsequent outbreaks on U.S. and French military ships suggests a similar explanation.

While still not proven, it sounds like SARS-CoV-2 jumped to humans from bats. It should not surprise us that having evolved in a dense population of mammals it would thrive in other high-density populations such as New York and nursing homes. Because we have lacked a robust testing capability, it has been less obvious until recently that, while it is easily transmitted, the virus has infected many who are asymptomatic (“Antibody surveys suggesting vast undercount of coronavirus infections may be unreliable,” Gretchen Vogel, Science, April 21, 2020). Subsequent surveys seem to confirm this higher level carrier state; it suggests that the virus is far less deadly than was previously suggested. However, it seems to be a crafty little bug attacking just about any organ system it lands on.

I don’t think any of us are surprised that the elderly population with weakened immune systems, particularly those in congregate housing, has been much more vulnerable. However, many of the deaths among younger apparently healthy people have defied explanation. The anecdotal observations that physicians, particularly those who practice in-your-face medicine (e.g., ophthalmologists and otolaryngologists) may be more vulnerable raises the issue of viral load. It may be that, although it can be extremely contagious, the virus is not terribly dangerous for most people until the inoculum dose of the virus reaches a certain level. To my knowledge this dose is unknown.

A published survey of more than 300 outbreaks from 120 Chinese cities also may support my suspicion that viral load is of critical importance. The researchers found that all the “identified outbreaks of three or more cases occurred in an indoor environment, which confirms that sharing indoor space is a major SARS-CoV-2 infection risk” (Huan Qian et al. “Indoor transmission of SARS-CoV-2,” MedRxiv. 2020 Apr 7. doi: 10.1101/2020.04.04.20053058). Again, this data shouldn’t surprise us when we look back at what little we know about the outbreaks in the confined spaces on cruise ships and in nursing homes.

I’m not sure that we have any data that helps us determine whether wearing a mask in an outdoor space has any more than symbolic value when we are talking about this particular virus. We may read that the virus in a droplet can survive on the surface it lands on for 8 minutes, and we can see those slow motion videos of the impressive plume of snot spray released by a sneeze. It would seem obvious that even outside someone within 10 feet of the sneeze has a good chance of being infected. However, how much of a threat is the asymptomatic carrier who passes within three feet of you while you are out on lovely summer day stroll? This armchair epidemiologist suspects that, when we are talking about an outside space, the 6-foot guideline for small groups of a dozen or less is overly restrictive. But until we know, I’m staying put in my armchair ... outside on the porch overlooking Casco Bay.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” He has no disclosures. Email him at [email protected].

Real epidemiologists are out knocking on doors, chasing down contacts, or hunched over their computers trying to make sense out of screens full of data and maps. A few are trying valiantly to talk some sense into our elected officials.

konradlew/Thinkstock

This leaves the rest of us with time on our hands to fabricate our own less-than-scientific explanations for the behavior of the SARS-CoV-2 virus. So I have decided to put on hold my current mental challenge of choosing which pasta shape to pair with the sauce I’ve prepared from an online recipe. Here is my educated guess based on what I can glean from media sources that may have been filtered through a variety politically biased lenses. Remember, I did go to medical school; however, when I was in college the DNA helix was still just theoretical.

From those halcyon days of mid-February when our attention was focused on the Diamond Princess quarantined in Yokohama Harbor, it didn’t take a board-certified epidemiologist to suspect that the virus was spreading through the ventilating system in the ship’s tight quarters. Subsequent outbreaks on U.S. and French military ships suggests a similar explanation.

While still not proven, it sounds like SARS-CoV-2 jumped to humans from bats. It should not surprise us that having evolved in a dense population of mammals it would thrive in other high-density populations such as New York and nursing homes. Because we have lacked a robust testing capability, it has been less obvious until recently that, while it is easily transmitted, the virus has infected many who are asymptomatic (“Antibody surveys suggesting vast undercount of coronavirus infections may be unreliable,” Gretchen Vogel, Science, April 21, 2020). Subsequent surveys seem to confirm this higher level carrier state; it suggests that the virus is far less deadly than was previously suggested. However, it seems to be a crafty little bug attacking just about any organ system it lands on.

I don’t think any of us are surprised that the elderly population with weakened immune systems, particularly those in congregate housing, has been much more vulnerable. However, many of the deaths among younger apparently healthy people have defied explanation. The anecdotal observations that physicians, particularly those who practice in-your-face medicine (e.g., ophthalmologists and otolaryngologists) may be more vulnerable raises the issue of viral load. It may be that, although it can be extremely contagious, the virus is not terribly dangerous for most people until the inoculum dose of the virus reaches a certain level. To my knowledge this dose is unknown.

A published survey of more than 300 outbreaks from 120 Chinese cities also may support my suspicion that viral load is of critical importance. The researchers found that all the “identified outbreaks of three or more cases occurred in an indoor environment, which confirms that sharing indoor space is a major SARS-CoV-2 infection risk” (Huan Qian et al. “Indoor transmission of SARS-CoV-2,” MedRxiv. 2020 Apr 7. doi: 10.1101/2020.04.04.20053058). Again, this data shouldn’t surprise us when we look back at what little we know about the outbreaks in the confined spaces on cruise ships and in nursing homes.

I’m not sure that we have any data that helps us determine whether wearing a mask in an outdoor space has any more than symbolic value when we are talking about this particular virus. We may read that the virus in a droplet can survive on the surface it lands on for 8 minutes, and we can see those slow motion videos of the impressive plume of snot spray released by a sneeze. It would seem obvious that even outside someone within 10 feet of the sneeze has a good chance of being infected. However, how much of a threat is the asymptomatic carrier who passes within three feet of you while you are out on lovely summer day stroll? This armchair epidemiologist suspects that, when we are talking about an outside space, the 6-foot guideline for small groups of a dozen or less is overly restrictive. But until we know, I’m staying put in my armchair ... outside on the porch overlooking Casco Bay.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” He has no disclosures. Email him at [email protected].

Real epidemiologists are out knocking on doors, chasing down contacts, or hunched over their computers trying to make sense out of screens full of data and maps. A few are trying valiantly to talk some sense into our elected officials.

konradlew/Thinkstock

This leaves the rest of us with time on our hands to fabricate our own less-than-scientific explanations for the behavior of the SARS-CoV-2 virus. So I have decided to put on hold my current mental challenge of choosing which pasta shape to pair with the sauce I’ve prepared from an online recipe. Here is my educated guess based on what I can glean from media sources that may have been filtered through a variety politically biased lenses. Remember, I did go to medical school; however, when I was in college the DNA helix was still just theoretical.

From those halcyon days of mid-February when our attention was focused on the Diamond Princess quarantined in Yokohama Harbor, it didn’t take a board-certified epidemiologist to suspect that the virus was spreading through the ventilating system in the ship’s tight quarters. Subsequent outbreaks on U.S. and French military ships suggests a similar explanation.

While still not proven, it sounds like SARS-CoV-2 jumped to humans from bats. It should not surprise us that having evolved in a dense population of mammals it would thrive in other high-density populations such as New York and nursing homes. Because we have lacked a robust testing capability, it has been less obvious until recently that, while it is easily transmitted, the virus has infected many who are asymptomatic (“Antibody surveys suggesting vast undercount of coronavirus infections may be unreliable,” Gretchen Vogel, Science, April 21, 2020). Subsequent surveys seem to confirm this higher level carrier state; it suggests that the virus is far less deadly than was previously suggested. However, it seems to be a crafty little bug attacking just about any organ system it lands on.

I don’t think any of us are surprised that the elderly population with weakened immune systems, particularly those in congregate housing, has been much more vulnerable. However, many of the deaths among younger apparently healthy people have defied explanation. The anecdotal observations that physicians, particularly those who practice in-your-face medicine (e.g., ophthalmologists and otolaryngologists) may be more vulnerable raises the issue of viral load. It may be that, although it can be extremely contagious, the virus is not terribly dangerous for most people until the inoculum dose of the virus reaches a certain level. To my knowledge this dose is unknown.

A published survey of more than 300 outbreaks from 120 Chinese cities also may support my suspicion that viral load is of critical importance. The researchers found that all the “identified outbreaks of three or more cases occurred in an indoor environment, which confirms that sharing indoor space is a major SARS-CoV-2 infection risk” (Huan Qian et al. “Indoor transmission of SARS-CoV-2,” MedRxiv. 2020 Apr 7. doi: 10.1101/2020.04.04.20053058). Again, this data shouldn’t surprise us when we look back at what little we know about the outbreaks in the confined spaces on cruise ships and in nursing homes.

I’m not sure that we have any data that helps us determine whether wearing a mask in an outdoor space has any more than symbolic value when we are talking about this particular virus. We may read that the virus in a droplet can survive on the surface it lands on for 8 minutes, and we can see those slow motion videos of the impressive plume of snot spray released by a sneeze. It would seem obvious that even outside someone within 10 feet of the sneeze has a good chance of being infected. However, how much of a threat is the asymptomatic carrier who passes within three feet of you while you are out on lovely summer day stroll? This armchair epidemiologist suspects that, when we are talking about an outside space, the 6-foot guideline for small groups of a dozen or less is overly restrictive. But until we know, I’m staying put in my armchair ... outside on the porch overlooking Casco Bay.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” He has no disclosures. Email him at [email protected].

PING – you look down at your phone and the words “URGENT – Meeting Today” stare back at you. The elevator door opens, and you step inside – 1 minute, the seemingly perfect amount of time for a quick inbox check.

As a hospitalist, chances are you have experienced this scenario, likely more than once. Email has become a double-edged sword, both a valuable communication tool and a source of stress and frustration.¹ A 2012 McKinsey analysis found that the average professional spends 28% of the day reading and answering emails.² Smartphone technology with email alerts and push notifications constantly diverts hospitalists’ attention away from important and nonurgent responsibilities such as manuscript writing, family time, and personal well-being.³

How can we break this cycle of compulsive connectivity? To keep email from controlling your life, we suggest the “Three Rs” (Resist, Reorganize, and Respond) of email effectiveness.
 

RESIST

The first key to take control of your inbox is to resist the urge to impulsively check and respond to emails. Consider these three solutions to bolster your ability to resist.

• Disable email push notifications. This will reduce the urge to continuously refresh your inbox on the wards.⁴ Excessively checking email can waste as much as 21 minutes per day.²
• Set an email budget.⁵ Schedule one to two appointments each day to handle email.⁶ Consider blocking 30 minutes after rounds and 30 minutes at the end of each day to address emails.
• Correspond at a computer. Limit email correspondence to your laptop or desktop. Access to a full keyboard and larger screen will maximize the efficiency of each email appointment.

REORGANIZE

After implementing these strategies to resist email temptations, reorganize your inbox with the following two-pronged approach.

• Focus your inbox: There are many options for reducing the volume of emails that flood your inbox. Try collaborative tools like Google Docs, Dropbox, Doodle polls, and Slack to shift communication away from email onto platforms optimized to your project’s specific needs. Additionally, email management tools like SaneBox and OtherInbox triage less important messages directly to folders, leaving only must-read-now messages in your inbox.² Lastly, activate spam filters and unsubscribe from mailing lists to eliminate email clutter.
• Commit to concise filing and finding: Archiving emails into a complex array of folders wastes as much as 14 minutes each day. Instead, limit your filing system to two folders: “Action” for email requiring further action and “Reading” for messages to reference at a later date.² Activating “Communication View” on Microsoft Outlook allows rapid review of messages that share the same subject heading.

RESPOND

Finally, once your inbox is reorganized, use the Four Ds for Decision Making model to optimize the way you respond to email.⁶ When you sit down for an email appointment, use the Four Ds, detailed below to avoid reading the same message repeatedly without taking action.

• Delete: Quickly delete any emails that do not directly require your attention or follow-up. Many emails can be immediately deleted without further thought.
• Do: If a task or response to an email will take less than 2 minutes, do it immediately. It will take at least the same amount to retrieve and reread an email as it will to handle it in real time.⁷ Often, this can be accomplished with a quick phone call or email reply.
• Defer: If an email response will take more than 2 minutes, use a system to take action at a later time. Move actionable items from your inbox to a to-do list or calendar appointment and file appropriate emails into the Action or Reading folders, detailed above. This method allows completion of important tasks in a timely manner outside of your fixed email budget. Delaying an email reply can also be advantageous by letting a problem mature, given that some of these issues will resolve without your specific intervention.
• Delegate: This can be difficult for many hospitalists who are accustomed to finishing each task themselves. If someone else can do the task as good as or better than you can, it is wise to delegate whenever possible.

Over the next few weeks, challenge yourself to resist email temptations, reorganize your inbox, and methodically respond to emails. This practice will help structure your day, maximize your efficiency, manage colleagues’ expectations, and create new time windows throughout your on-service weeks.

Dr. Nelson is a hospitalist at Ochsner Medical Center in New Orleans. Dr. Esquivel is a hospitalist and assistant professor at Weill Cornell Medicine, New York. Dr. Hall is a med-peds hospitalist and assistant professor at the University of Kentucky, Lexington.

References

1. MacKinnon R. How you manage your emails may be bad for your health. Science Daily. https://www.sciencedaily.com/releases/2016/01/160104081249.htm. Published Jan 4, 2016.

2. Plummer M. How to spend way less time on email every day. Harvard Business Review. https://hbr.org/2019/01/how-to-spend-way-less-time-on-email-every-day. 2019 Jan 22.

3. Covey SR. The 7 Habits of Highly Effective People: Powerful Lessons in Personal Change. New York: Free Press, 2004.

4. Ericson C. 5 Ways to Take Control of Your Email Inbox. Forbes. https://www.forbes.com/sites/learnvest/2014/03/17/5-ways-to-take-control-of-your-email-inbox/#3711f5946342. 2014 Mar 17.

5. Limit the time you spend on email. Harvard Business Review. https://hbr.org/2014/02/limit-the-time-you-spend-on-email. 2014 Feb 6.

6. McGhee S. Empty your inbox: 4 ways to take control of your email. Internet and Telephone Blog. https://www.itllc.net/it-support-ma/empty-your-inbox-4-ways-to-take-control-of-your-email/.

7. Allen D. Getting Things Done: The Art of Stress-Free Productivity. New York: Penguin Books, 2015.

PING – you look down at your phone and the words “URGENT – Meeting Today” stare back at you. The elevator door opens, and you step inside – 1 minute, the seemingly perfect amount of time for a quick inbox check.

As a hospitalist, chances are you have experienced this scenario, likely more than once. Email has become a double-edged sword, both a valuable communication tool and a source of stress and frustration.¹ A 2012 McKinsey analysis found that the average professional spends 28% of the day reading and answering emails.² Smartphone technology with email alerts and push notifications constantly diverts hospitalists’ attention away from important and nonurgent responsibilities such as manuscript writing, family time, and personal well-being.³

How can we break this cycle of compulsive connectivity? To keep email from controlling your life, we suggest the “Three Rs” (Resist, Reorganize, and Respond) of email effectiveness.
 

RESIST

The first key to take control of your inbox is to resist the urge to impulsively check and respond to emails. Consider these three solutions to bolster your ability to resist.

• Disable email push notifications. This will reduce the urge to continuously refresh your inbox on the wards.⁴ Excessively checking email can waste as much as 21 minutes per day.²
• Set an email budget.⁵ Schedule one to two appointments each day to handle email.⁶ Consider blocking 30 minutes after rounds and 30 minutes at the end of each day to address emails.
• Correspond at a computer. Limit email correspondence to your laptop or desktop. Access to a full keyboard and larger screen will maximize the efficiency of each email appointment.

REORGANIZE

After implementing these strategies to resist email temptations, reorganize your inbox with the following two-pronged approach.

• Focus your inbox: There are many options for reducing the volume of emails that flood your inbox. Try collaborative tools like Google Docs, Dropbox, Doodle polls, and Slack to shift communication away from email onto platforms optimized to your project’s specific needs. Additionally, email management tools like SaneBox and OtherInbox triage less important messages directly to folders, leaving only must-read-now messages in your inbox.² Lastly, activate spam filters and unsubscribe from mailing lists to eliminate email clutter.
• Commit to concise filing and finding: Archiving emails into a complex array of folders wastes as much as 14 minutes each day. Instead, limit your filing system to two folders: “Action” for email requiring further action and “Reading” for messages to reference at a later date.² Activating “Communication View” on Microsoft Outlook allows rapid review of messages that share the same subject heading.

RESPOND

Finally, once your inbox is reorganized, use the Four Ds for Decision Making model to optimize the way you respond to email.⁶ When you sit down for an email appointment, use the Four Ds, detailed below to avoid reading the same message repeatedly without taking action.

• Delete: Quickly delete any emails that do not directly require your attention or follow-up. Many emails can be immediately deleted without further thought.
• Do: If a task or response to an email will take less than 2 minutes, do it immediately. It will take at least the same amount to retrieve and reread an email as it will to handle it in real time.⁷ Often, this can be accomplished with a quick phone call or email reply.
• Defer: If an email response will take more than 2 minutes, use a system to take action at a later time. Move actionable items from your inbox to a to-do list or calendar appointment and file appropriate emails into the Action or Reading folders, detailed above. This method allows completion of important tasks in a timely manner outside of your fixed email budget. Delaying an email reply can also be advantageous by letting a problem mature, given that some of these issues will resolve without your specific intervention.
• Delegate: This can be difficult for many hospitalists who are accustomed to finishing each task themselves. If someone else can do the task as good as or better than you can, it is wise to delegate whenever possible.

Over the next few weeks, challenge yourself to resist email temptations, reorganize your inbox, and methodically respond to emails. This practice will help structure your day, maximize your efficiency, manage colleagues’ expectations, and create new time windows throughout your on-service weeks.

Dr. Nelson is a hospitalist at Ochsner Medical Center in New Orleans. Dr. Esquivel is a hospitalist and assistant professor at Weill Cornell Medicine, New York. Dr. Hall is a med-peds hospitalist and assistant professor at the University of Kentucky, Lexington.

References

1. MacKinnon R. How you manage your emails may be bad for your health. Science Daily. https://www.sciencedaily.com/releases/2016/01/160104081249.htm. Published Jan 4, 2016.

2. Plummer M. How to spend way less time on email every day. Harvard Business Review. https://hbr.org/2019/01/how-to-spend-way-less-time-on-email-every-day. 2019 Jan 22.

3. Covey SR. The 7 Habits of Highly Effective People: Powerful Lessons in Personal Change. New York: Free Press, 2004.

4. Ericson C. 5 Ways to Take Control of Your Email Inbox. Forbes. https://www.forbes.com/sites/learnvest/2014/03/17/5-ways-to-take-control-of-your-email-inbox/#3711f5946342. 2014 Mar 17.

5. Limit the time you spend on email. Harvard Business Review. https://hbr.org/2014/02/limit-the-time-you-spend-on-email. 2014 Feb 6.

6. McGhee S. Empty your inbox: 4 ways to take control of your email. Internet and Telephone Blog. https://www.itllc.net/it-support-ma/empty-your-inbox-4-ways-to-take-control-of-your-email/.

7. Allen D. Getting Things Done: The Art of Stress-Free Productivity. New York: Penguin Books, 2015.

PING – you look down at your phone and the words “URGENT – Meeting Today” stare back at you. The elevator door opens, and you step inside – 1 minute, the seemingly perfect amount of time for a quick inbox check.

As a hospitalist, chances are you have experienced this scenario, likely more than once. Email has become a double-edged sword, both a valuable communication tool and a source of stress and frustration.¹ A 2012 McKinsey analysis found that the average professional spends 28% of the day reading and answering emails.² Smartphone technology with email alerts and push notifications constantly diverts hospitalists’ attention away from important and nonurgent responsibilities such as manuscript writing, family time, and personal well-being.³

How can we break this cycle of compulsive connectivity? To keep email from controlling your life, we suggest the “Three Rs” (Resist, Reorganize, and Respond) of email effectiveness.
 

RESIST

The first key to take control of your inbox is to resist the urge to impulsively check and respond to emails. Consider these three solutions to bolster your ability to resist.

• Disable email push notifications. This will reduce the urge to continuously refresh your inbox on the wards.⁴ Excessively checking email can waste as much as 21 minutes per day.²
• Set an email budget.⁵ Schedule one to two appointments each day to handle email.⁶ Consider blocking 30 minutes after rounds and 30 minutes at the end of each day to address emails.
• Correspond at a computer. Limit email correspondence to your laptop or desktop. Access to a full keyboard and larger screen will maximize the efficiency of each email appointment.

REORGANIZE

After implementing these strategies to resist email temptations, reorganize your inbox with the following two-pronged approach.

• Focus your inbox: There are many options for reducing the volume of emails that flood your inbox. Try collaborative tools like Google Docs, Dropbox, Doodle polls, and Slack to shift communication away from email onto platforms optimized to your project’s specific needs. Additionally, email management tools like SaneBox and OtherInbox triage less important messages directly to folders, leaving only must-read-now messages in your inbox.² Lastly, activate spam filters and unsubscribe from mailing lists to eliminate email clutter.
• Commit to concise filing and finding: Archiving emails into a complex array of folders wastes as much as 14 minutes each day. Instead, limit your filing system to two folders: “Action” for email requiring further action and “Reading” for messages to reference at a later date.² Activating “Communication View” on Microsoft Outlook allows rapid review of messages that share the same subject heading.

RESPOND

Finally, once your inbox is reorganized, use the Four Ds for Decision Making model to optimize the way you respond to email.⁶ When you sit down for an email appointment, use the Four Ds, detailed below to avoid reading the same message repeatedly without taking action.

• Delete: Quickly delete any emails that do not directly require your attention or follow-up. Many emails can be immediately deleted without further thought.
• Do: If a task or response to an email will take less than 2 minutes, do it immediately. It will take at least the same amount to retrieve and reread an email as it will to handle it in real time.⁷ Often, this can be accomplished with a quick phone call or email reply.
• Defer: If an email response will take more than 2 minutes, use a system to take action at a later time. Move actionable items from your inbox to a to-do list or calendar appointment and file appropriate emails into the Action or Reading folders, detailed above. This method allows completion of important tasks in a timely manner outside of your fixed email budget. Delaying an email reply can also be advantageous by letting a problem mature, given that some of these issues will resolve without your specific intervention.
• Delegate: This can be difficult for many hospitalists who are accustomed to finishing each task themselves. If someone else can do the task as good as or better than you can, it is wise to delegate whenever possible.

Over the next few weeks, challenge yourself to resist email temptations, reorganize your inbox, and methodically respond to emails. This practice will help structure your day, maximize your efficiency, manage colleagues’ expectations, and create new time windows throughout your on-service weeks.

Dr. Nelson is a hospitalist at Ochsner Medical Center in New Orleans. Dr. Esquivel is a hospitalist and assistant professor at Weill Cornell Medicine, New York. Dr. Hall is a med-peds hospitalist and assistant professor at the University of Kentucky, Lexington.

References

1. MacKinnon R. How you manage your emails may be bad for your health. Science Daily. https://www.sciencedaily.com/releases/2016/01/160104081249.htm. Published Jan 4, 2016.

2. Plummer M. How to spend way less time on email every day. Harvard Business Review. https://hbr.org/2019/01/how-to-spend-way-less-time-on-email-every-day. 2019 Jan 22.

3. Covey SR. The 7 Habits of Highly Effective People: Powerful Lessons in Personal Change. New York: Free Press, 2004.

4. Ericson C. 5 Ways to Take Control of Your Email Inbox. Forbes. https://www.forbes.com/sites/learnvest/2014/03/17/5-ways-to-take-control-of-your-email-inbox/#3711f5946342. 2014 Mar 17.

5. Limit the time you spend on email. Harvard Business Review. https://hbr.org/2014/02/limit-the-time-you-spend-on-email. 2014 Feb 6.

6. McGhee S. Empty your inbox: 4 ways to take control of your email. Internet and Telephone Blog. https://www.itllc.net/it-support-ma/empty-your-inbox-4-ways-to-take-control-of-your-email/.

7. Allen D. Getting Things Done: The Art of Stress-Free Productivity. New York: Penguin Books, 2015.

We are months into the COVID-19 crisis, and mental health issues are proving to be rampant. In every crisis, there is opportunity, and this one is no different. The opportunity is clear. For Mental Health Awareness Month and beyond, we must convey a powerful message that mental health is key to our well-being and must be actively addressed. Because almost everyone has felt excess anxiety these last months, we have a unique chance to engage a wider audience.

To address the urgent need, the Mental Health Coalition was formed with the understanding that the mental health crisis is fueled by a pervasive and devastating stigma, preventing millions of individuals from being able to seek the critical treatment they need. Spearheaded by social activist and fashion designer, Kenneth Cole, it is a coalition of leading mental health organizations, brands, celebrities, and advocates who have joined forces to end the stigma surrounding mental health and to change the way people talk about, and care for, mental illness. The group’s mission listed on its website states: “We must increase the conversation around mental health. We must act to end silence, reduce stigma, and engage our community to inspire hope at this essential moment.”

As most of the United States has been under stay-at-home orders, our traditional relationships have been radically disrupted. New types of relationships are forming as we are relying even more on technology to connect us. Social media seems to be on the only “social” we can now safely engage in.

The coalition’s campaign, “#howareyoureally?” is harnessing the power of social media and creating a storytelling platform to allow users to more genuinely share their feelings in these unprecedented times. Celebrities include Whoopi Goldberg, Kendall Jenner, Chris Cuomo, Deepak Chopra, Kesha, and many more have already shared their stories.

“How Are You, Really?” challenges people to answer this question using social media in an open and honest fashion while still providing hope.

The second component of the initiative is to increase access to care, and they have a long list of collaborators, including leading mental health organizations such as the American Foundation for Suicide Prevention, Anxiety and Depression Association of America, Child Mind Institute, Depression and Bipolar Support Alliance, Didi Hirsch Mental Health Services, National Alliance on Mental Illness, and many more.

We have a unique opportunity this Mental Health Awareness Month, and I hope we will see more and more people sharing their stories and reaching out for help. As a community, we must be prepared to meet the escalating needs of our population.
 

Dr. Ritvo, a psychiatrist with more than 25 years’ experience, practices in Miami Beach, Fla. She is the author of “Bekindr – The Transformative Power of Kindness” (Hellertown, Pa.: Momosa Publishing, 2018) and is the founder of the Bekindr Global Initiative, a movement aimed at cultivating kindness in the world. Dr. Ritvo also is the cofounder of the Bold Beauty Project, a nonprofit group that pairs women with disabilities with photographers who create art exhibitions to raise awareness.

We are months into the COVID-19 crisis, and mental health issues are proving to be rampant. In every crisis, there is opportunity, and this one is no different. The opportunity is clear. For Mental Health Awareness Month and beyond, we must convey a powerful message that mental health is key to our well-being and must be actively addressed. Because almost everyone has felt excess anxiety these last months, we have a unique chance to engage a wider audience.

To address the urgent need, the Mental Health Coalition was formed with the understanding that the mental health crisis is fueled by a pervasive and devastating stigma, preventing millions of individuals from being able to seek the critical treatment they need. Spearheaded by social activist and fashion designer, Kenneth Cole, it is a coalition of leading mental health organizations, brands, celebrities, and advocates who have joined forces to end the stigma surrounding mental health and to change the way people talk about, and care for, mental illness. The group’s mission listed on its website states: “We must increase the conversation around mental health. We must act to end silence, reduce stigma, and engage our community to inspire hope at this essential moment.”

As most of the United States has been under stay-at-home orders, our traditional relationships have been radically disrupted. New types of relationships are forming as we are relying even more on technology to connect us. Social media seems to be on the only “social” we can now safely engage in.

The coalition’s campaign, “#howareyoureally?” is harnessing the power of social media and creating a storytelling platform to allow users to more genuinely share their feelings in these unprecedented times. Celebrities include Whoopi Goldberg, Kendall Jenner, Chris Cuomo, Deepak Chopra, Kesha, and many more have already shared their stories.

“How Are You, Really?” challenges people to answer this question using social media in an open and honest fashion while still providing hope.

The second component of the initiative is to increase access to care, and they have a long list of collaborators, including leading mental health organizations such as the American Foundation for Suicide Prevention, Anxiety and Depression Association of America, Child Mind Institute, Depression and Bipolar Support Alliance, Didi Hirsch Mental Health Services, National Alliance on Mental Illness, and many more.

We have a unique opportunity this Mental Health Awareness Month, and I hope we will see more and more people sharing their stories and reaching out for help. As a community, we must be prepared to meet the escalating needs of our population.
 

Dr. Ritvo, a psychiatrist with more than 25 years’ experience, practices in Miami Beach, Fla. She is the author of “Bekindr – The Transformative Power of Kindness” (Hellertown, Pa.: Momosa Publishing, 2018) and is the founder of the Bekindr Global Initiative, a movement aimed at cultivating kindness in the world. Dr. Ritvo also is the cofounder of the Bold Beauty Project, a nonprofit group that pairs women with disabilities with photographers who create art exhibitions to raise awareness.

We are months into the COVID-19 crisis, and mental health issues are proving to be rampant. In every crisis, there is opportunity, and this one is no different. The opportunity is clear. For Mental Health Awareness Month and beyond, we must convey a powerful message that mental health is key to our well-being and must be actively addressed. Because almost everyone has felt excess anxiety these last months, we have a unique chance to engage a wider audience.

To address the urgent need, the Mental Health Coalition was formed with the understanding that the mental health crisis is fueled by a pervasive and devastating stigma, preventing millions of individuals from being able to seek the critical treatment they need. Spearheaded by social activist and fashion designer, Kenneth Cole, it is a coalition of leading mental health organizations, brands, celebrities, and advocates who have joined forces to end the stigma surrounding mental health and to change the way people talk about, and care for, mental illness. The group’s mission listed on its website states: “We must increase the conversation around mental health. We must act to end silence, reduce stigma, and engage our community to inspire hope at this essential moment.”

As most of the United States has been under stay-at-home orders, our traditional relationships have been radically disrupted. New types of relationships are forming as we are relying even more on technology to connect us. Social media seems to be on the only “social” we can now safely engage in.

The coalition’s campaign, “#howareyoureally?” is harnessing the power of social media and creating a storytelling platform to allow users to more genuinely share their feelings in these unprecedented times. Celebrities include Whoopi Goldberg, Kendall Jenner, Chris Cuomo, Deepak Chopra, Kesha, and many more have already shared their stories.

“How Are You, Really?” challenges people to answer this question using social media in an open and honest fashion while still providing hope.

The second component of the initiative is to increase access to care, and they have a long list of collaborators, including leading mental health organizations such as the American Foundation for Suicide Prevention, Anxiety and Depression Association of America, Child Mind Institute, Depression and Bipolar Support Alliance, Didi Hirsch Mental Health Services, National Alliance on Mental Illness, and many more.

We have a unique opportunity this Mental Health Awareness Month, and I hope we will see more and more people sharing their stories and reaching out for help. As a community, we must be prepared to meet the escalating needs of our population.
 

Dr. Ritvo, a psychiatrist with more than 25 years’ experience, practices in Miami Beach, Fla. She is the author of “Bekindr – The Transformative Power of Kindness” (Hellertown, Pa.: Momosa Publishing, 2018) and is the founder of the Bekindr Global Initiative, a movement aimed at cultivating kindness in the world. Dr. Ritvo also is the cofounder of the Bold Beauty Project, a nonprofit group that pairs women with disabilities with photographers who create art exhibitions to raise awareness.

From the ash of our post “coron-apocalyptic” world, we emerge. It’s back to work, to life in a new normal. Patients are still scarce and scared, as are some doctors. Queues of patients wait to clear security and enter the sterile area at every medical office. Water bottles are allowed, fevers and visitors are not. Those who fail clearance or who are afraid to be seen in person must be treated virtually. In this context, virtually means by telephone or video, yet, aptly, it also means “nearly or almost,” as in we can nearly or almost treat them these ways. We’ve emerged safely, but we’ve lost sensibility. Because of this, what’s important in the doctor-patient relationships will drift a bit. Clinical acumen and technical skill won’t be enough. Successful practices will also have grace.

Hans Gerber/CC BY-SA 4.0

If your image of grace is Audrey Hepburn gliding along Fifth Avenue in a long black dress and elbow-length gloves, you’re in the right place. Ms. Hepburn embodied elegance and decorum and there are lessons to be drawn from her. Piling your hair high and donning oversized sunglasses along with your face mask would be to miss the point here though. Ms. Hepburn dressed exquisitely, yes, but her grace came from what wearing a difficult-to-walk-in dress meant to us, not to her. Appearance, self-control, and warmth are what made her charismatic.

To appear urbane requires effort; it’s the effort that we appreciate in someone who is graceful. When you’re thoughtful about how you look, you plan ahead, you work to look polished. In effect, you’re saying: “As my patient, you’re important enough for me to be well dressed.” It is a visible signal of all the unobservable work you’ve done to care for them. This is more critical now that our faces are covered and concern for infection means wearing shabby hospital scrubs rather than shirt and tie.

Effort is also required for telephone and video visits. In them, our doctor-patient connection is diminished – no matter how high definition, it’s a virtual affair. Ms. Hepburn would no doubt take the time to ensure she appeared professional, well lit, with a pleasing background. She’d plan for the call to be done in a quiet location and without distraction.

Whether in person or by phone, grace, as Ms. Hepburn demonstrated, is physical awareness and body control. She would often be completely still when someone is speaking, showing a countenance of warmth. She’d pause after the other person completed a thought and before replying. In doing so, she conveyed that she was present and engaged in what was being said. It is that confidence and ease of manner we perceived as grace.

I thought about this the other day during a mixed clinic of telephone and face-to-face visits. I had on my wrinkle-free scrubs (I could do better). I was listening to a patient describe all possible triggers for her hand dermatitis. My urge to interrupt grew with each paragraph of her storytelling. “Be patient,” I thought, “be at ease with her rambling. ... When she stops, thank her as if you were looking her in the eye acknowledging how interesting her observations were.” This is not just good manners, it’s the essence of grace: The art of showing how important others are to you.

Our world needs grace more than ever and what better place to start but with us. In pleasing, assisting, and honoring them, our patients can be reassured that we can and will care for them. Make Ms. Hepburn proud.

“For beautiful eyes, look for the good in others; for beautiful lips, speak only words of kindness; and for poise, walk with the knowledge that you are never alone.” – Audrey Hepburn

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. He has no disclosures related to this column. Write to him at [email protected] .

From the ash of our post “coron-apocalyptic” world, we emerge. It’s back to work, to life in a new normal. Patients are still scarce and scared, as are some doctors. Queues of patients wait to clear security and enter the sterile area at every medical office. Water bottles are allowed, fevers and visitors are not. Those who fail clearance or who are afraid to be seen in person must be treated virtually. In this context, virtually means by telephone or video, yet, aptly, it also means “nearly or almost,” as in we can nearly or almost treat them these ways. We’ve emerged safely, but we’ve lost sensibility. Because of this, what’s important in the doctor-patient relationships will drift a bit. Clinical acumen and technical skill won’t be enough. Successful practices will also have grace.

Hans Gerber/CC BY-SA 4.0

If your image of grace is Audrey Hepburn gliding along Fifth Avenue in a long black dress and elbow-length gloves, you’re in the right place. Ms. Hepburn embodied elegance and decorum and there are lessons to be drawn from her. Piling your hair high and donning oversized sunglasses along with your face mask would be to miss the point here though. Ms. Hepburn dressed exquisitely, yes, but her grace came from what wearing a difficult-to-walk-in dress meant to us, not to her. Appearance, self-control, and warmth are what made her charismatic.

To appear urbane requires effort; it’s the effort that we appreciate in someone who is graceful. When you’re thoughtful about how you look, you plan ahead, you work to look polished. In effect, you’re saying: “As my patient, you’re important enough for me to be well dressed.” It is a visible signal of all the unobservable work you’ve done to care for them. This is more critical now that our faces are covered and concern for infection means wearing shabby hospital scrubs rather than shirt and tie.

Effort is also required for telephone and video visits. In them, our doctor-patient connection is diminished – no matter how high definition, it’s a virtual affair. Ms. Hepburn would no doubt take the time to ensure she appeared professional, well lit, with a pleasing background. She’d plan for the call to be done in a quiet location and without distraction.

Whether in person or by phone, grace, as Ms. Hepburn demonstrated, is physical awareness and body control. She would often be completely still when someone is speaking, showing a countenance of warmth. She’d pause after the other person completed a thought and before replying. In doing so, she conveyed that she was present and engaged in what was being said. It is that confidence and ease of manner we perceived as grace.

I thought about this the other day during a mixed clinic of telephone and face-to-face visits. I had on my wrinkle-free scrubs (I could do better). I was listening to a patient describe all possible triggers for her hand dermatitis. My urge to interrupt grew with each paragraph of her storytelling. “Be patient,” I thought, “be at ease with her rambling. ... When she stops, thank her as if you were looking her in the eye acknowledging how interesting her observations were.” This is not just good manners, it’s the essence of grace: The art of showing how important others are to you.

Our world needs grace more than ever and what better place to start but with us. In pleasing, assisting, and honoring them, our patients can be reassured that we can and will care for them. Make Ms. Hepburn proud.

“For beautiful eyes, look for the good in others; for beautiful lips, speak only words of kindness; and for poise, walk with the knowledge that you are never alone.” – Audrey Hepburn

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. He has no disclosures related to this column. Write to him at [email protected] .

From the ash of our post “coron-apocalyptic” world, we emerge. It’s back to work, to life in a new normal. Patients are still scarce and scared, as are some doctors. Queues of patients wait to clear security and enter the sterile area at every medical office. Water bottles are allowed, fevers and visitors are not. Those who fail clearance or who are afraid to be seen in person must be treated virtually. In this context, virtually means by telephone or video, yet, aptly, it also means “nearly or almost,” as in we can nearly or almost treat them these ways. We’ve emerged safely, but we’ve lost sensibility. Because of this, what’s important in the doctor-patient relationships will drift a bit. Clinical acumen and technical skill won’t be enough. Successful practices will also have grace.

Hans Gerber/CC BY-SA 4.0

If your image of grace is Audrey Hepburn gliding along Fifth Avenue in a long black dress and elbow-length gloves, you’re in the right place. Ms. Hepburn embodied elegance and decorum and there are lessons to be drawn from her. Piling your hair high and donning oversized sunglasses along with your face mask would be to miss the point here though. Ms. Hepburn dressed exquisitely, yes, but her grace came from what wearing a difficult-to-walk-in dress meant to us, not to her. Appearance, self-control, and warmth are what made her charismatic.

To appear urbane requires effort; it’s the effort that we appreciate in someone who is graceful. When you’re thoughtful about how you look, you plan ahead, you work to look polished. In effect, you’re saying: “As my patient, you’re important enough for me to be well dressed.” It is a visible signal of all the unobservable work you’ve done to care for them. This is more critical now that our faces are covered and concern for infection means wearing shabby hospital scrubs rather than shirt and tie.

Effort is also required for telephone and video visits. In them, our doctor-patient connection is diminished – no matter how high definition, it’s a virtual affair. Ms. Hepburn would no doubt take the time to ensure she appeared professional, well lit, with a pleasing background. She’d plan for the call to be done in a quiet location and without distraction.

Whether in person or by phone, grace, as Ms. Hepburn demonstrated, is physical awareness and body control. She would often be completely still when someone is speaking, showing a countenance of warmth. She’d pause after the other person completed a thought and before replying. In doing so, she conveyed that she was present and engaged in what was being said. It is that confidence and ease of manner we perceived as grace.

I thought about this the other day during a mixed clinic of telephone and face-to-face visits. I had on my wrinkle-free scrubs (I could do better). I was listening to a patient describe all possible triggers for her hand dermatitis. My urge to interrupt grew with each paragraph of her storytelling. “Be patient,” I thought, “be at ease with her rambling. ... When she stops, thank her as if you were looking her in the eye acknowledging how interesting her observations were.” This is not just good manners, it’s the essence of grace: The art of showing how important others are to you.

Our world needs grace more than ever and what better place to start but with us. In pleasing, assisting, and honoring them, our patients can be reassured that we can and will care for them. Make Ms. Hepburn proud.

“For beautiful eyes, look for the good in others; for beautiful lips, speak only words of kindness; and for poise, walk with the knowledge that you are never alone.” – Audrey Hepburn

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. He has no disclosures related to this column. Write to him at [email protected] .

Friends of mine who work in the ED have noticed a drop-off in patients. Granted, so has my office, but theirs is a little less expected.

It’s not just in my region. An article on this site last week mentioned the same phenomenon. Not just minor stuff but visits for more serious conditions also have decreased. This means that either people are currently choosing to ignore those things entirely or are trying to get them handled at a later date in the outpatient setting.

Neither one is good.

One friend pointed out that since a fair percentage of visits to the ED aren’t really “emergencies” maybe this is part of the reason. With all the news about COVID-19, the risk of going to the ED for something minor isn’t worth it. This may apply to some, but not all. Certainly, if it clarifies to people what is and isn’t an emergency, that would be helpful to prevent ED overuse in the future.

Every day we all face a countless number of decisions, each with its own risks and benefits. When the question of whether or not to go to an ED comes up, usually the only perceived drawbacks are costs in time and money, compared with the benefit of believing you’re going to get the problem “fixed.”

In the era of coronavirus, with daily news reports on its spread and casualties, the risk of going to the ED is perceived to be higher, and so people are more willing to stay away. If you were going in for a sinus infection, this is probably a good idea. If you’re having a more serious problem and staying home ...

A cost of the pandemic that will come to light in the future will be people who unknowingly survived mild cardiac events, strokes, and other potentially serious problems. While they may do okay in the short term, in the long run they may not be aware they had a problem and so it will continue to go untreated. Coronary or cerebrovascular arteries that need to be reopened won’t be. People with poorly controlled hypertension, dyslipidemia, or diabetes won’t be started on medications they need until it may be too late to avoid more serious outcomes.

Likewise, I worry about an uptick in cancer-related deaths down the road. With the shutdown of many nonurgent procedures, patients may have missed a window for early diagnosis of a malignancy, either because the procedure wasn’t available or they were reluctant to venture out.

Medical data from 2020 will be analyzed many times in the coming years, not just for coronavirus, but for its effects on medical care as a whole. As the first worldwide pandemic of the information age, there will be a lot of lessons to be learned as to how medicine, science, and society in general should and should not respond. Both good and bad things will be learned, but whatever knowledge is gained will be critical for the inevitable next pandemic.

The future world is watching.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Friends of mine who work in the ED have noticed a drop-off in patients. Granted, so has my office, but theirs is a little less expected.

It’s not just in my region. An article on this site last week mentioned the same phenomenon. Not just minor stuff but visits for more serious conditions also have decreased. This means that either people are currently choosing to ignore those things entirely or are trying to get them handled at a later date in the outpatient setting.

Neither one is good.

One friend pointed out that since a fair percentage of visits to the ED aren’t really “emergencies” maybe this is part of the reason. With all the news about COVID-19, the risk of going to the ED for something minor isn’t worth it. This may apply to some, but not all. Certainly, if it clarifies to people what is and isn’t an emergency, that would be helpful to prevent ED overuse in the future.

Every day we all face a countless number of decisions, each with its own risks and benefits. When the question of whether or not to go to an ED comes up, usually the only perceived drawbacks are costs in time and money, compared with the benefit of believing you’re going to get the problem “fixed.”

In the era of coronavirus, with daily news reports on its spread and casualties, the risk of going to the ED is perceived to be higher, and so people are more willing to stay away. If you were going in for a sinus infection, this is probably a good idea. If you’re having a more serious problem and staying home ...

A cost of the pandemic that will come to light in the future will be people who unknowingly survived mild cardiac events, strokes, and other potentially serious problems. While they may do okay in the short term, in the long run they may not be aware they had a problem and so it will continue to go untreated. Coronary or cerebrovascular arteries that need to be reopened won’t be. People with poorly controlled hypertension, dyslipidemia, or diabetes won’t be started on medications they need until it may be too late to avoid more serious outcomes.

Likewise, I worry about an uptick in cancer-related deaths down the road. With the shutdown of many nonurgent procedures, patients may have missed a window for early diagnosis of a malignancy, either because the procedure wasn’t available or they were reluctant to venture out.

Medical data from 2020 will be analyzed many times in the coming years, not just for coronavirus, but for its effects on medical care as a whole. As the first worldwide pandemic of the information age, there will be a lot of lessons to be learned as to how medicine, science, and society in general should and should not respond. Both good and bad things will be learned, but whatever knowledge is gained will be critical for the inevitable next pandemic.

The future world is watching.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Friends of mine who work in the ED have noticed a drop-off in patients. Granted, so has my office, but theirs is a little less expected.

It’s not just in my region. An article on this site last week mentioned the same phenomenon. Not just minor stuff but visits for more serious conditions also have decreased. This means that either people are currently choosing to ignore those things entirely or are trying to get them handled at a later date in the outpatient setting.

Neither one is good.

One friend pointed out that since a fair percentage of visits to the ED aren’t really “emergencies” maybe this is part of the reason. With all the news about COVID-19, the risk of going to the ED for something minor isn’t worth it. This may apply to some, but not all. Certainly, if it clarifies to people what is and isn’t an emergency, that would be helpful to prevent ED overuse in the future.

Every day we all face a countless number of decisions, each with its own risks and benefits. When the question of whether or not to go to an ED comes up, usually the only perceived drawbacks are costs in time and money, compared with the benefit of believing you’re going to get the problem “fixed.”

In the era of coronavirus, with daily news reports on its spread and casualties, the risk of going to the ED is perceived to be higher, and so people are more willing to stay away. If you were going in for a sinus infection, this is probably a good idea. If you’re having a more serious problem and staying home ...

A cost of the pandemic that will come to light in the future will be people who unknowingly survived mild cardiac events, strokes, and other potentially serious problems. While they may do okay in the short term, in the long run they may not be aware they had a problem and so it will continue to go untreated. Coronary or cerebrovascular arteries that need to be reopened won’t be. People with poorly controlled hypertension, dyslipidemia, or diabetes won’t be started on medications they need until it may be too late to avoid more serious outcomes.

Likewise, I worry about an uptick in cancer-related deaths down the road. With the shutdown of many nonurgent procedures, patients may have missed a window for early diagnosis of a malignancy, either because the procedure wasn’t available or they were reluctant to venture out.

Medical data from 2020 will be analyzed many times in the coming years, not just for coronavirus, but for its effects on medical care as a whole. As the first worldwide pandemic of the information age, there will be a lot of lessons to be learned as to how medicine, science, and society in general should and should not respond. Both good and bad things will be learned, but whatever knowledge is gained will be critical for the inevitable next pandemic.

The future world is watching.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Reports have emerged about the unique vulnerability of psychiatric hospitals to the ravages of COVID-19.

In a South Korea psychiatric hospital, 101 of 103 patients contracted SARS-CoV-2 during an outbreak; 7 eventually died.^1,2 This report, among a few others, have led to the development of psychiatric COVID-19–positive units (PCU). However, it remains highly unclear how many are currently open, where they are located, or what their operations are like.

Early in the COVID-19 pandemic, it became clear to us that, as a public health measure, it would be necessary to test all patients for COVID-19 who were being considered for admission to our inpatient psychiatric units. We knew that we could not allow a medically asymptomatic “covertly” COVID-19–positive patient to be introduced to the social community of our inpatient units because of the risks of transmission to other patients and staff.

In coordination with our health system infection prevention experts, we have therefore required a confirmed negative COVID-19 polymerase chain reaction nasal swab performed no more than 48 hours prior to the time/date of acute psychiatric inpatient admission. Furthermore, as part of the broad health system response and surge planning, we were asked by our respective incident command centers to begin planning for a Psychiatric COVID-19–positive Unit (PCU) that might allow us to safely care for a cohort of patients needing such hospitalization.

It is worth emphasizing that the typical patient who is a candidate for a PCU is so acutely psychiatrically ill that they cannot be managed in a less restrictive environment than an inpatient psychiatric unit and, at the same time, is likely to not be medically ill enough to warrant admission to an internal medicine service in a general acute care hospital.

We have identified eight principles and critical decision points that can help inpatient units plan for the safe care of COVID-19–positive patients on a PCU.

1. Triage: Patients admitted to a PCU should be medically stable, particularly with regard to COVID-19 and respiratory symptomatology. PCUs should establish clear criteria for admission and discharge (or medical transfer). Examples of potential exclusionary criteria to a PCU include:

• Respiratory distress, shortness of breath, hypoxia, requirement for supplemental oxygen, or requirement for respiratory therapy breathing treatments.
• Fever, or signs of sepsis, or systemic inflammatory response syndrome.
• Medical frailty, significant medical comorbidities, delirium, or altered mental status;
• Requirements for continuous vital sign monitoring or of a monitoring frequency beyond the capacity of the PCU.

Discharge criteria may also include a symptom-based strategy because emerging evidence suggests that patients may be less infectious by day 10-14 of the disease course,³ and viral lab testing is very sensitive and will be positive for periods of time after individuals are no longer infectious. The symptom-based strategy allows for patients to not require retesting prior to discharge. However, some receiving facilities (for example residential or skilled nursing facilities) may necessitate testing, in which case a testing-based strategy can be used. The Centers for Disease Control and Prevention provides guidelines for both types of strategies.⁴

 

2. Infection control and personal protective equipment: PCUs require modifications or departures from the typical inpatient free-ranging environment in which common areas are provided for patients to engage in a community of care, including group therapy (such as occupational, recreational, Alcoholics Anonymous, and social work groups).

• Isolation: PCUs must consider whether they will require patients to isolate to their rooms or to allow modified or limited access to “public” or “community” areas. While there do not appear to be standard recommendations from the CDC or other public health entities regarding negative pressure or any specific room ventilation requirements, it is prudent to work with local infectious disease experts on protocols. Important considerations include spatial planning for infection control areas to don and doff appropriate personal protective equipment (PPE) and appropriate workspace to prevent contamination of non–COVID-19 work areas. Approaches can include establishing clearly identified and visually demarcated infection control “zones” (often referred to as “hot, warm, and cold zones”) that correspond to specific PPE requirements for staff. In addition, individuals should eat in their own rooms or designated areas because use of common areas for meals can potentially lead to aerosolized spread of the virus.
• Cohorting: Generally, PCUs should consider admitting only COVID-19–positive patients to a PCU to avoid exposure to other patients. Hospitals and health systems should determine protocols and locations for testing and managing “patients under investigation” for COVID-19, which should precede admission to the PCU.
• PPE: It is important to clearly establish and communicate PPE requirements and procedures for direct physical contact versus no physical contact (for example, visual safety checks). Identify clear supply chains for PPE and hand sanitizer.

3. Medical management and consultation: PCUs should establish clear pathways for accessing consultation from medical consultants. It may be ideal, in addition to standard daily psychiatric physician rounding, to have daily internal medicine rounding and/or medical nursing staff working on the unit. Given the potential of COVID-19–positive patients to rapidly devolve from asymptomatic to acutely ill, it is necessary to establish protocols for the provision of urgent medical care 24/7 and streamlined processes for transfer to a medical unit.

Clear protocols should be established to address any potential signs of decompensation in the respiratory status of a PCU unit, including administration of oxygen and restrictions (or appropriate precautions) related to aerosolizing treatment such as nebulizers or positive airway pressure.

4. Code blue protocol: Any emergent medical issues, including acute respiratory decompensation, should trigger a Code Blue response that has been specifically designed for COVID-19–positive patients, including considerations for proper PPE during resuscitation efforts.

5. Psychiatric staffing and workflows: When possible, it may be preferable to engage volunteer medical and nursing staff for the PCU, as opposed to mandating participation. Take into consideration support needs, including education and training about safe PPE practices, processes for testing health care workers, return-to-work guidance, and potential alternate housing.

• Telehealth: Clinicians (such as physicians, social workers, occupational therapists) should leverage and maximize the use of telemedicine to minimize direct or prolonged exposure to infectious disease risks.
• Nursing: It is important to establish appropriate ratios of nursing and support staff for a COVID-19–positive psychiatry unit given the unique work flows related to isolation precautions and to ensure patient and staff safety. These ratios may take into account patient-specific needs, including the need for additional staff to perform constant observation for high-risk patients, management of agitated patients, and sufficient staff to allow for relief and break-time from PPE. Admission and routine care processes should be adapted in order to limit equipment entering the room, such as computer workstations on wheels.
• Medication administration procedures: Develop work flows related to PPE and infection control when retrieving and administering medications.
• Workspace: Designate appropriate workspace for PCU clinicians to access computers and documents and to minimize use of non–COVID-19 unit work areas.

 

6. Restraints and management of agitated patients: PCUs should develop plans for addressing agitated patients, including contingency plans for whether seclusion or restraints should be administered in the patient’s individual room or in a dedicated restraint room in the PCU. Staff training should include protocols specifically designed for managing agitated patients in the PCU.

7. Discharge processes: If patients remain medically well and clear their COVID-19 PCR tests, it is conceivable that they might be transferred to a non–COVID-19 psychiatric unit if sufficient isolation time has passed and the infectious disease consultants deem it appropriate. It is also possible that patients would be discharged from a PCU to home or other residential setting. Such patients should be assessed for ability to comply with continued self-quarantine if necessary. Discharge planning must take into consideration follow-up plans for COVID-19 illness and primary care appointments, as well as needed psychiatric follow-up.

8. Patients’ rights: The apparently highly infectious and transmissible nature of SARS-CoV-2 creates novel tensions between a wide range of individual rights and the rights of others. In addition to manifesting in our general society, there are potentially unique tensions in acute inpatient psychiatric settings. Certain patients’ rights may require modification in a PCU (for example, access to outdoor space, personal belongings, visitors, and possibly civil commitment judicial hearings). These discussions may require input from hospital compliance officers, ethics committees, risk managers, and the local department of mental health and also may be partly solved by using video communication platforms.

A few other “pearls” may be of value: Psychiatric hospitals that are colocated with a general acute care hospital or ED might be better situated to develop protocols to safely care for COVID-19–positive psychiatric patients, by virtue of the close proximity of full-spectrum acute general hospital services. Direct engagement by a command center and hospital or health system senior leadership also seems crucial as a means for assuring authorization to proceed with planning what may be a frightening or controversial (but necessary) adaptation of inpatient psychiatric unit(s) to the exigencies of the COVID-19 pandemic.

The resources of a robust community hospital or academic health system (including infection prevention leaders who engage in continuous liaison with local, county, state, and federal public health expertise) are crucial to the “learning health system” model, which requires flexibility, rapid adaptation to new knowledge, and accessibility to infectious disease and other consultation for special situations. Frequent and open communication with all professional stakeholders (through town halls, Q&A sessions, group discussions, and so on) is important in the planning process to socialize the principles and concepts that are critical for providing care in a PCU, reducing anxiety, and bolstering collegiality and staff morale.

References

1. Kim MJ. “ ‘It was a medical disaster’: The psychiatric ward that saw 100 patients with new coronavirus.” Independent. 2020 Mar 1.

2. Korean Society of Infectious Diseases et al. J Korean Med Sci. 2020 Mar 16;35(10):e112.

3. Centers for Disease Control and Prevention. Symptom-based strategy to discontinue isolation for persons with COVID-19. Decision Memo. 2020 May 3.

4. He X et al. Nature Medicine. 2020. 26:672-5.
 

Dr. Cheung is associate medical director and chief quality officer at the Stewart and Lynda Resnick Neuropsychiatric Hospital at the University of California, Los Angeles. He has no conflicts of interest. Dr. Strouse is medical director, UCLA Stewart and Lynda Resnick Neuropsychiatric Hospital and Maddie Katz Professor at the UCLA department of psychiatry/Semel Institute. He has no conflicts of interest. Dr. Li is associate medical director of quality improvement at Yale-New Haven Psychiatric Hospital in Connecticut. She also serves as medical director of clinical operations at the Yale-New Haven Health System. Dr. Li is a 2019-2020 Health and Aging Policy Fellow and receives funding support from the program.

Reports have emerged about the unique vulnerability of psychiatric hospitals to the ravages of COVID-19.

In a South Korea psychiatric hospital, 101 of 103 patients contracted SARS-CoV-2 during an outbreak; 7 eventually died.^1,2 This report, among a few others, have led to the development of psychiatric COVID-19–positive units (PCU). However, it remains highly unclear how many are currently open, where they are located, or what their operations are like.

Early in the COVID-19 pandemic, it became clear to us that, as a public health measure, it would be necessary to test all patients for COVID-19 who were being considered for admission to our inpatient psychiatric units. We knew that we could not allow a medically asymptomatic “covertly” COVID-19–positive patient to be introduced to the social community of our inpatient units because of the risks of transmission to other patients and staff.

In coordination with our health system infection prevention experts, we have therefore required a confirmed negative COVID-19 polymerase chain reaction nasal swab performed no more than 48 hours prior to the time/date of acute psychiatric inpatient admission. Furthermore, as part of the broad health system response and surge planning, we were asked by our respective incident command centers to begin planning for a Psychiatric COVID-19–positive Unit (PCU) that might allow us to safely care for a cohort of patients needing such hospitalization.

It is worth emphasizing that the typical patient who is a candidate for a PCU is so acutely psychiatrically ill that they cannot be managed in a less restrictive environment than an inpatient psychiatric unit and, at the same time, is likely to not be medically ill enough to warrant admission to an internal medicine service in a general acute care hospital.

We have identified eight principles and critical decision points that can help inpatient units plan for the safe care of COVID-19–positive patients on a PCU.

1. Triage: Patients admitted to a PCU should be medically stable, particularly with regard to COVID-19 and respiratory symptomatology. PCUs should establish clear criteria for admission and discharge (or medical transfer). Examples of potential exclusionary criteria to a PCU include:

• Respiratory distress, shortness of breath, hypoxia, requirement for supplemental oxygen, or requirement for respiratory therapy breathing treatments.
• Fever, or signs of sepsis, or systemic inflammatory response syndrome.
• Medical frailty, significant medical comorbidities, delirium, or altered mental status;
• Requirements for continuous vital sign monitoring or of a monitoring frequency beyond the capacity of the PCU.

Discharge criteria may also include a symptom-based strategy because emerging evidence suggests that patients may be less infectious by day 10-14 of the disease course,³ and viral lab testing is very sensitive and will be positive for periods of time after individuals are no longer infectious. The symptom-based strategy allows for patients to not require retesting prior to discharge. However, some receiving facilities (for example residential or skilled nursing facilities) may necessitate testing, in which case a testing-based strategy can be used. The Centers for Disease Control and Prevention provides guidelines for both types of strategies.⁴

 

2. Infection control and personal protective equipment: PCUs require modifications or departures from the typical inpatient free-ranging environment in which common areas are provided for patients to engage in a community of care, including group therapy (such as occupational, recreational, Alcoholics Anonymous, and social work groups).

• Isolation: PCUs must consider whether they will require patients to isolate to their rooms or to allow modified or limited access to “public” or “community” areas. While there do not appear to be standard recommendations from the CDC or other public health entities regarding negative pressure or any specific room ventilation requirements, it is prudent to work with local infectious disease experts on protocols. Important considerations include spatial planning for infection control areas to don and doff appropriate personal protective equipment (PPE) and appropriate workspace to prevent contamination of non–COVID-19 work areas. Approaches can include establishing clearly identified and visually demarcated infection control “zones” (often referred to as “hot, warm, and cold zones”) that correspond to specific PPE requirements for staff. In addition, individuals should eat in their own rooms or designated areas because use of common areas for meals can potentially lead to aerosolized spread of the virus.
• Cohorting: Generally, PCUs should consider admitting only COVID-19–positive patients to a PCU to avoid exposure to other patients. Hospitals and health systems should determine protocols and locations for testing and managing “patients under investigation” for COVID-19, which should precede admission to the PCU.
• PPE: It is important to clearly establish and communicate PPE requirements and procedures for direct physical contact versus no physical contact (for example, visual safety checks). Identify clear supply chains for PPE and hand sanitizer.

3. Medical management and consultation: PCUs should establish clear pathways for accessing consultation from medical consultants. It may be ideal, in addition to standard daily psychiatric physician rounding, to have daily internal medicine rounding and/or medical nursing staff working on the unit. Given the potential of COVID-19–positive patients to rapidly devolve from asymptomatic to acutely ill, it is necessary to establish protocols for the provision of urgent medical care 24/7 and streamlined processes for transfer to a medical unit.

Clear protocols should be established to address any potential signs of decompensation in the respiratory status of a PCU unit, including administration of oxygen and restrictions (or appropriate precautions) related to aerosolizing treatment such as nebulizers or positive airway pressure.

4. Code blue protocol: Any emergent medical issues, including acute respiratory decompensation, should trigger a Code Blue response that has been specifically designed for COVID-19–positive patients, including considerations for proper PPE during resuscitation efforts.

5. Psychiatric staffing and workflows: When possible, it may be preferable to engage volunteer medical and nursing staff for the PCU, as opposed to mandating participation. Take into consideration support needs, including education and training about safe PPE practices, processes for testing health care workers, return-to-work guidance, and potential alternate housing.

• Telehealth: Clinicians (such as physicians, social workers, occupational therapists) should leverage and maximize the use of telemedicine to minimize direct or prolonged exposure to infectious disease risks.
• Nursing: It is important to establish appropriate ratios of nursing and support staff for a COVID-19–positive psychiatry unit given the unique work flows related to isolation precautions and to ensure patient and staff safety. These ratios may take into account patient-specific needs, including the need for additional staff to perform constant observation for high-risk patients, management of agitated patients, and sufficient staff to allow for relief and break-time from PPE. Admission and routine care processes should be adapted in order to limit equipment entering the room, such as computer workstations on wheels.
• Medication administration procedures: Develop work flows related to PPE and infection control when retrieving and administering medications.
• Workspace: Designate appropriate workspace for PCU clinicians to access computers and documents and to minimize use of non–COVID-19 unit work areas.

 

6. Restraints and management of agitated patients: PCUs should develop plans for addressing agitated patients, including contingency plans for whether seclusion or restraints should be administered in the patient’s individual room or in a dedicated restraint room in the PCU. Staff training should include protocols specifically designed for managing agitated patients in the PCU.

7. Discharge processes: If patients remain medically well and clear their COVID-19 PCR tests, it is conceivable that they might be transferred to a non–COVID-19 psychiatric unit if sufficient isolation time has passed and the infectious disease consultants deem it appropriate. It is also possible that patients would be discharged from a PCU to home or other residential setting. Such patients should be assessed for ability to comply with continued self-quarantine if necessary. Discharge planning must take into consideration follow-up plans for COVID-19 illness and primary care appointments, as well as needed psychiatric follow-up.

8. Patients’ rights: The apparently highly infectious and transmissible nature of SARS-CoV-2 creates novel tensions between a wide range of individual rights and the rights of others. In addition to manifesting in our general society, there are potentially unique tensions in acute inpatient psychiatric settings. Certain patients’ rights may require modification in a PCU (for example, access to outdoor space, personal belongings, visitors, and possibly civil commitment judicial hearings). These discussions may require input from hospital compliance officers, ethics committees, risk managers, and the local department of mental health and also may be partly solved by using video communication platforms.

A few other “pearls” may be of value: Psychiatric hospitals that are colocated with a general acute care hospital or ED might be better situated to develop protocols to safely care for COVID-19–positive psychiatric patients, by virtue of the close proximity of full-spectrum acute general hospital services. Direct engagement by a command center and hospital or health system senior leadership also seems crucial as a means for assuring authorization to proceed with planning what may be a frightening or controversial (but necessary) adaptation of inpatient psychiatric unit(s) to the exigencies of the COVID-19 pandemic.

The resources of a robust community hospital or academic health system (including infection prevention leaders who engage in continuous liaison with local, county, state, and federal public health expertise) are crucial to the “learning health system” model, which requires flexibility, rapid adaptation to new knowledge, and accessibility to infectious disease and other consultation for special situations. Frequent and open communication with all professional stakeholders (through town halls, Q&A sessions, group discussions, and so on) is important in the planning process to socialize the principles and concepts that are critical for providing care in a PCU, reducing anxiety, and bolstering collegiality and staff morale.

References

1. Kim MJ. “ ‘It was a medical disaster’: The psychiatric ward that saw 100 patients with new coronavirus.” Independent. 2020 Mar 1.

2. Korean Society of Infectious Diseases et al. J Korean Med Sci. 2020 Mar 16;35(10):e112.

3. Centers for Disease Control and Prevention. Symptom-based strategy to discontinue isolation for persons with COVID-19. Decision Memo. 2020 May 3.

4. He X et al. Nature Medicine. 2020. 26:672-5.
 

Dr. Cheung is associate medical director and chief quality officer at the Stewart and Lynda Resnick Neuropsychiatric Hospital at the University of California, Los Angeles. He has no conflicts of interest. Dr. Strouse is medical director, UCLA Stewart and Lynda Resnick Neuropsychiatric Hospital and Maddie Katz Professor at the UCLA department of psychiatry/Semel Institute. He has no conflicts of interest. Dr. Li is associate medical director of quality improvement at Yale-New Haven Psychiatric Hospital in Connecticut. She also serves as medical director of clinical operations at the Yale-New Haven Health System. Dr. Li is a 2019-2020 Health and Aging Policy Fellow and receives funding support from the program.

Reports have emerged about the unique vulnerability of psychiatric hospitals to the ravages of COVID-19.

In a South Korea psychiatric hospital, 101 of 103 patients contracted SARS-CoV-2 during an outbreak; 7 eventually died.^1,2 This report, among a few others, have led to the development of psychiatric COVID-19–positive units (PCU). However, it remains highly unclear how many are currently open, where they are located, or what their operations are like.

Early in the COVID-19 pandemic, it became clear to us that, as a public health measure, it would be necessary to test all patients for COVID-19 who were being considered for admission to our inpatient psychiatric units. We knew that we could not allow a medically asymptomatic “covertly” COVID-19–positive patient to be introduced to the social community of our inpatient units because of the risks of transmission to other patients and staff.

In coordination with our health system infection prevention experts, we have therefore required a confirmed negative COVID-19 polymerase chain reaction nasal swab performed no more than 48 hours prior to the time/date of acute psychiatric inpatient admission. Furthermore, as part of the broad health system response and surge planning, we were asked by our respective incident command centers to begin planning for a Psychiatric COVID-19–positive Unit (PCU) that might allow us to safely care for a cohort of patients needing such hospitalization.

It is worth emphasizing that the typical patient who is a candidate for a PCU is so acutely psychiatrically ill that they cannot be managed in a less restrictive environment than an inpatient psychiatric unit and, at the same time, is likely to not be medically ill enough to warrant admission to an internal medicine service in a general acute care hospital.

We have identified eight principles and critical decision points that can help inpatient units plan for the safe care of COVID-19–positive patients on a PCU.

1. Triage: Patients admitted to a PCU should be medically stable, particularly with regard to COVID-19 and respiratory symptomatology. PCUs should establish clear criteria for admission and discharge (or medical transfer). Examples of potential exclusionary criteria to a PCU include:

• Respiratory distress, shortness of breath, hypoxia, requirement for supplemental oxygen, or requirement for respiratory therapy breathing treatments.
• Fever, or signs of sepsis, or systemic inflammatory response syndrome.
• Medical frailty, significant medical comorbidities, delirium, or altered mental status;
• Requirements for continuous vital sign monitoring or of a monitoring frequency beyond the capacity of the PCU.

Discharge criteria may also include a symptom-based strategy because emerging evidence suggests that patients may be less infectious by day 10-14 of the disease course,³ and viral lab testing is very sensitive and will be positive for periods of time after individuals are no longer infectious. The symptom-based strategy allows for patients to not require retesting prior to discharge. However, some receiving facilities (for example residential or skilled nursing facilities) may necessitate testing, in which case a testing-based strategy can be used. The Centers for Disease Control and Prevention provides guidelines for both types of strategies.⁴

 

2. Infection control and personal protective equipment: PCUs require modifications or departures from the typical inpatient free-ranging environment in which common areas are provided for patients to engage in a community of care, including group therapy (such as occupational, recreational, Alcoholics Anonymous, and social work groups).

• Isolation: PCUs must consider whether they will require patients to isolate to their rooms or to allow modified or limited access to “public” or “community” areas. While there do not appear to be standard recommendations from the CDC or other public health entities regarding negative pressure or any specific room ventilation requirements, it is prudent to work with local infectious disease experts on protocols. Important considerations include spatial planning for infection control areas to don and doff appropriate personal protective equipment (PPE) and appropriate workspace to prevent contamination of non–COVID-19 work areas. Approaches can include establishing clearly identified and visually demarcated infection control “zones” (often referred to as “hot, warm, and cold zones”) that correspond to specific PPE requirements for staff. In addition, individuals should eat in their own rooms or designated areas because use of common areas for meals can potentially lead to aerosolized spread of the virus.
• Cohorting: Generally, PCUs should consider admitting only COVID-19–positive patients to a PCU to avoid exposure to other patients. Hospitals and health systems should determine protocols and locations for testing and managing “patients under investigation” for COVID-19, which should precede admission to the PCU.
• PPE: It is important to clearly establish and communicate PPE requirements and procedures for direct physical contact versus no physical contact (for example, visual safety checks). Identify clear supply chains for PPE and hand sanitizer.

3. Medical management and consultation: PCUs should establish clear pathways for accessing consultation from medical consultants. It may be ideal, in addition to standard daily psychiatric physician rounding, to have daily internal medicine rounding and/or medical nursing staff working on the unit. Given the potential of COVID-19–positive patients to rapidly devolve from asymptomatic to acutely ill, it is necessary to establish protocols for the provision of urgent medical care 24/7 and streamlined processes for transfer to a medical unit.

Clear protocols should be established to address any potential signs of decompensation in the respiratory status of a PCU unit, including administration of oxygen and restrictions (or appropriate precautions) related to aerosolizing treatment such as nebulizers or positive airway pressure.

4. Code blue protocol: Any emergent medical issues, including acute respiratory decompensation, should trigger a Code Blue response that has been specifically designed for COVID-19–positive patients, including considerations for proper PPE during resuscitation efforts.

5. Psychiatric staffing and workflows: When possible, it may be preferable to engage volunteer medical and nursing staff for the PCU, as opposed to mandating participation. Take into consideration support needs, including education and training about safe PPE practices, processes for testing health care workers, return-to-work guidance, and potential alternate housing.

• Telehealth: Clinicians (such as physicians, social workers, occupational therapists) should leverage and maximize the use of telemedicine to minimize direct or prolonged exposure to infectious disease risks.
• Nursing: It is important to establish appropriate ratios of nursing and support staff for a COVID-19–positive psychiatry unit given the unique work flows related to isolation precautions and to ensure patient and staff safety. These ratios may take into account patient-specific needs, including the need for additional staff to perform constant observation for high-risk patients, management of agitated patients, and sufficient staff to allow for relief and break-time from PPE. Admission and routine care processes should be adapted in order to limit equipment entering the room, such as computer workstations on wheels.
• Medication administration procedures: Develop work flows related to PPE and infection control when retrieving and administering medications.
• Workspace: Designate appropriate workspace for PCU clinicians to access computers and documents and to minimize use of non–COVID-19 unit work areas.

 

6. Restraints and management of agitated patients: PCUs should develop plans for addressing agitated patients, including contingency plans for whether seclusion or restraints should be administered in the patient’s individual room or in a dedicated restraint room in the PCU. Staff training should include protocols specifically designed for managing agitated patients in the PCU.

7. Discharge processes: If patients remain medically well and clear their COVID-19 PCR tests, it is conceivable that they might be transferred to a non–COVID-19 psychiatric unit if sufficient isolation time has passed and the infectious disease consultants deem it appropriate. It is also possible that patients would be discharged from a PCU to home or other residential setting. Such patients should be assessed for ability to comply with continued self-quarantine if necessary. Discharge planning must take into consideration follow-up plans for COVID-19 illness and primary care appointments, as well as needed psychiatric follow-up.

8. Patients’ rights: The apparently highly infectious and transmissible nature of SARS-CoV-2 creates novel tensions between a wide range of individual rights and the rights of others. In addition to manifesting in our general society, there are potentially unique tensions in acute inpatient psychiatric settings. Certain patients’ rights may require modification in a PCU (for example, access to outdoor space, personal belongings, visitors, and possibly civil commitment judicial hearings). These discussions may require input from hospital compliance officers, ethics committees, risk managers, and the local department of mental health and also may be partly solved by using video communication platforms.

A few other “pearls” may be of value: Psychiatric hospitals that are colocated with a general acute care hospital or ED might be better situated to develop protocols to safely care for COVID-19–positive psychiatric patients, by virtue of the close proximity of full-spectrum acute general hospital services. Direct engagement by a command center and hospital or health system senior leadership also seems crucial as a means for assuring authorization to proceed with planning what may be a frightening or controversial (but necessary) adaptation of inpatient psychiatric unit(s) to the exigencies of the COVID-19 pandemic.

The resources of a robust community hospital or academic health system (including infection prevention leaders who engage in continuous liaison with local, county, state, and federal public health expertise) are crucial to the “learning health system” model, which requires flexibility, rapid adaptation to new knowledge, and accessibility to infectious disease and other consultation for special situations. Frequent and open communication with all professional stakeholders (through town halls, Q&A sessions, group discussions, and so on) is important in the planning process to socialize the principles and concepts that are critical for providing care in a PCU, reducing anxiety, and bolstering collegiality and staff morale.

References

1. Kim MJ. “ ‘It was a medical disaster’: The psychiatric ward that saw 100 patients with new coronavirus.” Independent. 2020 Mar 1.

2. Korean Society of Infectious Diseases et al. J Korean Med Sci. 2020 Mar 16;35(10):e112.

3. Centers for Disease Control and Prevention. Symptom-based strategy to discontinue isolation for persons with COVID-19. Decision Memo. 2020 May 3.

4. He X et al. Nature Medicine. 2020. 26:672-5.
 

Dr. Cheung is associate medical director and chief quality officer at the Stewart and Lynda Resnick Neuropsychiatric Hospital at the University of California, Los Angeles. He has no conflicts of interest. Dr. Strouse is medical director, UCLA Stewart and Lynda Resnick Neuropsychiatric Hospital and Maddie Katz Professor at the UCLA department of psychiatry/Semel Institute. He has no conflicts of interest. Dr. Li is associate medical director of quality improvement at Yale-New Haven Psychiatric Hospital in Connecticut. She also serves as medical director of clinical operations at the Yale-New Haven Health System. Dr. Li is a 2019-2020 Health and Aging Policy Fellow and receives funding support from the program.

Protective measures recommended for cosmetic procedures have recently been published by Dover et al. in Facial Plastic Surgery & Aesthetic Medicine. The manuscript, titled “A path to resume aesthetic care Project AesCert Guidance Supplement – practical considerations for aesthetic medicine professionals supporting clinic preparedness in response to the SARS-CoV-2 outbreak,” provides thorough, detailed recommendations on all aspects of protection and preparedness for aesthetic clinical practices.

While health care offices, professional organizations, and governmental agencies come up with the optimal plans and protocols to keep patients, staff, and communities safe from COVID-19, specific guidelines for laser surgeries have been difficult to discern in this uncharted territory. During the last pandemic, the 1918 Spanish flu, caused by an H1N1 virus, laser procedures didn’t exist. Discussion among dermatologists and laser surgeons, including the aforementioned publication, have led to the following initial office recommendations (subject to change).

Office preparation and safety including:

• Prescreening patients for symptoms.
• Social distancing in the office, including waiting room areas (or eliminating waiting areas and bringing patients into exam rooms upon arrival).
• Decreasing patient load and increasing length of appointment times.
• Having no additional visitors during patient appointments, unless necessary (minor, caregiver).
• Patients wearing masks to appointments and hand washing/sanitizing upon arrival/departure.
• Providers wearing appropriate personal protective equipment (PPE) during visits.
• Instituting office disinfectant checklists.

For nonablative laser surgery specifically, especially for therapy of the face and neck, recommendations include the following:

• Lasers and office areas are thoroughly sanitized between each procedure.
• Providers wear appropriate PPE, including N95 masks if possible, wraparound safety glasses, gloves, as well as strong consideration of face shields).
• The duration and number of procedures should be limited, as should intraprocedure conversations and close face-to-face proximity with patient’s airways.
• Lasers with increased plume, including laser tattoo removal and laser hair removal, are the procedures with the most concern with regards to viral particle or infection transmission.

PPE is recommended (including masks – N95 if available – gloves, and face shield), as well as evacuator suction systems of the two-stage filtration type, and/or negative room pressure if available. For air-filtration evacuator suction systems, the device vacuum must be held within 2 inches of the treatment area for the best efficacy. Some have suggested performing laser tattoo removal through a hydrogel patch to help eliminate plume, which may also increase the cost of the procedure and may depend on the availability of the patches themselves. Nothing has been published on the use of the hydrogel patch in laser hair removal. Shaving or trimming of hairs prior to the procedure is critical.

While pulse dye and intense pulsed light (IPL) lasers have generally been deemed safer to use during the COVID-19 pandemic – with appropriate protective gear and general office precautions – I would recommend being mindful of potential plume created when using these lasers in hair-bearing areas. IPL is generally avoided in these regions, unless specific filters are used for hair removal treatment. But if use an IPL in a hair-bearing region, shaving or trimming of the hairs with the above precautions should be done first to reduce plume. As with all face-to-face procedures, the above PPE, contact, and intraprocedure conversation precautions should be taken.

Nonablative fractional resurfacing lasers are areas in which more questions lie. Some providers are comfortable performing nonablative fractional lasers with protective gear and air filtration systems, while others are recommending delaying these procedures until more information is available. The question essentially involves whether infection risk is higher with these procedures because of plume and if depth of penetration of the laser can release viral particles.

In addition to the other precautions above, with the high transmissibility of COVID-19, I would recommend considering precleansing the treatment area with soap and water or a sterile prep that won’t irritate the skin, which has activity against coronaviruses. A study by Kampf et al. demonstrated that coronaviruses can persist on surfaces such as metal, glass, or plastic for up to 9 days (human skin surface unknown) but can be effectively inactivated by surface disinfection procedures with 62%-71% ethanol, 0.5% hydrogen peroxide, or 0.1% sodium hypochlorite within 1 minute. Other biocidal agents that may be more tolerable on the skin surface, such as 0.05%-0.2% benzalkonium chloride or 0.02% chlorhexidine digluconate were less effective. Washing the face with soap and water may be the most tolerated and easiest cleansing method. Face-to-face respiratory transmission should be mitigated by the aforementioned methods.

 

Ablative laser surgery

Most laser surgeons agree that ablative laser surgery procedures should likely be delayed until the virus has waned more, because of the increased invasiveness of and recovery of wound healing from the procedure. There is increased evidence of SARS-CoV-2 infecting endothelial cells, raising concern about transmission via blood. A study of the cardiovascular manifestations seen in COVID-19 infection, published in The Lancet, showed the virus directly targets the endothelial cells that line blood vessels. Ablative laser surgery (fractional and fully ablative) is associated with blood or serous fluid on the skin surface immediately after the procedure and for up to 5-7 days post procedure, particularly with Er:Yag than with the CO₂ laser. Antibacterial and antiviral prophylaxis often is used with these procedures. While the aforementioned protocols for other nonablative lasers may help with ablative laser treatment, there is currently no known effective and available antiviral prophylactic medication against SARS-CoV-2, if needed.

PPE

HRAUN/E+

Personal protective equipment shortages are still a concern. Many hospitals are sterilizing and reusing traditionally disposable N95 masks in the inpatient setting, which is unprecedented. Resterilization will likely be necessary in outpatient medical offices as well, if the supply of masks does not increase. The supply chain will be a factor in considering PPE use in outpatient offices affecting the availability of PPE for emergency medicine, inpatient hospital, and ICU providers in direct contact with known COVID-19 patients.

With asymptomatic spread and the lack of adequate testing for COVID-19, as practices reopen, all practitioners will be on the front lines and should treat their practice and protect their patients, staff and themselves as such.
 

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They have no relevant disclosures.

References:

Dover JS et al. Facial Plast Surg Aesthet Med. 2020 May 5. doi: 10.1089/fpsam.2020.0239.

Kampf G et al. J Hosp Infect. 2020 Mar;104(3):246-51.

Varga Z et al. Lancet. 2020 May 2;395(10234):1417-8.

Protective measures recommended for cosmetic procedures have recently been published by Dover et al. in Facial Plastic Surgery & Aesthetic Medicine. The manuscript, titled “A path to resume aesthetic care Project AesCert Guidance Supplement – practical considerations for aesthetic medicine professionals supporting clinic preparedness in response to the SARS-CoV-2 outbreak,” provides thorough, detailed recommendations on all aspects of protection and preparedness for aesthetic clinical practices.

While health care offices, professional organizations, and governmental agencies come up with the optimal plans and protocols to keep patients, staff, and communities safe from COVID-19, specific guidelines for laser surgeries have been difficult to discern in this uncharted territory. During the last pandemic, the 1918 Spanish flu, caused by an H1N1 virus, laser procedures didn’t exist. Discussion among dermatologists and laser surgeons, including the aforementioned publication, have led to the following initial office recommendations (subject to change).

Office preparation and safety including:

• Prescreening patients for symptoms.
• Social distancing in the office, including waiting room areas (or eliminating waiting areas and bringing patients into exam rooms upon arrival).
• Decreasing patient load and increasing length of appointment times.
• Having no additional visitors during patient appointments, unless necessary (minor, caregiver).
• Patients wearing masks to appointments and hand washing/sanitizing upon arrival/departure.
• Providers wearing appropriate personal protective equipment (PPE) during visits.
• Instituting office disinfectant checklists.

For nonablative laser surgery specifically, especially for therapy of the face and neck, recommendations include the following:

• Lasers and office areas are thoroughly sanitized between each procedure.
• Providers wear appropriate PPE, including N95 masks if possible, wraparound safety glasses, gloves, as well as strong consideration of face shields).
• The duration and number of procedures should be limited, as should intraprocedure conversations and close face-to-face proximity with patient’s airways.
• Lasers with increased plume, including laser tattoo removal and laser hair removal, are the procedures with the most concern with regards to viral particle or infection transmission.

PPE is recommended (including masks – N95 if available – gloves, and face shield), as well as evacuator suction systems of the two-stage filtration type, and/or negative room pressure if available. For air-filtration evacuator suction systems, the device vacuum must be held within 2 inches of the treatment area for the best efficacy. Some have suggested performing laser tattoo removal through a hydrogel patch to help eliminate plume, which may also increase the cost of the procedure and may depend on the availability of the patches themselves. Nothing has been published on the use of the hydrogel patch in laser hair removal. Shaving or trimming of hairs prior to the procedure is critical.

While pulse dye and intense pulsed light (IPL) lasers have generally been deemed safer to use during the COVID-19 pandemic – with appropriate protective gear and general office precautions – I would recommend being mindful of potential plume created when using these lasers in hair-bearing areas. IPL is generally avoided in these regions, unless specific filters are used for hair removal treatment. But if use an IPL in a hair-bearing region, shaving or trimming of the hairs with the above precautions should be done first to reduce plume. As with all face-to-face procedures, the above PPE, contact, and intraprocedure conversation precautions should be taken.

Nonablative fractional resurfacing lasers are areas in which more questions lie. Some providers are comfortable performing nonablative fractional lasers with protective gear and air filtration systems, while others are recommending delaying these procedures until more information is available. The question essentially involves whether infection risk is higher with these procedures because of plume and if depth of penetration of the laser can release viral particles.

In addition to the other precautions above, with the high transmissibility of COVID-19, I would recommend considering precleansing the treatment area with soap and water or a sterile prep that won’t irritate the skin, which has activity against coronaviruses. A study by Kampf et al. demonstrated that coronaviruses can persist on surfaces such as metal, glass, or plastic for up to 9 days (human skin surface unknown) but can be effectively inactivated by surface disinfection procedures with 62%-71% ethanol, 0.5% hydrogen peroxide, or 0.1% sodium hypochlorite within 1 minute. Other biocidal agents that may be more tolerable on the skin surface, such as 0.05%-0.2% benzalkonium chloride or 0.02% chlorhexidine digluconate were less effective. Washing the face with soap and water may be the most tolerated and easiest cleansing method. Face-to-face respiratory transmission should be mitigated by the aforementioned methods.

 

Ablative laser surgery

Most laser surgeons agree that ablative laser surgery procedures should likely be delayed until the virus has waned more, because of the increased invasiveness of and recovery of wound healing from the procedure. There is increased evidence of SARS-CoV-2 infecting endothelial cells, raising concern about transmission via blood. A study of the cardiovascular manifestations seen in COVID-19 infection, published in The Lancet, showed the virus directly targets the endothelial cells that line blood vessels. Ablative laser surgery (fractional and fully ablative) is associated with blood or serous fluid on the skin surface immediately after the procedure and for up to 5-7 days post procedure, particularly with Er:Yag than with the CO₂ laser. Antibacterial and antiviral prophylaxis often is used with these procedures. While the aforementioned protocols for other nonablative lasers may help with ablative laser treatment, there is currently no known effective and available antiviral prophylactic medication against SARS-CoV-2, if needed.

PPE

HRAUN/E+

Personal protective equipment shortages are still a concern. Many hospitals are sterilizing and reusing traditionally disposable N95 masks in the inpatient setting, which is unprecedented. Resterilization will likely be necessary in outpatient medical offices as well, if the supply of masks does not increase. The supply chain will be a factor in considering PPE use in outpatient offices affecting the availability of PPE for emergency medicine, inpatient hospital, and ICU providers in direct contact with known COVID-19 patients.

With asymptomatic spread and the lack of adequate testing for COVID-19, as practices reopen, all practitioners will be on the front lines and should treat their practice and protect their patients, staff and themselves as such.
 

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They have no relevant disclosures.

References:

Dover JS et al. Facial Plast Surg Aesthet Med. 2020 May 5. doi: 10.1089/fpsam.2020.0239.

Kampf G et al. J Hosp Infect. 2020 Mar;104(3):246-51.

Varga Z et al. Lancet. 2020 May 2;395(10234):1417-8.

Protective measures recommended for cosmetic procedures have recently been published by Dover et al. in Facial Plastic Surgery & Aesthetic Medicine. The manuscript, titled “A path to resume aesthetic care Project AesCert Guidance Supplement – practical considerations for aesthetic medicine professionals supporting clinic preparedness in response to the SARS-CoV-2 outbreak,” provides thorough, detailed recommendations on all aspects of protection and preparedness for aesthetic clinical practices.

While health care offices, professional organizations, and governmental agencies come up with the optimal plans and protocols to keep patients, staff, and communities safe from COVID-19, specific guidelines for laser surgeries have been difficult to discern in this uncharted territory. During the last pandemic, the 1918 Spanish flu, caused by an H1N1 virus, laser procedures didn’t exist. Discussion among dermatologists and laser surgeons, including the aforementioned publication, have led to the following initial office recommendations (subject to change).

Office preparation and safety including:

• Prescreening patients for symptoms.
• Social distancing in the office, including waiting room areas (or eliminating waiting areas and bringing patients into exam rooms upon arrival).
• Decreasing patient load and increasing length of appointment times.
• Having no additional visitors during patient appointments, unless necessary (minor, caregiver).
• Patients wearing masks to appointments and hand washing/sanitizing upon arrival/departure.
• Providers wearing appropriate personal protective equipment (PPE) during visits.
• Instituting office disinfectant checklists.

For nonablative laser surgery specifically, especially for therapy of the face and neck, recommendations include the following:

• Lasers and office areas are thoroughly sanitized between each procedure.
• Providers wear appropriate PPE, including N95 masks if possible, wraparound safety glasses, gloves, as well as strong consideration of face shields).
• The duration and number of procedures should be limited, as should intraprocedure conversations and close face-to-face proximity with patient’s airways.
• Lasers with increased plume, including laser tattoo removal and laser hair removal, are the procedures with the most concern with regards to viral particle or infection transmission.

PPE is recommended (including masks – N95 if available – gloves, and face shield), as well as evacuator suction systems of the two-stage filtration type, and/or negative room pressure if available. For air-filtration evacuator suction systems, the device vacuum must be held within 2 inches of the treatment area for the best efficacy. Some have suggested performing laser tattoo removal through a hydrogel patch to help eliminate plume, which may also increase the cost of the procedure and may depend on the availability of the patches themselves. Nothing has been published on the use of the hydrogel patch in laser hair removal. Shaving or trimming of hairs prior to the procedure is critical.

While pulse dye and intense pulsed light (IPL) lasers have generally been deemed safer to use during the COVID-19 pandemic – with appropriate protective gear and general office precautions – I would recommend being mindful of potential plume created when using these lasers in hair-bearing areas. IPL is generally avoided in these regions, unless specific filters are used for hair removal treatment. But if use an IPL in a hair-bearing region, shaving or trimming of the hairs with the above precautions should be done first to reduce plume. As with all face-to-face procedures, the above PPE, contact, and intraprocedure conversation precautions should be taken.

Nonablative fractional resurfacing lasers are areas in which more questions lie. Some providers are comfortable performing nonablative fractional lasers with protective gear and air filtration systems, while others are recommending delaying these procedures until more information is available. The question essentially involves whether infection risk is higher with these procedures because of plume and if depth of penetration of the laser can release viral particles.

In addition to the other precautions above, with the high transmissibility of COVID-19, I would recommend considering precleansing the treatment area with soap and water or a sterile prep that won’t irritate the skin, which has activity against coronaviruses. A study by Kampf et al. demonstrated that coronaviruses can persist on surfaces such as metal, glass, or plastic for up to 9 days (human skin surface unknown) but can be effectively inactivated by surface disinfection procedures with 62%-71% ethanol, 0.5% hydrogen peroxide, or 0.1% sodium hypochlorite within 1 minute. Other biocidal agents that may be more tolerable on the skin surface, such as 0.05%-0.2% benzalkonium chloride or 0.02% chlorhexidine digluconate were less effective. Washing the face with soap and water may be the most tolerated and easiest cleansing method. Face-to-face respiratory transmission should be mitigated by the aforementioned methods.

 

Ablative laser surgery

Most laser surgeons agree that ablative laser surgery procedures should likely be delayed until the virus has waned more, because of the increased invasiveness of and recovery of wound healing from the procedure. There is increased evidence of SARS-CoV-2 infecting endothelial cells, raising concern about transmission via blood. A study of the cardiovascular manifestations seen in COVID-19 infection, published in The Lancet, showed the virus directly targets the endothelial cells that line blood vessels. Ablative laser surgery (fractional and fully ablative) is associated with blood or serous fluid on the skin surface immediately after the procedure and for up to 5-7 days post procedure, particularly with Er:Yag than with the CO₂ laser. Antibacterial and antiviral prophylaxis often is used with these procedures. While the aforementioned protocols for other nonablative lasers may help with ablative laser treatment, there is currently no known effective and available antiviral prophylactic medication against SARS-CoV-2, if needed.

PPE

HRAUN/E+

Personal protective equipment shortages are still a concern. Many hospitals are sterilizing and reusing traditionally disposable N95 masks in the inpatient setting, which is unprecedented. Resterilization will likely be necessary in outpatient medical offices as well, if the supply of masks does not increase. The supply chain will be a factor in considering PPE use in outpatient offices affecting the availability of PPE for emergency medicine, inpatient hospital, and ICU providers in direct contact with known COVID-19 patients.

With asymptomatic spread and the lack of adequate testing for COVID-19, as practices reopen, all practitioners will be on the front lines and should treat their practice and protect their patients, staff and themselves as such.
 

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They have no relevant disclosures.

References:

Dover JS et al. Facial Plast Surg Aesthet Med. 2020 May 5. doi: 10.1089/fpsam.2020.0239.

Kampf G et al. J Hosp Infect. 2020 Mar;104(3):246-51.

Varga Z et al. Lancet. 2020 May 2;395(10234):1417-8.

Each day, we’re inundated with news about the COVID-19 pandemic and how it continues to strain our health care system and resources. With more than 1.15 million positive cases in the United States and over 67,000 deaths as of this writing, it has been a scary yet humbling experience for everyone. There is no doubt this pandemic will be a defining moment in health care for several reasons. From supply chain disruptions and personal protective equipment (PPE) and ventilator shortages to exhausted caregivers – both physically and mentally – this event has pushed the envelope on finding answers from federal and state authorities. Hospital administrations are working harder than ever to rise to the challenge and do what is best for their frontline staff and, more importantly, the patients and the communities they serve.

The provider experience during COVID-19

Hospitalists are in a unique situation as frontline providers. Managing daily throughput of patients has always been a key role for the specialty. They also play an integral role in their own care teams alongside nurses, trainees, case managers, pharmacists, and others in cohorted COVID-19 units. Now more than ever, such a geographic placement of patients is quickly emerging as a must-have staffing model to reduce risk of cross-contamination and preserving critical PPE supplies. This heightened awareness, coupled with anxiety, sometimes leads to added stress and burnout risk for hospitalists.

Communication is critical in creating situational awareness and reducing anxiety within the teams. This is exactly where hospitalists can lead:

• Active presence in hospital incident command centers and infection control boards
• Close coordination with emergency medicine colleagues and bed placement navigators
• Developing protocols for appropriate testing
• Frequent daily huddles to discuss current state- and hospital-level testing guidelines
• Close involvement in the hospital operations committee
• Advocating for or securing more testing or supplies, especially PPE
• Effective communication about changes in PPE requirements and conservation strategies as per the Centers for Disease Control and Prevention, State Department of Health, and the hospital infection control board
• Crisis-driven changes, including development and review of triage and treatment protocols and elective procedure cancellations
• Census numbers and capacity/staffing adjustments within the team to meet temporary dips and surges in on-service patient volumes
• Frontline caregiver mental and physical health assessment

Daily huddles at key times (e.g., at shift start and end times) can help to identify these barriers. If operational issues arise, there should be a clear channel to escalate them to senior leadership.

Hospitalists could also use several strategies proven to improve staff morale and resilience. For instance, take this time to connect with friends and family virtually, unplug when off from work, explore one’s spiritual self through meditation and prayers, spend time with nature, exercise daily, seek humor, and develop or work on one’s hobby.
 

 

The patient experience during COVID-19

Some intriguing data is also being released about patient experience during the pandemic. A Press Ganey analysis of 350,000 comments between January and March 2020 shows that patients are looking for more information about their condition, primarily COVID-19 test delays and result notification time. There is also hypervigilance in patients’ minds about hand hygiene and overall cleanliness of the hospital. Patients also seek clarification and transparent explanation of their caregiver’s bedside mannerisms – for example, why did they gown up before entering – and their daily care plans.

Patients have been appreciative of providers and recognize the personal risk frontline staff put themselves through. Communication transparency seems to mitigate concerns about delays of care especially caused by operational challenges as a result of the pandemic.

In surveys specifically related to experiences including COVID-19, patients were more likely to rate more areas of service lower than in surveys that did not mention COVID-19. The patients also seemed to put more value on the quality of instructions and information they received and on perception of providers’ respect and listening abilities. These insights could prove invaluable in improving care delivery by hospitalists.

Isolation of patients has been shown in multiple studies to have negative outcomes. These patients are up to twice as likely to have an adverse event, and seven times more likely to have treatment-related avoidable adversity, poorer perceived patient experience, and overall perception of being cared for “less.” Add to this a higher level of depression and mental strain, and these patients quickly become “unsatisfied.”

At the ED level, the willingness to let family be present for care was the key area of concern listed – a metric that has changed rapidly since the early days of the pandemic.

The bottom line is these are trying times for everyone – both for providers and patients. Both look up to health system and group leadership for reassurance. Patients and families recognize the risks frontline providers are assuming. However, transparent communication across all levels is the key. Silos are disappearing and team based care is taking center stage.

Beyond the current public health crisis, these efforts will go a long way to create unshakable trust between health systems, providers, patients, and their loved ones.

Dr. Singh is currently the chief of inpatient operations at Adena Health System in Chillicothe, Ohio, where he also has key roles in medical informatics and health IT. He is also the president-elect of the Central Ohio Chapter of SHM.

Each day, we’re inundated with news about the COVID-19 pandemic and how it continues to strain our health care system and resources. With more than 1.15 million positive cases in the United States and over 67,000 deaths as of this writing, it has been a scary yet humbling experience for everyone. There is no doubt this pandemic will be a defining moment in health care for several reasons. From supply chain disruptions and personal protective equipment (PPE) and ventilator shortages to exhausted caregivers – both physically and mentally – this event has pushed the envelope on finding answers from federal and state authorities. Hospital administrations are working harder than ever to rise to the challenge and do what is best for their frontline staff and, more importantly, the patients and the communities they serve.

The provider experience during COVID-19

Hospitalists are in a unique situation as frontline providers. Managing daily throughput of patients has always been a key role for the specialty. They also play an integral role in their own care teams alongside nurses, trainees, case managers, pharmacists, and others in cohorted COVID-19 units. Now more than ever, such a geographic placement of patients is quickly emerging as a must-have staffing model to reduce risk of cross-contamination and preserving critical PPE supplies. This heightened awareness, coupled with anxiety, sometimes leads to added stress and burnout risk for hospitalists.

Communication is critical in creating situational awareness and reducing anxiety within the teams. This is exactly where hospitalists can lead:

• Active presence in hospital incident command centers and infection control boards
• Close coordination with emergency medicine colleagues and bed placement navigators
• Developing protocols for appropriate testing
• Frequent daily huddles to discuss current state- and hospital-level testing guidelines
• Close involvement in the hospital operations committee
• Advocating for or securing more testing or supplies, especially PPE
• Effective communication about changes in PPE requirements and conservation strategies as per the Centers for Disease Control and Prevention, State Department of Health, and the hospital infection control board
• Crisis-driven changes, including development and review of triage and treatment protocols and elective procedure cancellations
• Census numbers and capacity/staffing adjustments within the team to meet temporary dips and surges in on-service patient volumes
• Frontline caregiver mental and physical health assessment

Daily huddles at key times (e.g., at shift start and end times) can help to identify these barriers. If operational issues arise, there should be a clear channel to escalate them to senior leadership.

Hospitalists could also use several strategies proven to improve staff morale and resilience. For instance, take this time to connect with friends and family virtually, unplug when off from work, explore one’s spiritual self through meditation and prayers, spend time with nature, exercise daily, seek humor, and develop or work on one’s hobby.
 

 

The patient experience during COVID-19

Some intriguing data is also being released about patient experience during the pandemic. A Press Ganey analysis of 350,000 comments between January and March 2020 shows that patients are looking for more information about their condition, primarily COVID-19 test delays and result notification time. There is also hypervigilance in patients’ minds about hand hygiene and overall cleanliness of the hospital. Patients also seek clarification and transparent explanation of their caregiver’s bedside mannerisms – for example, why did they gown up before entering – and their daily care plans.

Patients have been appreciative of providers and recognize the personal risk frontline staff put themselves through. Communication transparency seems to mitigate concerns about delays of care especially caused by operational challenges as a result of the pandemic.

In surveys specifically related to experiences including COVID-19, patients were more likely to rate more areas of service lower than in surveys that did not mention COVID-19. The patients also seemed to put more value on the quality of instructions and information they received and on perception of providers’ respect and listening abilities. These insights could prove invaluable in improving care delivery by hospitalists.

Isolation of patients has been shown in multiple studies to have negative outcomes. These patients are up to twice as likely to have an adverse event, and seven times more likely to have treatment-related avoidable adversity, poorer perceived patient experience, and overall perception of being cared for “less.” Add to this a higher level of depression and mental strain, and these patients quickly become “unsatisfied.”

At the ED level, the willingness to let family be present for care was the key area of concern listed – a metric that has changed rapidly since the early days of the pandemic.

The bottom line is these are trying times for everyone – both for providers and patients. Both look up to health system and group leadership for reassurance. Patients and families recognize the risks frontline providers are assuming. However, transparent communication across all levels is the key. Silos are disappearing and team based care is taking center stage.

Beyond the current public health crisis, these efforts will go a long way to create unshakable trust between health systems, providers, patients, and their loved ones.

Dr. Singh is currently the chief of inpatient operations at Adena Health System in Chillicothe, Ohio, where he also has key roles in medical informatics and health IT. He is also the president-elect of the Central Ohio Chapter of SHM.

Each day, we’re inundated with news about the COVID-19 pandemic and how it continues to strain our health care system and resources. With more than 1.15 million positive cases in the United States and over 67,000 deaths as of this writing, it has been a scary yet humbling experience for everyone. There is no doubt this pandemic will be a defining moment in health care for several reasons. From supply chain disruptions and personal protective equipment (PPE) and ventilator shortages to exhausted caregivers – both physically and mentally – this event has pushed the envelope on finding answers from federal and state authorities. Hospital administrations are working harder than ever to rise to the challenge and do what is best for their frontline staff and, more importantly, the patients and the communities they serve.

The provider experience during COVID-19

Hospitalists are in a unique situation as frontline providers. Managing daily throughput of patients has always been a key role for the specialty. They also play an integral role in their own care teams alongside nurses, trainees, case managers, pharmacists, and others in cohorted COVID-19 units. Now more than ever, such a geographic placement of patients is quickly emerging as a must-have staffing model to reduce risk of cross-contamination and preserving critical PPE supplies. This heightened awareness, coupled with anxiety, sometimes leads to added stress and burnout risk for hospitalists.

Communication is critical in creating situational awareness and reducing anxiety within the teams. This is exactly where hospitalists can lead:

• Active presence in hospital incident command centers and infection control boards
• Close coordination with emergency medicine colleagues and bed placement navigators
• Developing protocols for appropriate testing
• Frequent daily huddles to discuss current state- and hospital-level testing guidelines
• Close involvement in the hospital operations committee
• Advocating for or securing more testing or supplies, especially PPE
• Effective communication about changes in PPE requirements and conservation strategies as per the Centers for Disease Control and Prevention, State Department of Health, and the hospital infection control board
• Crisis-driven changes, including development and review of triage and treatment protocols and elective procedure cancellations
• Census numbers and capacity/staffing adjustments within the team to meet temporary dips and surges in on-service patient volumes
• Frontline caregiver mental and physical health assessment

Daily huddles at key times (e.g., at shift start and end times) can help to identify these barriers. If operational issues arise, there should be a clear channel to escalate them to senior leadership.

Hospitalists could also use several strategies proven to improve staff morale and resilience. For instance, take this time to connect with friends and family virtually, unplug when off from work, explore one’s spiritual self through meditation and prayers, spend time with nature, exercise daily, seek humor, and develop or work on one’s hobby.
 

 

The patient experience during COVID-19

Some intriguing data is also being released about patient experience during the pandemic. A Press Ganey analysis of 350,000 comments between January and March 2020 shows that patients are looking for more information about their condition, primarily COVID-19 test delays and result notification time. There is also hypervigilance in patients’ minds about hand hygiene and overall cleanliness of the hospital. Patients also seek clarification and transparent explanation of their caregiver’s bedside mannerisms – for example, why did they gown up before entering – and their daily care plans.

Patients have been appreciative of providers and recognize the personal risk frontline staff put themselves through. Communication transparency seems to mitigate concerns about delays of care especially caused by operational challenges as a result of the pandemic.

In surveys specifically related to experiences including COVID-19, patients were more likely to rate more areas of service lower than in surveys that did not mention COVID-19. The patients also seemed to put more value on the quality of instructions and information they received and on perception of providers’ respect and listening abilities. These insights could prove invaluable in improving care delivery by hospitalists.

Isolation of patients has been shown in multiple studies to have negative outcomes. These patients are up to twice as likely to have an adverse event, and seven times more likely to have treatment-related avoidable adversity, poorer perceived patient experience, and overall perception of being cared for “less.” Add to this a higher level of depression and mental strain, and these patients quickly become “unsatisfied.”

At the ED level, the willingness to let family be present for care was the key area of concern listed – a metric that has changed rapidly since the early days of the pandemic.

The bottom line is these are trying times for everyone – both for providers and patients. Both look up to health system and group leadership for reassurance. Patients and families recognize the risks frontline providers are assuming. However, transparent communication across all levels is the key. Silos are disappearing and team based care is taking center stage.

Beyond the current public health crisis, these efforts will go a long way to create unshakable trust between health systems, providers, patients, and their loved ones.

Dr. Singh is currently the chief of inpatient operations at Adena Health System in Chillicothe, Ohio, where he also has key roles in medical informatics and health IT. He is also the president-elect of the Central Ohio Chapter of SHM.

Inexpensively obtained as a silk industry by-product, sericin is a glycoprotein found to confer various biologic effects.¹ The globular protein sericin has also long been known to exhibit antityrosinase and immunomodulatory activities.^2,3 This column focuses on the wide range of emerging and potential applications of sericin in cutaneous treatments.

Protection against solar radiation and photoaging

Sailesh Patnaik/CCA-SA 4.0 International

Studies in mice to evaluate the potential antioxidant and skin-protective effects of sericin by Zhaorigetu et al. in 2003 revealed that, by diminishing oxidative stress, cyclooxygenase-2 protein, and cell proliferation, sericin exerted a photoprotective effect against acute harm and tumor promotion elicited by UVB.⁴

Using mouse skin models, Dash et al. showed in 2008 that the silk protein sericin derived from the tropical tasar silkworm is a robust antioxidant and photoprotective agent, displaying a capacity to block UVB-induced apoptosis in irradiated (30 mJ/cm² UVB) human keratinocytes and, as compared with the mulberry silkworm, yielding protection against oxidative stress.^5,6

In 2015, Berardesca et al. conducted a randomized, double-blind, vehicle-controlled, split-face study over 8 weeks in 40 women (ages 40-70 years) to assess the antiaging effects of topically applied combination therapy including gold silk sericin, niacinamide, and signaline. The investigators observed significant improvements in stratum corneum hydration, barrier function, skin elasticity, and roughness as compared with skin treated with the control formulation. They concluded that this combination formulation featuring gold silk sericin warrants attention in the arsenal for ameliorating signs of aging female facial skin.⁷

A year earlier, Aramwit and Bang introduced a bacterial nanocellulose gel shown to effectively release silk sericin for facial treatment. Formulated at a pH of 4.5, the bioactive mask exhibited an ultrafine and pure fiber network structure. The authors noted that the gel was less adhesive than the commercially available paper mask, while the silk sericin product displayed greater moisture absorption capacity. In vitro cytotoxicity assessments also revealed that the product is safe for facial treatments.⁸

Cosmeceutical antioxidant for hyperpigmentation

In 2019, Kumar et al. demonstrated the inhibitory effect of topically applied silk sericin derived from Antheraea assamensis against UV-induced melanogenesis in mouse melanoma. They suggested that the formulation shows promise as a cosmeceutical antioxidant agent designed to address hyperpigmentation.³

The previous year, Aramwit et al. demonstrated using an in vitro model that urea-extracted sericin displays a capacity to inhibit melanogenesis by hindering tyrosinase activity, attenuating inflammation and allergic reactions, and reducing the expression of microphthalmia-associated transcription factor, a marker of melanogenesis regulation, in melanocytes and keratinocytes.²

Potential use as an adjunct psoriasis treatment

A combination of naringin (from Citrus maxima) and sericin (from Bombyx mori) was evaluated in 2019 by Deenonpoe et al. for the treatment of psoriasis. They isolated human peripheral blood mononuclear cells from 10 healthy subjects and 10 patients with psoriasis. The combination formulation was much more effective than either compound alone in significantly reducing mRNA expression and the synthesis of proinflammatory cytokines in samples from psoriasis patients. The investigators concluded that the down-regulation of proinflammatory cytokines imparted by the naringin/sericin product points toward its possible clinical use as a complementary treatment for psoriasis and other inflammation-mediated conditions.⁹

 

Uremic pruritus and burn wounds

A randomized, double-blind, placebo-controlled 6-week study in 2012 conducted by Aramwit et al. assessed the use of sericin cream versus a cream base placebo in the treatment of uremic pruritus in 50 hemodialysis patients, 47 of whom completed the study. Significant differences in the creams were identified, with hydration vastly improved in patients using the sericin cream. Significant reductions in pruritus and dyspigmentation were also observed in the treatment group, with an overall quality of life improvement noted in relation to pain score.¹⁰

Gail Hampshire/Wikimedia Commons CC BY 2.0

The ensuing year, Aramwit et al. showed that silk sericin promoted wound healing in vitro and, when added to silver sulfadiazine cream and evaluated in a randomized, double-blind, standard-controlled study, demonstrated clinical efficacy in healing burn wounds.¹¹

Wound healing

An expanding body of research suggests the role of sericin in wound healing. In 2007, Aramwit et al. found that sericin, which boasts notable hydrophilic qualities, was effective as a wound-healing agent in rats. The tested sericin cream successfully reduced wound size and wound healing time was substantially shorter than in animals treated with control formula. Treatment for 15 days yielded complete healing, no ulceration, and higher collagen levels, as determined by histologic examination, in comparison with control.¹² Other studies using sericin hydrogel as well as a sericin-based nanofibrous matrix with chitosan have demonstrated success in wound healing in mice.^13,14

Human studies

In 2018, Napavichayanun et al. reported on the clinical efficacy and safety of bacterial cellulose wound dressings including silk sericin and PHMB as compared with Bactigras (an antiseptic dressing) as a control in split-thickness skin graft donor-site wound treatment. In this single-blinded, randomized, controlled study of 21 patients, pain scores were significantly lower and wound quality higher in the skin treated with the sericin product. The test formulation was protected against infection without inducing adverse effects.¹⁵

Previously, a silk sericin–releasing wound dressing introduced in 2014 was found to significantly diminish pain and promote more rapid healing in patients with split-thickness skin graft donor sites as compared with treatment with the Bactigras wound dressing.¹⁶

Sericin in tissue repair and as a drug delivery carrier

Sericin is associated with antioxidant and moisturizing properties as well as a mitogenic influence on mammalian cells, with a particular impact on keratinocytes and fibroblasts that render it useful in biomaterials designed for skin tissue repair.¹⁷

Wang et al. have cross-linked dialdehyde carboxymethyl cellulose with silk sericin derived from the B. mori cocoon to develop a film with impressive blood compatibility and cytocompatibility that shows potential for use as a wound dressing, artificial skin, and in tissue engineering.¹⁸

Similarly, Liang et al. have been successful in preparing a medical tissue glue incorporating a gelatin, sericin, and carboxymethyl chitosan blend solution, cross-linked with 1-ethyl-3-(3-dimethylaminopropyl)-carbodiimide. The tissue glue has been found to offer notable biocompatibility and structural traits at low cost.¹⁹

Sericin protein also evinces potential as a biocompatible, bioviable carrier for drug delivery. Suktham et al. showed that resveratrol-loaded sericin nanoparticles robustly hindered growth of colorectal adenocarcinoma cells while cytotoxic to skin fibroblasts, suggesting the viability or potential of sericin nanoparticles as bionanocarriers in a drug delivery system.²⁰ In addition, Tao et al. found silk sericin to be effective when blended with poly(vinyl alcohol) in a hydrogel with antibacterial properties as a drug delivery carrier with potential for use as wound dressing.²¹

Conclusion

There is a plethora of new evidence to justify the inclusion of sericin in dermatologic research and skin care, specifically wound care. Much more research is necessary, though, to explore how the antioxidant and moisturizing activities of the protein may be harnessed to confer skin-protective effects, especially against UV damage.

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers,“The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems. Write to her at [email protected]

References

1. Lamboni L et al. Biotechnol Adv. 2015 Dec;33(8):1855-67.

2. Aramwit P et al. Biol Res. 2018 Nov 29;51(1):54.

3. Kumar JP, Mandal BB. Photochem Photobiol Sci. 2019 Oct 9:18(10):2497-508.

4. Zhaorigetu S et al. J Photochem Photobiol B. 2003 Oct 15;71(1-3):11-7.

5. Dash R et al. Mol Cell Biochem. 2008 Apr;311(1-2):111-9.

6. Dash R et al. BMB Rep. 2008 Mar 31;41(3):236-41.

7. Berardesca E et al. Int J Cosmet Sci. 2015 Dec;37(6):606-12.

8. Aramwit P, Bang N. BMC Biotechnol. 2014 Dec 9;14:104.

9. Deenonpoe R et al. BMC Complement Altern Med. 2019 Jul 10;19(1):168.

10. Aramwit P et al. BMC Nephrol. 2012 Sep 24;13:119.

11. Aramwit P et al. Arch Dermatol Res. 2013 Sep;305(7):585-94.

12. Aramwit P, Sangcakul A. Biosci Biotechnol Biochem. 2007 Oct;71(10):2473-7.

13. Qi C et al. Biomater Sci. 2018 Nov 1;6(11):2859-70.

14. Sapru S et al. Acta Biomater. 2018 Sep 15;78:137-50.

15. Napavichayanun S et al. Arch Dermatol Res. 2018 Dec;310(10):795-805.

16. Siritientong T et al. Pharm Res. 2014 Jan;31(1):104-16.

17. Lamboni L et al. Biotechnol Adv. 2015 Dec;33(8):1855-67.

18. Wang P et al. Carbohydr Polym. 2019 May 15;212:403-11.

19. Liang M et al. J Appl Biomater Funct Mater. 2018 Apr;16(2):97-106.

20. Suktham K et al. Int J Pharm. 2018 Feb 15;537(1-2):48-56.

21. Tao G et al. Mater Sci Eng C Mater Biol Appl. 2019 Aug;101:341-51.

Inexpensively obtained as a silk industry by-product, sericin is a glycoprotein found to confer various biologic effects.¹ The globular protein sericin has also long been known to exhibit antityrosinase and immunomodulatory activities.^2,3 This column focuses on the wide range of emerging and potential applications of sericin in cutaneous treatments.

Protection against solar radiation and photoaging

Sailesh Patnaik/CCA-SA 4.0 International

Studies in mice to evaluate the potential antioxidant and skin-protective effects of sericin by Zhaorigetu et al. in 2003 revealed that, by diminishing oxidative stress, cyclooxygenase-2 protein, and cell proliferation, sericin exerted a photoprotective effect against acute harm and tumor promotion elicited by UVB.⁴

Using mouse skin models, Dash et al. showed in 2008 that the silk protein sericin derived from the tropical tasar silkworm is a robust antioxidant and photoprotective agent, displaying a capacity to block UVB-induced apoptosis in irradiated (30 mJ/cm² UVB) human keratinocytes and, as compared with the mulberry silkworm, yielding protection against oxidative stress.^5,6

In 2015, Berardesca et al. conducted a randomized, double-blind, vehicle-controlled, split-face study over 8 weeks in 40 women (ages 40-70 years) to assess the antiaging effects of topically applied combination therapy including gold silk sericin, niacinamide, and signaline. The investigators observed significant improvements in stratum corneum hydration, barrier function, skin elasticity, and roughness as compared with skin treated with the control formulation. They concluded that this combination formulation featuring gold silk sericin warrants attention in the arsenal for ameliorating signs of aging female facial skin.⁷

A year earlier, Aramwit and Bang introduced a bacterial nanocellulose gel shown to effectively release silk sericin for facial treatment. Formulated at a pH of 4.5, the bioactive mask exhibited an ultrafine and pure fiber network structure. The authors noted that the gel was less adhesive than the commercially available paper mask, while the silk sericin product displayed greater moisture absorption capacity. In vitro cytotoxicity assessments also revealed that the product is safe for facial treatments.⁸

Cosmeceutical antioxidant for hyperpigmentation

In 2019, Kumar et al. demonstrated the inhibitory effect of topically applied silk sericin derived from Antheraea assamensis against UV-induced melanogenesis in mouse melanoma. They suggested that the formulation shows promise as a cosmeceutical antioxidant agent designed to address hyperpigmentation.³

The previous year, Aramwit et al. demonstrated using an in vitro model that urea-extracted sericin displays a capacity to inhibit melanogenesis by hindering tyrosinase activity, attenuating inflammation and allergic reactions, and reducing the expression of microphthalmia-associated transcription factor, a marker of melanogenesis regulation, in melanocytes and keratinocytes.²

Potential use as an adjunct psoriasis treatment

A combination of naringin (from Citrus maxima) and sericin (from Bombyx mori) was evaluated in 2019 by Deenonpoe et al. for the treatment of psoriasis. They isolated human peripheral blood mononuclear cells from 10 healthy subjects and 10 patients with psoriasis. The combination formulation was much more effective than either compound alone in significantly reducing mRNA expression and the synthesis of proinflammatory cytokines in samples from psoriasis patients. The investigators concluded that the down-regulation of proinflammatory cytokines imparted by the naringin/sericin product points toward its possible clinical use as a complementary treatment for psoriasis and other inflammation-mediated conditions.⁹

 

Uremic pruritus and burn wounds

A randomized, double-blind, placebo-controlled 6-week study in 2012 conducted by Aramwit et al. assessed the use of sericin cream versus a cream base placebo in the treatment of uremic pruritus in 50 hemodialysis patients, 47 of whom completed the study. Significant differences in the creams were identified, with hydration vastly improved in patients using the sericin cream. Significant reductions in pruritus and dyspigmentation were also observed in the treatment group, with an overall quality of life improvement noted in relation to pain score.¹⁰

Gail Hampshire/Wikimedia Commons CC BY 2.0

The ensuing year, Aramwit et al. showed that silk sericin promoted wound healing in vitro and, when added to silver sulfadiazine cream and evaluated in a randomized, double-blind, standard-controlled study, demonstrated clinical efficacy in healing burn wounds.¹¹

Wound healing

An expanding body of research suggests the role of sericin in wound healing. In 2007, Aramwit et al. found that sericin, which boasts notable hydrophilic qualities, was effective as a wound-healing agent in rats. The tested sericin cream successfully reduced wound size and wound healing time was substantially shorter than in animals treated with control formula. Treatment for 15 days yielded complete healing, no ulceration, and higher collagen levels, as determined by histologic examination, in comparison with control.¹² Other studies using sericin hydrogel as well as a sericin-based nanofibrous matrix with chitosan have demonstrated success in wound healing in mice.^13,14

Human studies

In 2018, Napavichayanun et al. reported on the clinical efficacy and safety of bacterial cellulose wound dressings including silk sericin and PHMB as compared with Bactigras (an antiseptic dressing) as a control in split-thickness skin graft donor-site wound treatment. In this single-blinded, randomized, controlled study of 21 patients, pain scores were significantly lower and wound quality higher in the skin treated with the sericin product. The test formulation was protected against infection without inducing adverse effects.¹⁵

Previously, a silk sericin–releasing wound dressing introduced in 2014 was found to significantly diminish pain and promote more rapid healing in patients with split-thickness skin graft donor sites as compared with treatment with the Bactigras wound dressing.¹⁶

Sericin in tissue repair and as a drug delivery carrier

Sericin is associated with antioxidant and moisturizing properties as well as a mitogenic influence on mammalian cells, with a particular impact on keratinocytes and fibroblasts that render it useful in biomaterials designed for skin tissue repair.¹⁷

Wang et al. have cross-linked dialdehyde carboxymethyl cellulose with silk sericin derived from the B. mori cocoon to develop a film with impressive blood compatibility and cytocompatibility that shows potential for use as a wound dressing, artificial skin, and in tissue engineering.¹⁸

Similarly, Liang et al. have been successful in preparing a medical tissue glue incorporating a gelatin, sericin, and carboxymethyl chitosan blend solution, cross-linked with 1-ethyl-3-(3-dimethylaminopropyl)-carbodiimide. The tissue glue has been found to offer notable biocompatibility and structural traits at low cost.¹⁹

Sericin protein also evinces potential as a biocompatible, bioviable carrier for drug delivery. Suktham et al. showed that resveratrol-loaded sericin nanoparticles robustly hindered growth of colorectal adenocarcinoma cells while cytotoxic to skin fibroblasts, suggesting the viability or potential of sericin nanoparticles as bionanocarriers in a drug delivery system.²⁰ In addition, Tao et al. found silk sericin to be effective when blended with poly(vinyl alcohol) in a hydrogel with antibacterial properties as a drug delivery carrier with potential for use as wound dressing.²¹

Conclusion

There is a plethora of new evidence to justify the inclusion of sericin in dermatologic research and skin care, specifically wound care. Much more research is necessary, though, to explore how the antioxidant and moisturizing activities of the protein may be harnessed to confer skin-protective effects, especially against UV damage.

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers,“The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems. Write to her at [email protected]

References

1. Lamboni L et al. Biotechnol Adv. 2015 Dec;33(8):1855-67.

2. Aramwit P et al. Biol Res. 2018 Nov 29;51(1):54.

3. Kumar JP, Mandal BB. Photochem Photobiol Sci. 2019 Oct 9:18(10):2497-508.

4. Zhaorigetu S et al. J Photochem Photobiol B. 2003 Oct 15;71(1-3):11-7.

5. Dash R et al. Mol Cell Biochem. 2008 Apr;311(1-2):111-9.

6. Dash R et al. BMB Rep. 2008 Mar 31;41(3):236-41.

7. Berardesca E et al. Int J Cosmet Sci. 2015 Dec;37(6):606-12.

8. Aramwit P, Bang N. BMC Biotechnol. 2014 Dec 9;14:104.

9. Deenonpoe R et al. BMC Complement Altern Med. 2019 Jul 10;19(1):168.

10. Aramwit P et al. BMC Nephrol. 2012 Sep 24;13:119.

11. Aramwit P et al. Arch Dermatol Res. 2013 Sep;305(7):585-94.

12. Aramwit P, Sangcakul A. Biosci Biotechnol Biochem. 2007 Oct;71(10):2473-7.

13. Qi C et al. Biomater Sci. 2018 Nov 1;6(11):2859-70.

14. Sapru S et al. Acta Biomater. 2018 Sep 15;78:137-50.

15. Napavichayanun S et al. Arch Dermatol Res. 2018 Dec;310(10):795-805.

16. Siritientong T et al. Pharm Res. 2014 Jan;31(1):104-16.

17. Lamboni L et al. Biotechnol Adv. 2015 Dec;33(8):1855-67.

18. Wang P et al. Carbohydr Polym. 2019 May 15;212:403-11.

19. Liang M et al. J Appl Biomater Funct Mater. 2018 Apr;16(2):97-106.

20. Suktham K et al. Int J Pharm. 2018 Feb 15;537(1-2):48-56.

21. Tao G et al. Mater Sci Eng C Mater Biol Appl. 2019 Aug;101:341-51.

Inexpensively obtained as a silk industry by-product, sericin is a glycoprotein found to confer various biologic effects.¹ The globular protein sericin has also long been known to exhibit antityrosinase and immunomodulatory activities.^2,3 This column focuses on the wide range of emerging and potential applications of sericin in cutaneous treatments.

Protection against solar radiation and photoaging

Sailesh Patnaik/CCA-SA 4.0 International

Studies in mice to evaluate the potential antioxidant and skin-protective effects of sericin by Zhaorigetu et al. in 2003 revealed that, by diminishing oxidative stress, cyclooxygenase-2 protein, and cell proliferation, sericin exerted a photoprotective effect against acute harm and tumor promotion elicited by UVB.⁴

Using mouse skin models, Dash et al. showed in 2008 that the silk protein sericin derived from the tropical tasar silkworm is a robust antioxidant and photoprotective agent, displaying a capacity to block UVB-induced apoptosis in irradiated (30 mJ/cm² UVB) human keratinocytes and, as compared with the mulberry silkworm, yielding protection against oxidative stress.^5,6

In 2015, Berardesca et al. conducted a randomized, double-blind, vehicle-controlled, split-face study over 8 weeks in 40 women (ages 40-70 years) to assess the antiaging effects of topically applied combination therapy including gold silk sericin, niacinamide, and signaline. The investigators observed significant improvements in stratum corneum hydration, barrier function, skin elasticity, and roughness as compared with skin treated with the control formulation. They concluded that this combination formulation featuring gold silk sericin warrants attention in the arsenal for ameliorating signs of aging female facial skin.⁷

A year earlier, Aramwit and Bang introduced a bacterial nanocellulose gel shown to effectively release silk sericin for facial treatment. Formulated at a pH of 4.5, the bioactive mask exhibited an ultrafine and pure fiber network structure. The authors noted that the gel was less adhesive than the commercially available paper mask, while the silk sericin product displayed greater moisture absorption capacity. In vitro cytotoxicity assessments also revealed that the product is safe for facial treatments.⁸

Cosmeceutical antioxidant for hyperpigmentation

In 2019, Kumar et al. demonstrated the inhibitory effect of topically applied silk sericin derived from Antheraea assamensis against UV-induced melanogenesis in mouse melanoma. They suggested that the formulation shows promise as a cosmeceutical antioxidant agent designed to address hyperpigmentation.³

The previous year, Aramwit et al. demonstrated using an in vitro model that urea-extracted sericin displays a capacity to inhibit melanogenesis by hindering tyrosinase activity, attenuating inflammation and allergic reactions, and reducing the expression of microphthalmia-associated transcription factor, a marker of melanogenesis regulation, in melanocytes and keratinocytes.²

Potential use as an adjunct psoriasis treatment

A combination of naringin (from Citrus maxima) and sericin (from Bombyx mori) was evaluated in 2019 by Deenonpoe et al. for the treatment of psoriasis. They isolated human peripheral blood mononuclear cells from 10 healthy subjects and 10 patients with psoriasis. The combination formulation was much more effective than either compound alone in significantly reducing mRNA expression and the synthesis of proinflammatory cytokines in samples from psoriasis patients. The investigators concluded that the down-regulation of proinflammatory cytokines imparted by the naringin/sericin product points toward its possible clinical use as a complementary treatment for psoriasis and other inflammation-mediated conditions.⁹

 

Uremic pruritus and burn wounds

A randomized, double-blind, placebo-controlled 6-week study in 2012 conducted by Aramwit et al. assessed the use of sericin cream versus a cream base placebo in the treatment of uremic pruritus in 50 hemodialysis patients, 47 of whom completed the study. Significant differences in the creams were identified, with hydration vastly improved in patients using the sericin cream. Significant reductions in pruritus and dyspigmentation were also observed in the treatment group, with an overall quality of life improvement noted in relation to pain score.¹⁰

Gail Hampshire/Wikimedia Commons CC BY 2.0

The ensuing year, Aramwit et al. showed that silk sericin promoted wound healing in vitro and, when added to silver sulfadiazine cream and evaluated in a randomized, double-blind, standard-controlled study, demonstrated clinical efficacy in healing burn wounds.¹¹

Wound healing

An expanding body of research suggests the role of sericin in wound healing. In 2007, Aramwit et al. found that sericin, which boasts notable hydrophilic qualities, was effective as a wound-healing agent in rats. The tested sericin cream successfully reduced wound size and wound healing time was substantially shorter than in animals treated with control formula. Treatment for 15 days yielded complete healing, no ulceration, and higher collagen levels, as determined by histologic examination, in comparison with control.¹² Other studies using sericin hydrogel as well as a sericin-based nanofibrous matrix with chitosan have demonstrated success in wound healing in mice.^13,14

Human studies

In 2018, Napavichayanun et al. reported on the clinical efficacy and safety of bacterial cellulose wound dressings including silk sericin and PHMB as compared with Bactigras (an antiseptic dressing) as a control in split-thickness skin graft donor-site wound treatment. In this single-blinded, randomized, controlled study of 21 patients, pain scores were significantly lower and wound quality higher in the skin treated with the sericin product. The test formulation was protected against infection without inducing adverse effects.¹⁵

Previously, a silk sericin–releasing wound dressing introduced in 2014 was found to significantly diminish pain and promote more rapid healing in patients with split-thickness skin graft donor sites as compared with treatment with the Bactigras wound dressing.¹⁶

Sericin in tissue repair and as a drug delivery carrier

Sericin is associated with antioxidant and moisturizing properties as well as a mitogenic influence on mammalian cells, with a particular impact on keratinocytes and fibroblasts that render it useful in biomaterials designed for skin tissue repair.¹⁷

Wang et al. have cross-linked dialdehyde carboxymethyl cellulose with silk sericin derived from the B. mori cocoon to develop a film with impressive blood compatibility and cytocompatibility that shows potential for use as a wound dressing, artificial skin, and in tissue engineering.¹⁸

Similarly, Liang et al. have been successful in preparing a medical tissue glue incorporating a gelatin, sericin, and carboxymethyl chitosan blend solution, cross-linked with 1-ethyl-3-(3-dimethylaminopropyl)-carbodiimide. The tissue glue has been found to offer notable biocompatibility and structural traits at low cost.¹⁹

Sericin protein also evinces potential as a biocompatible, bioviable carrier for drug delivery. Suktham et al. showed that resveratrol-loaded sericin nanoparticles robustly hindered growth of colorectal adenocarcinoma cells while cytotoxic to skin fibroblasts, suggesting the viability or potential of sericin nanoparticles as bionanocarriers in a drug delivery system.²⁰ In addition, Tao et al. found silk sericin to be effective when blended with poly(vinyl alcohol) in a hydrogel with antibacterial properties as a drug delivery carrier with potential for use as wound dressing.²¹

Conclusion

There is a plethora of new evidence to justify the inclusion of sericin in dermatologic research and skin care, specifically wound care. Much more research is necessary, though, to explore how the antioxidant and moisturizing activities of the protein may be harnessed to confer skin-protective effects, especially against UV damage.

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers,“The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems. Write to her at [email protected]

References

1. Lamboni L et al. Biotechnol Adv. 2015 Dec;33(8):1855-67.

2. Aramwit P et al. Biol Res. 2018 Nov 29;51(1):54.

3. Kumar JP, Mandal BB. Photochem Photobiol Sci. 2019 Oct 9:18(10):2497-508.

4. Zhaorigetu S et al. J Photochem Photobiol B. 2003 Oct 15;71(1-3):11-7.

5. Dash R et al. Mol Cell Biochem. 2008 Apr;311(1-2):111-9.

6. Dash R et al. BMB Rep. 2008 Mar 31;41(3):236-41.

7. Berardesca E et al. Int J Cosmet Sci. 2015 Dec;37(6):606-12.

8. Aramwit P, Bang N. BMC Biotechnol. 2014 Dec 9;14:104.

9. Deenonpoe R et al. BMC Complement Altern Med. 2019 Jul 10;19(1):168.

10. Aramwit P et al. BMC Nephrol. 2012 Sep 24;13:119.

11. Aramwit P et al. Arch Dermatol Res. 2013 Sep;305(7):585-94.

12. Aramwit P, Sangcakul A. Biosci Biotechnol Biochem. 2007 Oct;71(10):2473-7.

13. Qi C et al. Biomater Sci. 2018 Nov 1;6(11):2859-70.

14. Sapru S et al. Acta Biomater. 2018 Sep 15;78:137-50.

15. Napavichayanun S et al. Arch Dermatol Res. 2018 Dec;310(10):795-805.

16. Siritientong T et al. Pharm Res. 2014 Jan;31(1):104-16.

17. Lamboni L et al. Biotechnol Adv. 2015 Dec;33(8):1855-67.

18. Wang P et al. Carbohydr Polym. 2019 May 15;212:403-11.

19. Liang M et al. J Appl Biomater Funct Mater. 2018 Apr;16(2):97-106.

20. Suktham K et al. Int J Pharm. 2018 Feb 15;537(1-2):48-56.

21. Tao G et al. Mater Sci Eng C Mater Biol Appl. 2019 Aug;101:341-51.