Hospital Medicine

COVID-19, the disease caused by the novel coronavirus SARS-CoV-2, was declared a pandemic on March 11, 2020. Although most patients (81%) develop mild illness, 14% develop severe illness, and 5% develop critical illness, including acute respiratory failure, septic shock, and multiorgan dysfunction.¹

Point-of-care ultrasound (POCUS), or bedside ultrasound performed by a clinician caring for the patient, is being used to support the diagnosis and serially monitor patients with COVID-19. We performed a literature search of electronically discoverable peer-reviewed publications on POCUS use in COVID-19 from December 1, 2019, to April 10, 2020. We review key POCUS applications that are most relevant to frontline providers in the care of COVID-19 patients.

Diagnosing COVID-19 disease by polymerase chain reaction is limited by availability of testing, delays in test positivity (mean 5.1 days), and high false-negative rate early in the course of the disease (sensitivity 81%).² Chest computed tomography (CT) scans are often requested during the initial evaluation of suspected COVID-19, but the American College of Radiology has recommend against the routine use of CT scans for diagnosing COVID-19.³

The diagnostic accuracy of lung ultrasound (LUS) has been shown to be similar to chest CT scans in patients presenting with respiratory complaints, such as dyspnea and hypoxemia, caused by non–COVID-19 pneumonia (sensitivity, 85%; specificity, 93%).⁴ Normal LUS findings correlate well with CT chest scans showing absence of typical ground glass opacities. This negative predictive value is very important.⁵ However, early in the course of COVID-19, similar to CT scans, LUS may be normal during the first 5 days or in patients with mild disease.² Unique advantages of LUS in COVID-19 include immediate availability of results, repeatability over time, and performance at the bedside, which avoids transportation of patients to radiology suites and disinfection of large imaging equipment.

LUS findings in COVID-19 include (a) an irregular, thickened pleural line, (b) B-lines in various patterns (discrete and confluent), (c) small subpleural consolidations, and (d) absence of pleural effusions (Figure). Bilateral, multifocal disease is common, while lobar alveolar consolidation is less common.^6,7 In addition to supporting the initial diagnosis, LUS is being used to serially monitor hospitalized COVID-19 patients. As lung interstitial fluid content increases, discrete B-lines become confluent, and the number of affected lung zones increases, which can guide decisions about escalation of care. LUS is often used to guide decisions about prone ventilation, extracorporeal membrane oxygenation, and weaning from mechanical ventilation in acute respiratory failure of non–COVID-19 patients,⁸ and these concepts are being applied to COVID-19 patients. During recovery, reappearance of A-lines can be seen, but normalization of the LUS pattern is gradual over several weeks based on our experience and one report.⁹ Multiple LUS protocols examining 6 to 12 lung zones have been published prior to the COVID-19 pandemic. We recommend continuing to use an institutional protocol and evaluating at least one to two rib interspaces on the anterior, lateral, and posterior chest wall.

Myriad cardiac complications have been described in COVID-19 – including acute coronary syndrome, myocarditis, cardiomyopathy with heart failure, and arrhythmias – secondary to increased cardiac stress from hypoxia, direct myocardial infection, or indirect injury from a hyperinflammatory response. Mortality is higher in patients with hypertension, diabetes, and coronary artery disease.^10,11 Cardiac POCUS is being used to evaluate COVID-19 patients when troponin and B-type natriuretic peptide (BNP) are elevated or when there are hemodynamic or electrocardiogram changes. Given the high incidence of venous thromboembolism (VTE) in COVID-19,¹² cardiac POCUS is being used to rapidly assess for right ventricular (RV) dysfunction and acute pulmonary hypertension.

The American Society of Echocardiography has recommended the use of cardiac POCUS by frontline providers for detection or characterization of preexisting cardiovascular disease, early identification of worsening cardiac function, serial monitoring and examination, and elucidation of cardiovascular pathologies associated with COVID-19.¹³ Sharing cardiac POCUS images in real time or through an image archive can reduce the need for consultative echocardiography, which ultimately reduces staff exposure, conserves personal protective equipment, and reduces need for decontamination of echocardiographic equipment.

The minimum cardiac POCUS views recommended in COVID-19 patients include the parasternal long-axis and short-axis views (midventricular level), either the apical or subcostal four-chamber view, and the subcostal long-axis view of the inferior vena cava.¹³ The goal of a cardiac POCUS exam is to qualitatively assess left ventricular (LV) systolic function, RV size and contractility, gross valvular and regional wall motion abnormalities, and pericardial effusion. In prone position ventilation, the swimmer’s position with one arm elevated above the shoulder may permit acquisition of apical views. Finally, integrated cardiopulmonary ultrasonography, including evaluation for deep vein thrombosis (DVT; see below), is ideal for proper characterization of underlying LV and RV function, volume status, and titration of vasopressor and inotropic support.

COVID-19 has been associated with a proinflammatory and hypercoagulable state with elevated d-dimer and higher-than-­expected incidence of VTE (27%) in critically ill patients.^12,14 Previous studies have demonstrated that frontline providers, including hospitalists, can detect lower extremity (LE) DVTs with high diagnostic accuracy using POCUS.¹⁵ Given the high incidence of DVTs despite prophylactic anticoagulation, some reports have suggested screening or serially monitoring for LE DVT in hospitalized COVID-19 patients.¹⁶ In patients with suspected pulmonary embolism (PE), POCUS can rapidly detect venous thrombosis that justifies prompt initiation of anticoagulation (eg, finding DVT or clot-in-transit), supportive findings of PE (eg, acute RV dysfunction, pulmonary infarcts), or alternative diagnoses (eg, bacterial pneumonia). However, it is important to recognize POCUS cannot definitively rule out PE. Additionally, subpleural consolidations are common in COVID-19 patients and could be caused by either infection or infarction. The American Society of Hematology has endorsed the use of POCUS, LE compression ultrasonography, and echocardiography in COVID-19 patients with suspected PE when availability of CT pulmonary angiography or ventilation-perfusion lung scans is limited.¹⁴

A POCUS exam for LE DVT consists of two-dimensional venous compression alone and yields results similar to formal vascular studies in both critically ill and noncritically ill patients. Because proximal LE thrombi have the highest risk of embolization, evaluation of the common femoral vein, femoral vein, and popliteal vein is most important.¹⁵ Either inability to compress a vein completely with wall-to-wall apposition or visualization of echogenic thrombus within the vein is diagnostic of DVT. Acute thrombi are gelatinous and may appear anechoic, while subacute or chronic thrombi are echogenic, but all veins with a DVT will not compress completely.

Ultrasound guidance for central venous catheter (CVC) insertion has been shown to increase procedure success rates and decrease mechanical complications, primarily arterial puncture and pneumothorax. Similarly, higher success rates and fewer insertion attempts have been observed with ultrasound-guided peripheral intravenous line and arterial line placement.¹⁷ Ultrasound-­guided PIV placement can reduce referrals for midlines and peripherally inserted central catheters in hospitalized patients.¹⁸

In COVID-19 patients, use of ultrasound guidance for vascular access has distinct advantages. First, given the high incidence of DVT in COVID-19 patients,¹² POCUS allows preprocedural evaluation of the target vessel for thrombosis, as well as anatomic variations and stenosis. Second, visualizing the needle tip and guidewire within the target vein prior to dilation nearly eliminates the risk of arterial puncture and inadvertent arterial dilation, which is particularly important in COVID-19 patients receiving high-dose prophylactic or therapeutic anticoagulation. Third, when inserting internal jugular and subclavian CVCs, visualization of normal lung sliding before and after the procedure safely rules out pneumothorax. However, if lung sliding is not seen before the procedure, it cannot be used to rule out pneumothorax afterward. Additionally, visualizing absence of the catheter tip in the right atrium and presence of a rapid atrial swirl sign within 2 seconds of briskly injecting 10 mL of saline confirms catheter tip placement near the superior vena cava/right atrial junction, which can eliminate the need for a postprocedure chest radiograph.¹⁷

POCUS can be used to rapidly confirm endotracheal tube (ETT) placement, which can reduce reliance on postintubation chest radiographs. A meta-analysis of prospective and randomized trials showed transtracheal ultrasonography had high sensitivity (98.7%) and specificity (97.1%) for confirming tracheal placement of ETTs.¹⁹ Confirming endotracheal intubation involves two steps: First, a linear transducer is placed transversely over the suprasternal notch to visualize the ETT passing through the trachea, and not the esophagus, during insertion. Second, after the ETT cuff has been inflated, bilateral lung sliding should be seen in sync with the respiratory cycle if the ETT is in the trachea. Absent lung sliding, but preserved lung pulse, on the anterior hemithorax is likely caused by main stem bronchial intubation, and withdrawing the ETT until bilateral lung sliding is seen confirms tracheal placement. Additionally, the following steps are recommended to reduce the risk of exposure to healthcare workers: minimizing use of bag-valve-mask ventilation, performing rapid sequence intubation using video laryngoscopy, and connecting the ETT to the ventilator immediately.

Important considerations when selecting an ultrasound machine for use in COVID-19 patients include image quality, portability, functionality, and ease of disinfection. Advantages of handheld devices include portability and ease of disinfection, whereas cart-based systems generally have better image quality and functionality. To minimize the risk of cross contamination, an ultrasound machine should be dedicated exclusively for use on patients with confirmed COVID-19 and not shared with patients with suspected COVID-19.²⁰ To minimize exposure to COVID-19 patients, frontline providers should perform POCUS exams only when findings may change management, and timing of the exam and views acquired should be selected deliberately.

Ultrasound machine disinfection should be integrated into routine donning and doffing procedures. When possible, both handheld and cart-based machines should be draped with protective covers during aerosol-generating procedures. Single use ultrasound gel packets are recommended in order to decrease the risk of nosocomial infection.²⁰ After every use of an ultrasound machine on intact skin or for percutaneous procedures, low-level disinfection should be performed with an Environmental Protection Agency–recommended product that is effective against coronavirus.

Some ultrasound manufacturers have added teleultrasound software that allows remote training of novice POCUS users and remote guidance in actual patient care. Teleultrasound can be utilized to share images in real time with consultants or expert providers.

POCUS is uniquely poised to improve patient care during the COVID-19 pandemic. POCUS can be used to support the diagnosis of COVID-19 patients and monitor patients with confirmed disease. Common POCUS applications used in COVID-19 patients include evaluation of the lungs, heart, and deep veins, as well as performance of bedside procedures. Ultrasound machine portability and disinfection are important considerations in COVID-19 patients.

COVID-19, the disease caused by the novel coronavirus SARS-CoV-2, was declared a pandemic on March 11, 2020. Although most patients (81%) develop mild illness, 14% develop severe illness, and 5% develop critical illness, including acute respiratory failure, septic shock, and multiorgan dysfunction.¹

Point-of-care ultrasound (POCUS), or bedside ultrasound performed by a clinician caring for the patient, is being used to support the diagnosis and serially monitor patients with COVID-19. We performed a literature search of electronically discoverable peer-reviewed publications on POCUS use in COVID-19 from December 1, 2019, to April 10, 2020. We review key POCUS applications that are most relevant to frontline providers in the care of COVID-19 patients.

Diagnosing COVID-19 disease by polymerase chain reaction is limited by availability of testing, delays in test positivity (mean 5.1 days), and high false-negative rate early in the course of the disease (sensitivity 81%).² Chest computed tomography (CT) scans are often requested during the initial evaluation of suspected COVID-19, but the American College of Radiology has recommend against the routine use of CT scans for diagnosing COVID-19.³

The diagnostic accuracy of lung ultrasound (LUS) has been shown to be similar to chest CT scans in patients presenting with respiratory complaints, such as dyspnea and hypoxemia, caused by non–COVID-19 pneumonia (sensitivity, 85%; specificity, 93%).⁴ Normal LUS findings correlate well with CT chest scans showing absence of typical ground glass opacities. This negative predictive value is very important.⁵ However, early in the course of COVID-19, similar to CT scans, LUS may be normal during the first 5 days or in patients with mild disease.² Unique advantages of LUS in COVID-19 include immediate availability of results, repeatability over time, and performance at the bedside, which avoids transportation of patients to radiology suites and disinfection of large imaging equipment.

LUS findings in COVID-19 include (a) an irregular, thickened pleural line, (b) B-lines in various patterns (discrete and confluent), (c) small subpleural consolidations, and (d) absence of pleural effusions (Figure). Bilateral, multifocal disease is common, while lobar alveolar consolidation is less common.^6,7 In addition to supporting the initial diagnosis, LUS is being used to serially monitor hospitalized COVID-19 patients. As lung interstitial fluid content increases, discrete B-lines become confluent, and the number of affected lung zones increases, which can guide decisions about escalation of care. LUS is often used to guide decisions about prone ventilation, extracorporeal membrane oxygenation, and weaning from mechanical ventilation in acute respiratory failure of non–COVID-19 patients,⁸ and these concepts are being applied to COVID-19 patients. During recovery, reappearance of A-lines can be seen, but normalization of the LUS pattern is gradual over several weeks based on our experience and one report.⁹ Multiple LUS protocols examining 6 to 12 lung zones have been published prior to the COVID-19 pandemic. We recommend continuing to use an institutional protocol and evaluating at least one to two rib interspaces on the anterior, lateral, and posterior chest wall.

Myriad cardiac complications have been described in COVID-19 – including acute coronary syndrome, myocarditis, cardiomyopathy with heart failure, and arrhythmias – secondary to increased cardiac stress from hypoxia, direct myocardial infection, or indirect injury from a hyperinflammatory response. Mortality is higher in patients with hypertension, diabetes, and coronary artery disease.^10,11 Cardiac POCUS is being used to evaluate COVID-19 patients when troponin and B-type natriuretic peptide (BNP) are elevated or when there are hemodynamic or electrocardiogram changes. Given the high incidence of venous thromboembolism (VTE) in COVID-19,¹² cardiac POCUS is being used to rapidly assess for right ventricular (RV) dysfunction and acute pulmonary hypertension.

The American Society of Echocardiography has recommended the use of cardiac POCUS by frontline providers for detection or characterization of preexisting cardiovascular disease, early identification of worsening cardiac function, serial monitoring and examination, and elucidation of cardiovascular pathologies associated with COVID-19.¹³ Sharing cardiac POCUS images in real time or through an image archive can reduce the need for consultative echocardiography, which ultimately reduces staff exposure, conserves personal protective equipment, and reduces need for decontamination of echocardiographic equipment.

The minimum cardiac POCUS views recommended in COVID-19 patients include the parasternal long-axis and short-axis views (midventricular level), either the apical or subcostal four-chamber view, and the subcostal long-axis view of the inferior vena cava.¹³ The goal of a cardiac POCUS exam is to qualitatively assess left ventricular (LV) systolic function, RV size and contractility, gross valvular and regional wall motion abnormalities, and pericardial effusion. In prone position ventilation, the swimmer’s position with one arm elevated above the shoulder may permit acquisition of apical views. Finally, integrated cardiopulmonary ultrasonography, including evaluation for deep vein thrombosis (DVT; see below), is ideal for proper characterization of underlying LV and RV function, volume status, and titration of vasopressor and inotropic support.

COVID-19 has been associated with a proinflammatory and hypercoagulable state with elevated d-dimer and higher-than-­expected incidence of VTE (27%) in critically ill patients.^12,14 Previous studies have demonstrated that frontline providers, including hospitalists, can detect lower extremity (LE) DVTs with high diagnostic accuracy using POCUS.¹⁵ Given the high incidence of DVTs despite prophylactic anticoagulation, some reports have suggested screening or serially monitoring for LE DVT in hospitalized COVID-19 patients.¹⁶ In patients with suspected pulmonary embolism (PE), POCUS can rapidly detect venous thrombosis that justifies prompt initiation of anticoagulation (eg, finding DVT or clot-in-transit), supportive findings of PE (eg, acute RV dysfunction, pulmonary infarcts), or alternative diagnoses (eg, bacterial pneumonia). However, it is important to recognize POCUS cannot definitively rule out PE. Additionally, subpleural consolidations are common in COVID-19 patients and could be caused by either infection or infarction. The American Society of Hematology has endorsed the use of POCUS, LE compression ultrasonography, and echocardiography in COVID-19 patients with suspected PE when availability of CT pulmonary angiography or ventilation-perfusion lung scans is limited.¹⁴

A POCUS exam for LE DVT consists of two-dimensional venous compression alone and yields results similar to formal vascular studies in both critically ill and noncritically ill patients. Because proximal LE thrombi have the highest risk of embolization, evaluation of the common femoral vein, femoral vein, and popliteal vein is most important.¹⁵ Either inability to compress a vein completely with wall-to-wall apposition or visualization of echogenic thrombus within the vein is diagnostic of DVT. Acute thrombi are gelatinous and may appear anechoic, while subacute or chronic thrombi are echogenic, but all veins with a DVT will not compress completely.

Ultrasound guidance for central venous catheter (CVC) insertion has been shown to increase procedure success rates and decrease mechanical complications, primarily arterial puncture and pneumothorax. Similarly, higher success rates and fewer insertion attempts have been observed with ultrasound-guided peripheral intravenous line and arterial line placement.¹⁷ Ultrasound-­guided PIV placement can reduce referrals for midlines and peripherally inserted central catheters in hospitalized patients.¹⁸

In COVID-19 patients, use of ultrasound guidance for vascular access has distinct advantages. First, given the high incidence of DVT in COVID-19 patients,¹² POCUS allows preprocedural evaluation of the target vessel for thrombosis, as well as anatomic variations and stenosis. Second, visualizing the needle tip and guidewire within the target vein prior to dilation nearly eliminates the risk of arterial puncture and inadvertent arterial dilation, which is particularly important in COVID-19 patients receiving high-dose prophylactic or therapeutic anticoagulation. Third, when inserting internal jugular and subclavian CVCs, visualization of normal lung sliding before and after the procedure safely rules out pneumothorax. However, if lung sliding is not seen before the procedure, it cannot be used to rule out pneumothorax afterward. Additionally, visualizing absence of the catheter tip in the right atrium and presence of a rapid atrial swirl sign within 2 seconds of briskly injecting 10 mL of saline confirms catheter tip placement near the superior vena cava/right atrial junction, which can eliminate the need for a postprocedure chest radiograph.¹⁷

POCUS can be used to rapidly confirm endotracheal tube (ETT) placement, which can reduce reliance on postintubation chest radiographs. A meta-analysis of prospective and randomized trials showed transtracheal ultrasonography had high sensitivity (98.7%) and specificity (97.1%) for confirming tracheal placement of ETTs.¹⁹ Confirming endotracheal intubation involves two steps: First, a linear transducer is placed transversely over the suprasternal notch to visualize the ETT passing through the trachea, and not the esophagus, during insertion. Second, after the ETT cuff has been inflated, bilateral lung sliding should be seen in sync with the respiratory cycle if the ETT is in the trachea. Absent lung sliding, but preserved lung pulse, on the anterior hemithorax is likely caused by main stem bronchial intubation, and withdrawing the ETT until bilateral lung sliding is seen confirms tracheal placement. Additionally, the following steps are recommended to reduce the risk of exposure to healthcare workers: minimizing use of bag-valve-mask ventilation, performing rapid sequence intubation using video laryngoscopy, and connecting the ETT to the ventilator immediately.

Important considerations when selecting an ultrasound machine for use in COVID-19 patients include image quality, portability, functionality, and ease of disinfection. Advantages of handheld devices include portability and ease of disinfection, whereas cart-based systems generally have better image quality and functionality. To minimize the risk of cross contamination, an ultrasound machine should be dedicated exclusively for use on patients with confirmed COVID-19 and not shared with patients with suspected COVID-19.²⁰ To minimize exposure to COVID-19 patients, frontline providers should perform POCUS exams only when findings may change management, and timing of the exam and views acquired should be selected deliberately.

Ultrasound machine disinfection should be integrated into routine donning and doffing procedures. When possible, both handheld and cart-based machines should be draped with protective covers during aerosol-generating procedures. Single use ultrasound gel packets are recommended in order to decrease the risk of nosocomial infection.²⁰ After every use of an ultrasound machine on intact skin or for percutaneous procedures, low-level disinfection should be performed with an Environmental Protection Agency–recommended product that is effective against coronavirus.

Some ultrasound manufacturers have added teleultrasound software that allows remote training of novice POCUS users and remote guidance in actual patient care. Teleultrasound can be utilized to share images in real time with consultants or expert providers.

POCUS is uniquely poised to improve patient care during the COVID-19 pandemic. POCUS can be used to support the diagnosis of COVID-19 patients and monitor patients with confirmed disease. Common POCUS applications used in COVID-19 patients include evaluation of the lungs, heart, and deep veins, as well as performance of bedside procedures. Ultrasound machine portability and disinfection are important considerations in COVID-19 patients.

COVID-19, the disease caused by the novel coronavirus SARS-CoV-2, was declared a pandemic on March 11, 2020. Although most patients (81%) develop mild illness, 14% develop severe illness, and 5% develop critical illness, including acute respiratory failure, septic shock, and multiorgan dysfunction.¹

Point-of-care ultrasound (POCUS), or bedside ultrasound performed by a clinician caring for the patient, is being used to support the diagnosis and serially monitor patients with COVID-19. We performed a literature search of electronically discoverable peer-reviewed publications on POCUS use in COVID-19 from December 1, 2019, to April 10, 2020. We review key POCUS applications that are most relevant to frontline providers in the care of COVID-19 patients.

Diagnosing COVID-19 disease by polymerase chain reaction is limited by availability of testing, delays in test positivity (mean 5.1 days), and high false-negative rate early in the course of the disease (sensitivity 81%).² Chest computed tomography (CT) scans are often requested during the initial evaluation of suspected COVID-19, but the American College of Radiology has recommend against the routine use of CT scans for diagnosing COVID-19.³

The diagnostic accuracy of lung ultrasound (LUS) has been shown to be similar to chest CT scans in patients presenting with respiratory complaints, such as dyspnea and hypoxemia, caused by non–COVID-19 pneumonia (sensitivity, 85%; specificity, 93%).⁴ Normal LUS findings correlate well with CT chest scans showing absence of typical ground glass opacities. This negative predictive value is very important.⁵ However, early in the course of COVID-19, similar to CT scans, LUS may be normal during the first 5 days or in patients with mild disease.² Unique advantages of LUS in COVID-19 include immediate availability of results, repeatability over time, and performance at the bedside, which avoids transportation of patients to radiology suites and disinfection of large imaging equipment.

LUS findings in COVID-19 include (a) an irregular, thickened pleural line, (b) B-lines in various patterns (discrete and confluent), (c) small subpleural consolidations, and (d) absence of pleural effusions (Figure). Bilateral, multifocal disease is common, while lobar alveolar consolidation is less common.^6,7 In addition to supporting the initial diagnosis, LUS is being used to serially monitor hospitalized COVID-19 patients. As lung interstitial fluid content increases, discrete B-lines become confluent, and the number of affected lung zones increases, which can guide decisions about escalation of care. LUS is often used to guide decisions about prone ventilation, extracorporeal membrane oxygenation, and weaning from mechanical ventilation in acute respiratory failure of non–COVID-19 patients,⁸ and these concepts are being applied to COVID-19 patients. During recovery, reappearance of A-lines can be seen, but normalization of the LUS pattern is gradual over several weeks based on our experience and one report.⁹ Multiple LUS protocols examining 6 to 12 lung zones have been published prior to the COVID-19 pandemic. We recommend continuing to use an institutional protocol and evaluating at least one to two rib interspaces on the anterior, lateral, and posterior chest wall.

Myriad cardiac complications have been described in COVID-19 – including acute coronary syndrome, myocarditis, cardiomyopathy with heart failure, and arrhythmias – secondary to increased cardiac stress from hypoxia, direct myocardial infection, or indirect injury from a hyperinflammatory response. Mortality is higher in patients with hypertension, diabetes, and coronary artery disease.^10,11 Cardiac POCUS is being used to evaluate COVID-19 patients when troponin and B-type natriuretic peptide (BNP) are elevated or when there are hemodynamic or electrocardiogram changes. Given the high incidence of venous thromboembolism (VTE) in COVID-19,¹² cardiac POCUS is being used to rapidly assess for right ventricular (RV) dysfunction and acute pulmonary hypertension.

The American Society of Echocardiography has recommended the use of cardiac POCUS by frontline providers for detection or characterization of preexisting cardiovascular disease, early identification of worsening cardiac function, serial monitoring and examination, and elucidation of cardiovascular pathologies associated with COVID-19.¹³ Sharing cardiac POCUS images in real time or through an image archive can reduce the need for consultative echocardiography, which ultimately reduces staff exposure, conserves personal protective equipment, and reduces need for decontamination of echocardiographic equipment.

The minimum cardiac POCUS views recommended in COVID-19 patients include the parasternal long-axis and short-axis views (midventricular level), either the apical or subcostal four-chamber view, and the subcostal long-axis view of the inferior vena cava.¹³ The goal of a cardiac POCUS exam is to qualitatively assess left ventricular (LV) systolic function, RV size and contractility, gross valvular and regional wall motion abnormalities, and pericardial effusion. In prone position ventilation, the swimmer’s position with one arm elevated above the shoulder may permit acquisition of apical views. Finally, integrated cardiopulmonary ultrasonography, including evaluation for deep vein thrombosis (DVT; see below), is ideal for proper characterization of underlying LV and RV function, volume status, and titration of vasopressor and inotropic support.

COVID-19 has been associated with a proinflammatory and hypercoagulable state with elevated d-dimer and higher-than-­expected incidence of VTE (27%) in critically ill patients.^12,14 Previous studies have demonstrated that frontline providers, including hospitalists, can detect lower extremity (LE) DVTs with high diagnostic accuracy using POCUS.¹⁵ Given the high incidence of DVTs despite prophylactic anticoagulation, some reports have suggested screening or serially monitoring for LE DVT in hospitalized COVID-19 patients.¹⁶ In patients with suspected pulmonary embolism (PE), POCUS can rapidly detect venous thrombosis that justifies prompt initiation of anticoagulation (eg, finding DVT or clot-in-transit), supportive findings of PE (eg, acute RV dysfunction, pulmonary infarcts), or alternative diagnoses (eg, bacterial pneumonia). However, it is important to recognize POCUS cannot definitively rule out PE. Additionally, subpleural consolidations are common in COVID-19 patients and could be caused by either infection or infarction. The American Society of Hematology has endorsed the use of POCUS, LE compression ultrasonography, and echocardiography in COVID-19 patients with suspected PE when availability of CT pulmonary angiography or ventilation-perfusion lung scans is limited.¹⁴

A POCUS exam for LE DVT consists of two-dimensional venous compression alone and yields results similar to formal vascular studies in both critically ill and noncritically ill patients. Because proximal LE thrombi have the highest risk of embolization, evaluation of the common femoral vein, femoral vein, and popliteal vein is most important.¹⁵ Either inability to compress a vein completely with wall-to-wall apposition or visualization of echogenic thrombus within the vein is diagnostic of DVT. Acute thrombi are gelatinous and may appear anechoic, while subacute or chronic thrombi are echogenic, but all veins with a DVT will not compress completely.

Ultrasound guidance for central venous catheter (CVC) insertion has been shown to increase procedure success rates and decrease mechanical complications, primarily arterial puncture and pneumothorax. Similarly, higher success rates and fewer insertion attempts have been observed with ultrasound-guided peripheral intravenous line and arterial line placement.¹⁷ Ultrasound-­guided PIV placement can reduce referrals for midlines and peripherally inserted central catheters in hospitalized patients.¹⁸

In COVID-19 patients, use of ultrasound guidance for vascular access has distinct advantages. First, given the high incidence of DVT in COVID-19 patients,¹² POCUS allows preprocedural evaluation of the target vessel for thrombosis, as well as anatomic variations and stenosis. Second, visualizing the needle tip and guidewire within the target vein prior to dilation nearly eliminates the risk of arterial puncture and inadvertent arterial dilation, which is particularly important in COVID-19 patients receiving high-dose prophylactic or therapeutic anticoagulation. Third, when inserting internal jugular and subclavian CVCs, visualization of normal lung sliding before and after the procedure safely rules out pneumothorax. However, if lung sliding is not seen before the procedure, it cannot be used to rule out pneumothorax afterward. Additionally, visualizing absence of the catheter tip in the right atrium and presence of a rapid atrial swirl sign within 2 seconds of briskly injecting 10 mL of saline confirms catheter tip placement near the superior vena cava/right atrial junction, which can eliminate the need for a postprocedure chest radiograph.¹⁷

POCUS can be used to rapidly confirm endotracheal tube (ETT) placement, which can reduce reliance on postintubation chest radiographs. A meta-analysis of prospective and randomized trials showed transtracheal ultrasonography had high sensitivity (98.7%) and specificity (97.1%) for confirming tracheal placement of ETTs.¹⁹ Confirming endotracheal intubation involves two steps: First, a linear transducer is placed transversely over the suprasternal notch to visualize the ETT passing through the trachea, and not the esophagus, during insertion. Second, after the ETT cuff has been inflated, bilateral lung sliding should be seen in sync with the respiratory cycle if the ETT is in the trachea. Absent lung sliding, but preserved lung pulse, on the anterior hemithorax is likely caused by main stem bronchial intubation, and withdrawing the ETT until bilateral lung sliding is seen confirms tracheal placement. Additionally, the following steps are recommended to reduce the risk of exposure to healthcare workers: minimizing use of bag-valve-mask ventilation, performing rapid sequence intubation using video laryngoscopy, and connecting the ETT to the ventilator immediately.

Important considerations when selecting an ultrasound machine for use in COVID-19 patients include image quality, portability, functionality, and ease of disinfection. Advantages of handheld devices include portability and ease of disinfection, whereas cart-based systems generally have better image quality and functionality. To minimize the risk of cross contamination, an ultrasound machine should be dedicated exclusively for use on patients with confirmed COVID-19 and not shared with patients with suspected COVID-19.²⁰ To minimize exposure to COVID-19 patients, frontline providers should perform POCUS exams only when findings may change management, and timing of the exam and views acquired should be selected deliberately.

Ultrasound machine disinfection should be integrated into routine donning and doffing procedures. When possible, both handheld and cart-based machines should be draped with protective covers during aerosol-generating procedures. Single use ultrasound gel packets are recommended in order to decrease the risk of nosocomial infection.²⁰ After every use of an ultrasound machine on intact skin or for percutaneous procedures, low-level disinfection should be performed with an Environmental Protection Agency–recommended product that is effective against coronavirus.

Some ultrasound manufacturers have added teleultrasound software that allows remote training of novice POCUS users and remote guidance in actual patient care. Teleultrasound can be utilized to share images in real time with consultants or expert providers.

POCUS is uniquely poised to improve patient care during the COVID-19 pandemic. POCUS can be used to support the diagnosis of COVID-19 patients and monitor patients with confirmed disease. Common POCUS applications used in COVID-19 patients include evaluation of the lungs, heart, and deep veins, as well as performance of bedside procedures. Ultrasound machine portability and disinfection are important considerations in COVID-19 patients.

Voluntary accountable care organizations (ACOs) and bundled payments have concurrently become cornerstone strategies in Medicare’s shift from volume-based fee-for-service toward value-based payment.

Physician practice and hospital participation in Medicare’s largest ACO model, the Medicare Shared Savings Program (MSSP),¹ grew to include 561 organizations in 2018. Under MSSP, participants assume financial accountability for the global quality and costs of care for defined populations of Medicare fee-for-service patients. ACOs that manage to maintain or improve quality while achieving savings (ie, containing costs below a predefined population-wide spending benchmark) are eligible to receive a portion of the difference back from Medicare in the form of “shared savings”.

Similarly, hospital participation in Medicare’s bundled payment programs has grown over time. Most notably, more than 700 participants enrolled in the recently concluded Bundled Payments for Care Improvement (BPCI) initiative,² Medicare’s largest bundled payment program over the past five years.³ Under BPCI, participants assumed financial accountability for the quality and costs of care for all Medicare patients triggering a qualifying “episode of care”. Participants that limit episode spending below a predefined benchmark without compromising quality were eligible for financial incentives.

As both ACOs and bundled payments grow in prominence and scale, they may increasingly overlap if patients attributed to ACOs receive care at bundled payment hospitals. Overlap could create synergies by increasing incentives to address shared processes (eg, discharge planning) or outcomes (eg, readmissions).⁴ An ACO focus on reducing hospital admissions could complement bundled payment efforts to increase hospital efficiency.

Conversely, Medicare’s approach to allocating savings and losses can penalize ACOs or bundled payment participants.³ For example, when a patient included in an MSSP ACO population receives episodic care at a hospital participating in BPCI, the historical costs of care for the hospital and the episode type, not the actual costs of care for that specific patient and his/her episode, are counted in the performance of the ACO. In other words, in these cases, the performance of the MSSP ACO is dependent on the historical spending at BPCI hospitals—despite it being out of ACO’s control and having little to do with the actual care its patients receive at BPCI hospitals—and MSSP ACOs cannot benefit from improvements over time. Therefore, MSSP ACOs may be functionally penalized if patients receive care at historically high-cost BPCI hospitals regardless of whether they have considerably improved the value of care delivered. As a corollary, Medicare rules involve a “claw back” stipulation in which savings are recouped from hospitals that participate in both BPCI and MSSP, effectively discouraging participation in both payment models.

Although these dynamics are complex, they highlight an intuitive point that has gained increasing awareness,⁵ ie, policymakers must understand the magnitude of overlap to evaluate the urgency in coordinating between the payment models. Our objective was to describe the extent of overlap and the characteristics of patients affected by it.

We used 100% institutional Medicare claims, MSSP beneficiary attribution, and BPCI hospital data to identify fee-for-service beneficiaries attributed to MSSP and/or receiving care at BPCI hospitals for its 48 included episodes from the start of BPCI in 2013 quarter 4 through 2016 quarter 4.

We examined the trends in the number of episodes across the following three groups: MSSP-attributed patients hospitalized at BPCI hospitals for an episode included in BPCI (Overlap), MSSP-attributed patients hospitalized for that episode at non-BPCI hospitals (MSSP-only), and non-MSSP-attributed patients hospitalized at BPCI hospitals for a BPCI episode (BPCI-only). We used Medicare and United States Census Bureau data to compare groups with respect to sociodemographic (eg, age, sex, residence in a low-income area),⁶ clinical (eg, Elixhauser comorbidity index),⁷ and prior utilization (eg, skilled nursing facility discharge) characteristics.

Categorical and continuous variables were compared using logistic regression and one-way analysis of variance, respectively. Analyses were performed using Stata (StataCorp, College Station, Texas), version 15.0. Statistical tests were 2-tailed and significant at α = 0.05. This study was approved by the institutional review board at the University of Pennsylvania.

The number of MSSP ACOs increased from 220 in 2013 to 432 in 2016. The number of BPCI hospitals increased from 9 to 389 over this period, peaking at 413 hospitals in 2015. Over our study period, a total of 243,392, 2,824,898, and 702,864 episodes occurred in the Overlap, ACO-only, and BPCI-only groups, respectively (Table). Among episodes, patients in the Overlap group generally showed lower severity than those in other groups, although the differences were small. The BPCI-only, MSSP-only, and Overlap groups also exhibited small differences with respect to other characteristics such as the proportion of patients with Medicare/Medicaid dual-eligibility (15% of individual vs 16% and 12%, respectively) and prior use of skilled nursing facilities (33% vs 34% vs 31%, respectively) and acute care hospitals (45% vs 41% vs 39%, respectively) (P < .001 for all).

The overall overlap facing MSSP patients (overlap as a proportion of all MSSP patients) increased from 0.3% at the end of 2013 to 10% at the end of 2016, whereas over the same period, overlap facing bundled payment patients (overlap as a proportion of all bundled payment patients) increased from 11.9% to 27% (Appendix Figure). Overlap facing MSSP ACOs varied according to episode type, ranging from 3% for both acute myocardial infarction and chronic obstructive pulmonary disease episodes to 18% for automatic implantable cardiac defibrillator episodes at the end of 2016. Similarly, overlap facing bundled payment patients varied from 21% for spinal fusion episodes to 32% for lower extremity joint replacement and automatic implantable cardiac defibrillator episodes.

To our knowledge, this is the first study to describe the sizable and growing overlap facing ACOs with attributed patients who receive care at bundled payment hospitals, as well as bundled payment hospitals that treat patients attributed to ACOs.

The major implication of our findings is that policymakers must address and anticipate forthcoming payment model overlap as a key policy priority. Given the emphasis on ACOs and bundled payments as payment models—for example, Medicare continues to implement both nationwide via the Next Generation ACO model⁸ and the recently launched BPCI-Advanced program⁹—policymakers urgently need insights about the extent of payment model overlap. In that context, it is notable that although we have evaluated MSSP and BPCI as flagship programs, true overlap may actually be greater once other programs are considered.

Several factors may underlie the differences in the magnitude of overlap facing bundled payment versus ACO patients. The models differ in how they identify relevant patient populations, with patients falling under bundled payments via hospitalization for certain episode types but patients falling under ACOs via attribution based on the plurality of primary care services. Furthermore, BPCI participation lagged behind MSSP participation in time, while also occurring disproportionately in areas with existing MSSP ACOs.

Given these findings, understanding the implications of overlap should be a priority for future research and policy strategies. Potential policy considerations should include revising cost accounting processes so that when ACO-attributed patients receive episodic care at bundled payment hospitals, actual rather than historical hospital costs are counted toward ACO cost performance. To encourage hospitals to assume more accountability over outcomes—the ostensible overarching goal of value-based payment reform—Medicare could elect not to recoup savings from hospitals in both payment models. Although such changes require careful accounting to protect Medicare from financial losses as it forgoes some savings achieved through payment reforms, this may be worthwhile if hospital engagement in both models yields synergies.

Importantly, any policy changes made to address program overlap would need to accommodate ongoing changes in ACO, bundled payments, and other payment programs. For example, Medicare overhauled MSSP in December 2018. Compared to the earlier rules, in which ACOs could avoid downside financial risk altogether via “upside only” arrangements for up to six years, new MSSP rules require all participants to assume downside risk after several years of participation. Separately, forthcoming payment reforms such as direct contracting¹⁰ may draw clinicians and hospitals previously not participating in either Medicare fee-for-service or value-based payment models into payment reform. These factors may affect overlap in unpredictable ways (eg, they may increase the overlap by increasing the number of patients whose care is covered by different payment models or they may decrease overlap by raising the financial stakes of payment reforms to a degree that organizations drop out altogether).

This study has limitations. First, generalizability is limited by the fact that our analysis did not include bundled payment episodes assigned to physician group participants in BPCI or hospitals in mandatory joint replacement bundles under the Medicare Comprehensive Care for Joint Replacement model.¹¹ Second, although this study provides the first description of overlap between ACO and bundled payment programs, it was descriptive in nature. Future research is needed to evaluate the impact of overlap on clinical, quality, and cost outcomes. This is particularly important because although we observed only small differences in patient characteristics among MSSP-only, BPCI-only, and Overlap groups, characteristics could change differentially over time. Payment reforms must be carefully monitored for potentially unintended consequences that could arise from differential changes in patient characteristics (eg, cherry-picking behavior that is disadvantageous to vulnerable individuals).

Nonetheless, this study underscores the importance and extent of overlap and the urgency to consider policy measures to coordinate between the payment models.

Acknowledgments

The authors thank research assistance from Sandra Vanderslice who did not receive any compensation for her work. This research was supported in part by The Commonwealth Fund. Rachel Werner was supported in part by K24-AG047908 from the NIA.

Voluntary accountable care organizations (ACOs) and bundled payments have concurrently become cornerstone strategies in Medicare’s shift from volume-based fee-for-service toward value-based payment.

Physician practice and hospital participation in Medicare’s largest ACO model, the Medicare Shared Savings Program (MSSP),¹ grew to include 561 organizations in 2018. Under MSSP, participants assume financial accountability for the global quality and costs of care for defined populations of Medicare fee-for-service patients. ACOs that manage to maintain or improve quality while achieving savings (ie, containing costs below a predefined population-wide spending benchmark) are eligible to receive a portion of the difference back from Medicare in the form of “shared savings”.

Similarly, hospital participation in Medicare’s bundled payment programs has grown over time. Most notably, more than 700 participants enrolled in the recently concluded Bundled Payments for Care Improvement (BPCI) initiative,² Medicare’s largest bundled payment program over the past five years.³ Under BPCI, participants assumed financial accountability for the quality and costs of care for all Medicare patients triggering a qualifying “episode of care”. Participants that limit episode spending below a predefined benchmark without compromising quality were eligible for financial incentives.

As both ACOs and bundled payments grow in prominence and scale, they may increasingly overlap if patients attributed to ACOs receive care at bundled payment hospitals. Overlap could create synergies by increasing incentives to address shared processes (eg, discharge planning) or outcomes (eg, readmissions).⁴ An ACO focus on reducing hospital admissions could complement bundled payment efforts to increase hospital efficiency.

Conversely, Medicare’s approach to allocating savings and losses can penalize ACOs or bundled payment participants.³ For example, when a patient included in an MSSP ACO population receives episodic care at a hospital participating in BPCI, the historical costs of care for the hospital and the episode type, not the actual costs of care for that specific patient and his/her episode, are counted in the performance of the ACO. In other words, in these cases, the performance of the MSSP ACO is dependent on the historical spending at BPCI hospitals—despite it being out of ACO’s control and having little to do with the actual care its patients receive at BPCI hospitals—and MSSP ACOs cannot benefit from improvements over time. Therefore, MSSP ACOs may be functionally penalized if patients receive care at historically high-cost BPCI hospitals regardless of whether they have considerably improved the value of care delivered. As a corollary, Medicare rules involve a “claw back” stipulation in which savings are recouped from hospitals that participate in both BPCI and MSSP, effectively discouraging participation in both payment models.

Although these dynamics are complex, they highlight an intuitive point that has gained increasing awareness,⁵ ie, policymakers must understand the magnitude of overlap to evaluate the urgency in coordinating between the payment models. Our objective was to describe the extent of overlap and the characteristics of patients affected by it.

We used 100% institutional Medicare claims, MSSP beneficiary attribution, and BPCI hospital data to identify fee-for-service beneficiaries attributed to MSSP and/or receiving care at BPCI hospitals for its 48 included episodes from the start of BPCI in 2013 quarter 4 through 2016 quarter 4.

We examined the trends in the number of episodes across the following three groups: MSSP-attributed patients hospitalized at BPCI hospitals for an episode included in BPCI (Overlap), MSSP-attributed patients hospitalized for that episode at non-BPCI hospitals (MSSP-only), and non-MSSP-attributed patients hospitalized at BPCI hospitals for a BPCI episode (BPCI-only). We used Medicare and United States Census Bureau data to compare groups with respect to sociodemographic (eg, age, sex, residence in a low-income area),⁶ clinical (eg, Elixhauser comorbidity index),⁷ and prior utilization (eg, skilled nursing facility discharge) characteristics.

Categorical and continuous variables were compared using logistic regression and one-way analysis of variance, respectively. Analyses were performed using Stata (StataCorp, College Station, Texas), version 15.0. Statistical tests were 2-tailed and significant at α = 0.05. This study was approved by the institutional review board at the University of Pennsylvania.

The number of MSSP ACOs increased from 220 in 2013 to 432 in 2016. The number of BPCI hospitals increased from 9 to 389 over this period, peaking at 413 hospitals in 2015. Over our study period, a total of 243,392, 2,824,898, and 702,864 episodes occurred in the Overlap, ACO-only, and BPCI-only groups, respectively (Table). Among episodes, patients in the Overlap group generally showed lower severity than those in other groups, although the differences were small. The BPCI-only, MSSP-only, and Overlap groups also exhibited small differences with respect to other characteristics such as the proportion of patients with Medicare/Medicaid dual-eligibility (15% of individual vs 16% and 12%, respectively) and prior use of skilled nursing facilities (33% vs 34% vs 31%, respectively) and acute care hospitals (45% vs 41% vs 39%, respectively) (P < .001 for all).

The overall overlap facing MSSP patients (overlap as a proportion of all MSSP patients) increased from 0.3% at the end of 2013 to 10% at the end of 2016, whereas over the same period, overlap facing bundled payment patients (overlap as a proportion of all bundled payment patients) increased from 11.9% to 27% (Appendix Figure). Overlap facing MSSP ACOs varied according to episode type, ranging from 3% for both acute myocardial infarction and chronic obstructive pulmonary disease episodes to 18% for automatic implantable cardiac defibrillator episodes at the end of 2016. Similarly, overlap facing bundled payment patients varied from 21% for spinal fusion episodes to 32% for lower extremity joint replacement and automatic implantable cardiac defibrillator episodes.

To our knowledge, this is the first study to describe the sizable and growing overlap facing ACOs with attributed patients who receive care at bundled payment hospitals, as well as bundled payment hospitals that treat patients attributed to ACOs.

The major implication of our findings is that policymakers must address and anticipate forthcoming payment model overlap as a key policy priority. Given the emphasis on ACOs and bundled payments as payment models—for example, Medicare continues to implement both nationwide via the Next Generation ACO model⁸ and the recently launched BPCI-Advanced program⁹—policymakers urgently need insights about the extent of payment model overlap. In that context, it is notable that although we have evaluated MSSP and BPCI as flagship programs, true overlap may actually be greater once other programs are considered.

Several factors may underlie the differences in the magnitude of overlap facing bundled payment versus ACO patients. The models differ in how they identify relevant patient populations, with patients falling under bundled payments via hospitalization for certain episode types but patients falling under ACOs via attribution based on the plurality of primary care services. Furthermore, BPCI participation lagged behind MSSP participation in time, while also occurring disproportionately in areas with existing MSSP ACOs.

Given these findings, understanding the implications of overlap should be a priority for future research and policy strategies. Potential policy considerations should include revising cost accounting processes so that when ACO-attributed patients receive episodic care at bundled payment hospitals, actual rather than historical hospital costs are counted toward ACO cost performance. To encourage hospitals to assume more accountability over outcomes—the ostensible overarching goal of value-based payment reform—Medicare could elect not to recoup savings from hospitals in both payment models. Although such changes require careful accounting to protect Medicare from financial losses as it forgoes some savings achieved through payment reforms, this may be worthwhile if hospital engagement in both models yields synergies.

Importantly, any policy changes made to address program overlap would need to accommodate ongoing changes in ACO, bundled payments, and other payment programs. For example, Medicare overhauled MSSP in December 2018. Compared to the earlier rules, in which ACOs could avoid downside financial risk altogether via “upside only” arrangements for up to six years, new MSSP rules require all participants to assume downside risk after several years of participation. Separately, forthcoming payment reforms such as direct contracting¹⁰ may draw clinicians and hospitals previously not participating in either Medicare fee-for-service or value-based payment models into payment reform. These factors may affect overlap in unpredictable ways (eg, they may increase the overlap by increasing the number of patients whose care is covered by different payment models or they may decrease overlap by raising the financial stakes of payment reforms to a degree that organizations drop out altogether).

This study has limitations. First, generalizability is limited by the fact that our analysis did not include bundled payment episodes assigned to physician group participants in BPCI or hospitals in mandatory joint replacement bundles under the Medicare Comprehensive Care for Joint Replacement model.¹¹ Second, although this study provides the first description of overlap between ACO and bundled payment programs, it was descriptive in nature. Future research is needed to evaluate the impact of overlap on clinical, quality, and cost outcomes. This is particularly important because although we observed only small differences in patient characteristics among MSSP-only, BPCI-only, and Overlap groups, characteristics could change differentially over time. Payment reforms must be carefully monitored for potentially unintended consequences that could arise from differential changes in patient characteristics (eg, cherry-picking behavior that is disadvantageous to vulnerable individuals).

Nonetheless, this study underscores the importance and extent of overlap and the urgency to consider policy measures to coordinate between the payment models.

Acknowledgments

The authors thank research assistance from Sandra Vanderslice who did not receive any compensation for her work. This research was supported in part by The Commonwealth Fund. Rachel Werner was supported in part by K24-AG047908 from the NIA.

Voluntary accountable care organizations (ACOs) and bundled payments have concurrently become cornerstone strategies in Medicare’s shift from volume-based fee-for-service toward value-based payment.

Physician practice and hospital participation in Medicare’s largest ACO model, the Medicare Shared Savings Program (MSSP),¹ grew to include 561 organizations in 2018. Under MSSP, participants assume financial accountability for the global quality and costs of care for defined populations of Medicare fee-for-service patients. ACOs that manage to maintain or improve quality while achieving savings (ie, containing costs below a predefined population-wide spending benchmark) are eligible to receive a portion of the difference back from Medicare in the form of “shared savings”.

Similarly, hospital participation in Medicare’s bundled payment programs has grown over time. Most notably, more than 700 participants enrolled in the recently concluded Bundled Payments for Care Improvement (BPCI) initiative,² Medicare’s largest bundled payment program over the past five years.³ Under BPCI, participants assumed financial accountability for the quality and costs of care for all Medicare patients triggering a qualifying “episode of care”. Participants that limit episode spending below a predefined benchmark without compromising quality were eligible for financial incentives.

As both ACOs and bundled payments grow in prominence and scale, they may increasingly overlap if patients attributed to ACOs receive care at bundled payment hospitals. Overlap could create synergies by increasing incentives to address shared processes (eg, discharge planning) or outcomes (eg, readmissions).⁴ An ACO focus on reducing hospital admissions could complement bundled payment efforts to increase hospital efficiency.

Conversely, Medicare’s approach to allocating savings and losses can penalize ACOs or bundled payment participants.³ For example, when a patient included in an MSSP ACO population receives episodic care at a hospital participating in BPCI, the historical costs of care for the hospital and the episode type, not the actual costs of care for that specific patient and his/her episode, are counted in the performance of the ACO. In other words, in these cases, the performance of the MSSP ACO is dependent on the historical spending at BPCI hospitals—despite it being out of ACO’s control and having little to do with the actual care its patients receive at BPCI hospitals—and MSSP ACOs cannot benefit from improvements over time. Therefore, MSSP ACOs may be functionally penalized if patients receive care at historically high-cost BPCI hospitals regardless of whether they have considerably improved the value of care delivered. As a corollary, Medicare rules involve a “claw back” stipulation in which savings are recouped from hospitals that participate in both BPCI and MSSP, effectively discouraging participation in both payment models.

Although these dynamics are complex, they highlight an intuitive point that has gained increasing awareness,⁵ ie, policymakers must understand the magnitude of overlap to evaluate the urgency in coordinating between the payment models. Our objective was to describe the extent of overlap and the characteristics of patients affected by it.

We used 100% institutional Medicare claims, MSSP beneficiary attribution, and BPCI hospital data to identify fee-for-service beneficiaries attributed to MSSP and/or receiving care at BPCI hospitals for its 48 included episodes from the start of BPCI in 2013 quarter 4 through 2016 quarter 4.

We examined the trends in the number of episodes across the following three groups: MSSP-attributed patients hospitalized at BPCI hospitals for an episode included in BPCI (Overlap), MSSP-attributed patients hospitalized for that episode at non-BPCI hospitals (MSSP-only), and non-MSSP-attributed patients hospitalized at BPCI hospitals for a BPCI episode (BPCI-only). We used Medicare and United States Census Bureau data to compare groups with respect to sociodemographic (eg, age, sex, residence in a low-income area),⁶ clinical (eg, Elixhauser comorbidity index),⁷ and prior utilization (eg, skilled nursing facility discharge) characteristics.

Categorical and continuous variables were compared using logistic regression and one-way analysis of variance, respectively. Analyses were performed using Stata (StataCorp, College Station, Texas), version 15.0. Statistical tests were 2-tailed and significant at α = 0.05. This study was approved by the institutional review board at the University of Pennsylvania.

The number of MSSP ACOs increased from 220 in 2013 to 432 in 2016. The number of BPCI hospitals increased from 9 to 389 over this period, peaking at 413 hospitals in 2015. Over our study period, a total of 243,392, 2,824,898, and 702,864 episodes occurred in the Overlap, ACO-only, and BPCI-only groups, respectively (Table). Among episodes, patients in the Overlap group generally showed lower severity than those in other groups, although the differences were small. The BPCI-only, MSSP-only, and Overlap groups also exhibited small differences with respect to other characteristics such as the proportion of patients with Medicare/Medicaid dual-eligibility (15% of individual vs 16% and 12%, respectively) and prior use of skilled nursing facilities (33% vs 34% vs 31%, respectively) and acute care hospitals (45% vs 41% vs 39%, respectively) (P < .001 for all).

The overall overlap facing MSSP patients (overlap as a proportion of all MSSP patients) increased from 0.3% at the end of 2013 to 10% at the end of 2016, whereas over the same period, overlap facing bundled payment patients (overlap as a proportion of all bundled payment patients) increased from 11.9% to 27% (Appendix Figure). Overlap facing MSSP ACOs varied according to episode type, ranging from 3% for both acute myocardial infarction and chronic obstructive pulmonary disease episodes to 18% for automatic implantable cardiac defibrillator episodes at the end of 2016. Similarly, overlap facing bundled payment patients varied from 21% for spinal fusion episodes to 32% for lower extremity joint replacement and automatic implantable cardiac defibrillator episodes.

To our knowledge, this is the first study to describe the sizable and growing overlap facing ACOs with attributed patients who receive care at bundled payment hospitals, as well as bundled payment hospitals that treat patients attributed to ACOs.

The major implication of our findings is that policymakers must address and anticipate forthcoming payment model overlap as a key policy priority. Given the emphasis on ACOs and bundled payments as payment models—for example, Medicare continues to implement both nationwide via the Next Generation ACO model⁸ and the recently launched BPCI-Advanced program⁹—policymakers urgently need insights about the extent of payment model overlap. In that context, it is notable that although we have evaluated MSSP and BPCI as flagship programs, true overlap may actually be greater once other programs are considered.

Several factors may underlie the differences in the magnitude of overlap facing bundled payment versus ACO patients. The models differ in how they identify relevant patient populations, with patients falling under bundled payments via hospitalization for certain episode types but patients falling under ACOs via attribution based on the plurality of primary care services. Furthermore, BPCI participation lagged behind MSSP participation in time, while also occurring disproportionately in areas with existing MSSP ACOs.

Given these findings, understanding the implications of overlap should be a priority for future research and policy strategies. Potential policy considerations should include revising cost accounting processes so that when ACO-attributed patients receive episodic care at bundled payment hospitals, actual rather than historical hospital costs are counted toward ACO cost performance. To encourage hospitals to assume more accountability over outcomes—the ostensible overarching goal of value-based payment reform—Medicare could elect not to recoup savings from hospitals in both payment models. Although such changes require careful accounting to protect Medicare from financial losses as it forgoes some savings achieved through payment reforms, this may be worthwhile if hospital engagement in both models yields synergies.

Importantly, any policy changes made to address program overlap would need to accommodate ongoing changes in ACO, bundled payments, and other payment programs. For example, Medicare overhauled MSSP in December 2018. Compared to the earlier rules, in which ACOs could avoid downside financial risk altogether via “upside only” arrangements for up to six years, new MSSP rules require all participants to assume downside risk after several years of participation. Separately, forthcoming payment reforms such as direct contracting¹⁰ may draw clinicians and hospitals previously not participating in either Medicare fee-for-service or value-based payment models into payment reform. These factors may affect overlap in unpredictable ways (eg, they may increase the overlap by increasing the number of patients whose care is covered by different payment models or they may decrease overlap by raising the financial stakes of payment reforms to a degree that organizations drop out altogether).

This study has limitations. First, generalizability is limited by the fact that our analysis did not include bundled payment episodes assigned to physician group participants in BPCI or hospitals in mandatory joint replacement bundles under the Medicare Comprehensive Care for Joint Replacement model.¹¹ Second, although this study provides the first description of overlap between ACO and bundled payment programs, it was descriptive in nature. Future research is needed to evaluate the impact of overlap on clinical, quality, and cost outcomes. This is particularly important because although we observed only small differences in patient characteristics among MSSP-only, BPCI-only, and Overlap groups, characteristics could change differentially over time. Payment reforms must be carefully monitored for potentially unintended consequences that could arise from differential changes in patient characteristics (eg, cherry-picking behavior that is disadvantageous to vulnerable individuals).

Nonetheless, this study underscores the importance and extent of overlap and the urgency to consider policy measures to coordinate between the payment models.

Acknowledgments

The authors thank research assistance from Sandra Vanderslice who did not receive any compensation for her work. This research was supported in part by The Commonwealth Fund. Rachel Werner was supported in part by K24-AG047908 from the NIA.

With more than 3 million people diagnosed and more than 200,000 deaths worldwide at the time this article was written, coronavirus disease of 2019 (COVID-19) poses an unprecedented challenge to the public and to our healthcare system.¹ The United States has surpassed every other country in the total number of COVID-19 cases. Hospitals in hotspots are operating beyond capacity, while others prepare for a predicted surge of patients suffering from COVID-19. Now more than ever, clinicians need to prioritize limited time and resources wisely in this rapidly changing environment. Our most precious limited resource, healthcare workers (HCWs), bravely care for patients while trying to avoid acquiring the infection. With each test and treatment, clinicians must carefully consider harms and benefits, including exposing themselves and other HCWs to SARS-CoV-2, the virus causing this disease.

Delivering any healthcare service in which the potential harm exceeds benefit represents one form of overuse. In the era of COVID-19, the harmful consequences of overuse go beyond the patient to the healthcare team. For example, unnecessary chest computed tomography (CT) to help diagnose COVID-19 comes with the usual risks to the patient including radiation, but it may also reveal a suspicious nodule. That incidental finding can lead to downstream consequences, such as more imaging, blood work, and biopsy. In the current pandemic, however, that CT comes with more than just the usual risk. The initial unnecessary chest CT can risk exposing the transporter, the staff in the hallways and elevator en route, the radiology staff operating the CT scanner, and the maintenance staff who must clean the room and scanner afterward. Potential downstream harms to staff include exposure of the pulmonary and interventional radiology consultants, as well as the staff who perform repeat imaging after the biopsy. Evaluation of the nodule potentially prolongs the patient’s stay and exposes more staff. Clinicians must weigh the benefits and harms of each test and treatment carefully with consideration of both the patient and the staff involved. Moreover, it may turn out that the patient and staff without symptoms of COVID-19 may pose the most risk to one another.

Choosing Wisely® partnered with patients and clinician societies to develop a Top 5 recommendations list for eliminating unnecessary testing and treatment. Our multi-institutional group from the High Value Practice Academic Alliance proposed this Top 5 list of overuse practices in hospital medicine that can lead to harm of both patients and HCWs in the COVID-19 era (Table). The following recommendations apply to all patients with unsuspected, suspected, or confirmed SARS-CoV-2 infection in the hospital setting.

• Do not obtain nonurgent labs in separate blood draws if they can be batched together.

This recommendation expands on the original Society of Hospital Medicine Choosing Wisely recommendation: Don’t perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability.² Aside from patient harms such as pain and hospital-acquired anemia, the risk of exposure to HCWs who perform phlebotomy (phlebotomists, nurses, and other clinicians), as well as staff who transport, handle, and process the bloodwork in the lab, must be minimized. Most prior interventions to eliminate unnecessary bloodwork focused on the number of lab tests,³ but some also aimed to batch nonurgent labs together to effectively reduce unnecessary needlesticks (“think twice, stick once”).⁴ This concept can be brought into this pandemic to provide safe and appropriate care for both patients and HCWs.

• Do not use bronchodilators unless there is active obstructive airway disease, and if needed, use metered dose inhalers instead of nebulizers.

We do not recommend using bronchodilators to treat COVID-19 symptoms unless patients develop acute bronchospastic symptoms of their underlying obstructive airway disease.⁵ When needed, use metered dose inhalers (MDIs),⁶ if available, instead of nebulizers because the latter potentiates aerosolization that could lead to higher risk of spreading the infection. The risk extends to respiratory technicians and nurses who administer the nebulizer, as well as other HCWs who enter the room during or after administration. The Centers for Disease Control and Prevention (CDC) considers nebulized bronchodilator therapy a “high-risk” exposure for HCWs not wearing the proper personal protectvie equipment.⁷ Moreover, MDI therapy produces equivalent outcomes to nebulized treatments for patients who are not critically ill.⁶ Unfortunately, the supply of MDIs during this crisis has not kept up with the increased demand.⁸

There are no clear guidelines for reuse of MDIs in COVID-19; however, options include labeling patients’ MDIs to use for hospitalization and discharge or labeling an MDI for use during hospitalization and then disinfecting for reuse. For safety reasons, MDIs of COVID-19 patients should be reused only for other patients with COVID-19.⁸

• Do not use posteroanterior and lateral chest X-ray as initial imaging. Use a portable chest X-ray instead.

The CDC does not currently recommend diagnosing COVID-19 by chest X-ray (CXR).⁷ When used appropriately, CXR can provide information to support a COVID-19 diagnosis and rule out other etiologies that cause respiratory symptoms.⁹ Posteroanterior (PA) and lateral CXR are more sensitive than portable CXR for detecting pleural effusions, and lateral CXR is needed to examine structures along the axis of the body. Portable CXR also may cause the heart to appear magnified and the mediastinum widened, the diaphragm to appear higher, and vascular shadows to be obscured.¹⁰ The improved ability to detect these subtle differences should be weighed against the increased risk to HCWs required to perform PA and lateral CXR. A portable CXR exposes a relatively smaller number of staff who come to the bedside versus the larger number of people exposed in transporting the patient out of the room and into the hallway, elevator, and the radiology suite for a PA and lateral CXR.

• Avoid in-person evaluations in favor of virtual communication unless necessary.

To minimize HCW exposure to COVID-19 and optimize infection control, the CDC recommends the use of telemedicine when possible.⁷ Telemedicine refers to the use of technology to support clinical care across some distance, which includes video visits and remote clinical monitoring. At the time of writing, the Centers for Medicare & Medicaid Services had waived the rural site of care requirement for Medicare beneficiaries, granted 49 Medicaid waivers to states to enhance flexibility, and (at least temporarily) added inpatient care to the list of reimbursed telemedicine services.¹¹ Funding for expanded coverage under Medicare is included in the recent Coronavirus Preparedness and Response Supplemental Appropriations Act.¹² These federal changes open the door for commercial payers and state Medicaid programs to further boost telemedicine through reimbursement parity to in-person visits and other coverage policies. Hospitalists can ride this momentum and learn from ambulatory colleagues to harness the power of telemedicine and minimize unnecessary face-to-face interactions with patients who are suspected or confirmed to have COVID-19.¹³ Even if providers have to enter the patient’s room, telemedicine may still allow for large virtual family meetings despite strict visitor restrictions and physical distance with loved ones. If in-person visits are necessary, only one designated person should enter the patient’s room instead of the entire team.

• Do not delay goals of care conversations for hospitalized patients who are unlikely to benefit from life-sustaining treatments.

The COVID-19 pandemic amplifies the need for early goals of care discussions. Mortality rates range higher with acute respiratory distress syndrome from COVID-19, compared with other etiologies, and is associated with extended intensive care unit stays.¹⁴ The harms extend beyond the patient and families to our HCWs through psychological distress and heightened exposure from aerosolization during resuscitation. Advance care planning should center on the values and preferences of the patient. Rather than asking if the patient or family would want certain treatments, it is crucial for clinicians to be direct in making do-not-resuscitate recommendations if deemed futile care.¹⁵ This practice is well within legal confines and is distinct from withdrawal or withholding of life-sustaining resources.¹⁵

HCWs providing inpatient care during this pandemic remain among the highest risk for contracting the infection. As of April 9, 2020, nearly 9,300 HCWs in the United States have contracted COVID-19.¹⁶ One thing remains clear: If we want to protect our patients, we must start by protecting our HCWs. We must think critically to evaluate the potential harms to our extended healthcare teams and strive further to eliminate overuse from our care.

The authors represent members of the High Value Practice Academic Alliance. The High Value Practice Academic Alliance is a consortium of academic medical centers in the United States and Canada working to advance high-value healthcare through collaborative quality improvement, research, and education. Additional information is available at http://www.hvpaa.org.

With more than 3 million people diagnosed and more than 200,000 deaths worldwide at the time this article was written, coronavirus disease of 2019 (COVID-19) poses an unprecedented challenge to the public and to our healthcare system.¹ The United States has surpassed every other country in the total number of COVID-19 cases. Hospitals in hotspots are operating beyond capacity, while others prepare for a predicted surge of patients suffering from COVID-19. Now more than ever, clinicians need to prioritize limited time and resources wisely in this rapidly changing environment. Our most precious limited resource, healthcare workers (HCWs), bravely care for patients while trying to avoid acquiring the infection. With each test and treatment, clinicians must carefully consider harms and benefits, including exposing themselves and other HCWs to SARS-CoV-2, the virus causing this disease.

Delivering any healthcare service in which the potential harm exceeds benefit represents one form of overuse. In the era of COVID-19, the harmful consequences of overuse go beyond the patient to the healthcare team. For example, unnecessary chest computed tomography (CT) to help diagnose COVID-19 comes with the usual risks to the patient including radiation, but it may also reveal a suspicious nodule. That incidental finding can lead to downstream consequences, such as more imaging, blood work, and biopsy. In the current pandemic, however, that CT comes with more than just the usual risk. The initial unnecessary chest CT can risk exposing the transporter, the staff in the hallways and elevator en route, the radiology staff operating the CT scanner, and the maintenance staff who must clean the room and scanner afterward. Potential downstream harms to staff include exposure of the pulmonary and interventional radiology consultants, as well as the staff who perform repeat imaging after the biopsy. Evaluation of the nodule potentially prolongs the patient’s stay and exposes more staff. Clinicians must weigh the benefits and harms of each test and treatment carefully with consideration of both the patient and the staff involved. Moreover, it may turn out that the patient and staff without symptoms of COVID-19 may pose the most risk to one another.

Choosing Wisely® partnered with patients and clinician societies to develop a Top 5 recommendations list for eliminating unnecessary testing and treatment. Our multi-institutional group from the High Value Practice Academic Alliance proposed this Top 5 list of overuse practices in hospital medicine that can lead to harm of both patients and HCWs in the COVID-19 era (Table). The following recommendations apply to all patients with unsuspected, suspected, or confirmed SARS-CoV-2 infection in the hospital setting.

• Do not obtain nonurgent labs in separate blood draws if they can be batched together.

This recommendation expands on the original Society of Hospital Medicine Choosing Wisely recommendation: Don’t perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability.² Aside from patient harms such as pain and hospital-acquired anemia, the risk of exposure to HCWs who perform phlebotomy (phlebotomists, nurses, and other clinicians), as well as staff who transport, handle, and process the bloodwork in the lab, must be minimized. Most prior interventions to eliminate unnecessary bloodwork focused on the number of lab tests,³ but some also aimed to batch nonurgent labs together to effectively reduce unnecessary needlesticks (“think twice, stick once”).⁴ This concept can be brought into this pandemic to provide safe and appropriate care for both patients and HCWs.

• Do not use bronchodilators unless there is active obstructive airway disease, and if needed, use metered dose inhalers instead of nebulizers.

We do not recommend using bronchodilators to treat COVID-19 symptoms unless patients develop acute bronchospastic symptoms of their underlying obstructive airway disease.⁵ When needed, use metered dose inhalers (MDIs),⁶ if available, instead of nebulizers because the latter potentiates aerosolization that could lead to higher risk of spreading the infection. The risk extends to respiratory technicians and nurses who administer the nebulizer, as well as other HCWs who enter the room during or after administration. The Centers for Disease Control and Prevention (CDC) considers nebulized bronchodilator therapy a “high-risk” exposure for HCWs not wearing the proper personal protectvie equipment.⁷ Moreover, MDI therapy produces equivalent outcomes to nebulized treatments for patients who are not critically ill.⁶ Unfortunately, the supply of MDIs during this crisis has not kept up with the increased demand.⁸

There are no clear guidelines for reuse of MDIs in COVID-19; however, options include labeling patients’ MDIs to use for hospitalization and discharge or labeling an MDI for use during hospitalization and then disinfecting for reuse. For safety reasons, MDIs of COVID-19 patients should be reused only for other patients with COVID-19.⁸

• Do not use posteroanterior and lateral chest X-ray as initial imaging. Use a portable chest X-ray instead.

The CDC does not currently recommend diagnosing COVID-19 by chest X-ray (CXR).⁷ When used appropriately, CXR can provide information to support a COVID-19 diagnosis and rule out other etiologies that cause respiratory symptoms.⁹ Posteroanterior (PA) and lateral CXR are more sensitive than portable CXR for detecting pleural effusions, and lateral CXR is needed to examine structures along the axis of the body. Portable CXR also may cause the heart to appear magnified and the mediastinum widened, the diaphragm to appear higher, and vascular shadows to be obscured.¹⁰ The improved ability to detect these subtle differences should be weighed against the increased risk to HCWs required to perform PA and lateral CXR. A portable CXR exposes a relatively smaller number of staff who come to the bedside versus the larger number of people exposed in transporting the patient out of the room and into the hallway, elevator, and the radiology suite for a PA and lateral CXR.

• Avoid in-person evaluations in favor of virtual communication unless necessary.

To minimize HCW exposure to COVID-19 and optimize infection control, the CDC recommends the use of telemedicine when possible.⁷ Telemedicine refers to the use of technology to support clinical care across some distance, which includes video visits and remote clinical monitoring. At the time of writing, the Centers for Medicare & Medicaid Services had waived the rural site of care requirement for Medicare beneficiaries, granted 49 Medicaid waivers to states to enhance flexibility, and (at least temporarily) added inpatient care to the list of reimbursed telemedicine services.¹¹ Funding for expanded coverage under Medicare is included in the recent Coronavirus Preparedness and Response Supplemental Appropriations Act.¹² These federal changes open the door for commercial payers and state Medicaid programs to further boost telemedicine through reimbursement parity to in-person visits and other coverage policies. Hospitalists can ride this momentum and learn from ambulatory colleagues to harness the power of telemedicine and minimize unnecessary face-to-face interactions with patients who are suspected or confirmed to have COVID-19.¹³ Even if providers have to enter the patient’s room, telemedicine may still allow for large virtual family meetings despite strict visitor restrictions and physical distance with loved ones. If in-person visits are necessary, only one designated person should enter the patient’s room instead of the entire team.

• Do not delay goals of care conversations for hospitalized patients who are unlikely to benefit from life-sustaining treatments.

The COVID-19 pandemic amplifies the need for early goals of care discussions. Mortality rates range higher with acute respiratory distress syndrome from COVID-19, compared with other etiologies, and is associated with extended intensive care unit stays.¹⁴ The harms extend beyond the patient and families to our HCWs through psychological distress and heightened exposure from aerosolization during resuscitation. Advance care planning should center on the values and preferences of the patient. Rather than asking if the patient or family would want certain treatments, it is crucial for clinicians to be direct in making do-not-resuscitate recommendations if deemed futile care.¹⁵ This practice is well within legal confines and is distinct from withdrawal or withholding of life-sustaining resources.¹⁵

HCWs providing inpatient care during this pandemic remain among the highest risk for contracting the infection. As of April 9, 2020, nearly 9,300 HCWs in the United States have contracted COVID-19.¹⁶ One thing remains clear: If we want to protect our patients, we must start by protecting our HCWs. We must think critically to evaluate the potential harms to our extended healthcare teams and strive further to eliminate overuse from our care.

The authors represent members of the High Value Practice Academic Alliance. The High Value Practice Academic Alliance is a consortium of academic medical centers in the United States and Canada working to advance high-value healthcare through collaborative quality improvement, research, and education. Additional information is available at http://www.hvpaa.org.

With more than 3 million people diagnosed and more than 200,000 deaths worldwide at the time this article was written, coronavirus disease of 2019 (COVID-19) poses an unprecedented challenge to the public and to our healthcare system.¹ The United States has surpassed every other country in the total number of COVID-19 cases. Hospitals in hotspots are operating beyond capacity, while others prepare for a predicted surge of patients suffering from COVID-19. Now more than ever, clinicians need to prioritize limited time and resources wisely in this rapidly changing environment. Our most precious limited resource, healthcare workers (HCWs), bravely care for patients while trying to avoid acquiring the infection. With each test and treatment, clinicians must carefully consider harms and benefits, including exposing themselves and other HCWs to SARS-CoV-2, the virus causing this disease.

Delivering any healthcare service in which the potential harm exceeds benefit represents one form of overuse. In the era of COVID-19, the harmful consequences of overuse go beyond the patient to the healthcare team. For example, unnecessary chest computed tomography (CT) to help diagnose COVID-19 comes with the usual risks to the patient including radiation, but it may also reveal a suspicious nodule. That incidental finding can lead to downstream consequences, such as more imaging, blood work, and biopsy. In the current pandemic, however, that CT comes with more than just the usual risk. The initial unnecessary chest CT can risk exposing the transporter, the staff in the hallways and elevator en route, the radiology staff operating the CT scanner, and the maintenance staff who must clean the room and scanner afterward. Potential downstream harms to staff include exposure of the pulmonary and interventional radiology consultants, as well as the staff who perform repeat imaging after the biopsy. Evaluation of the nodule potentially prolongs the patient’s stay and exposes more staff. Clinicians must weigh the benefits and harms of each test and treatment carefully with consideration of both the patient and the staff involved. Moreover, it may turn out that the patient and staff without symptoms of COVID-19 may pose the most risk to one another.

Choosing Wisely® partnered with patients and clinician societies to develop a Top 5 recommendations list for eliminating unnecessary testing and treatment. Our multi-institutional group from the High Value Practice Academic Alliance proposed this Top 5 list of overuse practices in hospital medicine that can lead to harm of both patients and HCWs in the COVID-19 era (Table). The following recommendations apply to all patients with unsuspected, suspected, or confirmed SARS-CoV-2 infection in the hospital setting.

• Do not obtain nonurgent labs in separate blood draws if they can be batched together.

This recommendation expands on the original Society of Hospital Medicine Choosing Wisely recommendation: Don’t perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability.² Aside from patient harms such as pain and hospital-acquired anemia, the risk of exposure to HCWs who perform phlebotomy (phlebotomists, nurses, and other clinicians), as well as staff who transport, handle, and process the bloodwork in the lab, must be minimized. Most prior interventions to eliminate unnecessary bloodwork focused on the number of lab tests,³ but some also aimed to batch nonurgent labs together to effectively reduce unnecessary needlesticks (“think twice, stick once”).⁴ This concept can be brought into this pandemic to provide safe and appropriate care for both patients and HCWs.

• Do not use bronchodilators unless there is active obstructive airway disease, and if needed, use metered dose inhalers instead of nebulizers.

We do not recommend using bronchodilators to treat COVID-19 symptoms unless patients develop acute bronchospastic symptoms of their underlying obstructive airway disease.⁵ When needed, use metered dose inhalers (MDIs),⁶ if available, instead of nebulizers because the latter potentiates aerosolization that could lead to higher risk of spreading the infection. The risk extends to respiratory technicians and nurses who administer the nebulizer, as well as other HCWs who enter the room during or after administration. The Centers for Disease Control and Prevention (CDC) considers nebulized bronchodilator therapy a “high-risk” exposure for HCWs not wearing the proper personal protectvie equipment.⁷ Moreover, MDI therapy produces equivalent outcomes to nebulized treatments for patients who are not critically ill.⁶ Unfortunately, the supply of MDIs during this crisis has not kept up with the increased demand.⁸

There are no clear guidelines for reuse of MDIs in COVID-19; however, options include labeling patients’ MDIs to use for hospitalization and discharge or labeling an MDI for use during hospitalization and then disinfecting for reuse. For safety reasons, MDIs of COVID-19 patients should be reused only for other patients with COVID-19.⁸

• Do not use posteroanterior and lateral chest X-ray as initial imaging. Use a portable chest X-ray instead.

The CDC does not currently recommend diagnosing COVID-19 by chest X-ray (CXR).⁷ When used appropriately, CXR can provide information to support a COVID-19 diagnosis and rule out other etiologies that cause respiratory symptoms.⁹ Posteroanterior (PA) and lateral CXR are more sensitive than portable CXR for detecting pleural effusions, and lateral CXR is needed to examine structures along the axis of the body. Portable CXR also may cause the heart to appear magnified and the mediastinum widened, the diaphragm to appear higher, and vascular shadows to be obscured.¹⁰ The improved ability to detect these subtle differences should be weighed against the increased risk to HCWs required to perform PA and lateral CXR. A portable CXR exposes a relatively smaller number of staff who come to the bedside versus the larger number of people exposed in transporting the patient out of the room and into the hallway, elevator, and the radiology suite for a PA and lateral CXR.

• Avoid in-person evaluations in favor of virtual communication unless necessary.

To minimize HCW exposure to COVID-19 and optimize infection control, the CDC recommends the use of telemedicine when possible.⁷ Telemedicine refers to the use of technology to support clinical care across some distance, which includes video visits and remote clinical monitoring. At the time of writing, the Centers for Medicare & Medicaid Services had waived the rural site of care requirement for Medicare beneficiaries, granted 49 Medicaid waivers to states to enhance flexibility, and (at least temporarily) added inpatient care to the list of reimbursed telemedicine services.¹¹ Funding for expanded coverage under Medicare is included in the recent Coronavirus Preparedness and Response Supplemental Appropriations Act.¹² These federal changes open the door for commercial payers and state Medicaid programs to further boost telemedicine through reimbursement parity to in-person visits and other coverage policies. Hospitalists can ride this momentum and learn from ambulatory colleagues to harness the power of telemedicine and minimize unnecessary face-to-face interactions with patients who are suspected or confirmed to have COVID-19.¹³ Even if providers have to enter the patient’s room, telemedicine may still allow for large virtual family meetings despite strict visitor restrictions and physical distance with loved ones. If in-person visits are necessary, only one designated person should enter the patient’s room instead of the entire team.

• Do not delay goals of care conversations for hospitalized patients who are unlikely to benefit from life-sustaining treatments.

The COVID-19 pandemic amplifies the need for early goals of care discussions. Mortality rates range higher with acute respiratory distress syndrome from COVID-19, compared with other etiologies, and is associated with extended intensive care unit stays.¹⁴ The harms extend beyond the patient and families to our HCWs through psychological distress and heightened exposure from aerosolization during resuscitation. Advance care planning should center on the values and preferences of the patient. Rather than asking if the patient or family would want certain treatments, it is crucial for clinicians to be direct in making do-not-resuscitate recommendations if deemed futile care.¹⁵ This practice is well within legal confines and is distinct from withdrawal or withholding of life-sustaining resources.¹⁵

HCWs providing inpatient care during this pandemic remain among the highest risk for contracting the infection. As of April 9, 2020, nearly 9,300 HCWs in the United States have contracted COVID-19.¹⁶ One thing remains clear: If we want to protect our patients, we must start by protecting our HCWs. We must think critically to evaluate the potential harms to our extended healthcare teams and strive further to eliminate overuse from our care.

The authors represent members of the High Value Practice Academic Alliance. The High Value Practice Academic Alliance is a consortium of academic medical centers in the United States and Canada working to advance high-value healthcare through collaborative quality improvement, research, and education. Additional information is available at http://www.hvpaa.org.

As the death toll from the coronavirus disease 2019 (COVID-19) pandemic rapidly increases, the need to make a timely and accurate diagnosis has never been greater. Even before the pandemic, diagnostic errors (ie, missed, delayed, and incorrect diagnoses) had been one of the leading contributors to harm in health care.¹ The COVID-19 pandemic is likely to increase the risk of such errors for several reasons. The disease itself is new and knowledge of its clinical manifestations is still evolving. Both physical and psychological safety of clinicians and health system capacity are compromised and can affect clinical decision-making.² Situational factors such as staffing shortages and workarounds are more common, and clinicians in certain geographic areas are experiencing epic levels of stress, fatigue, and burnout. Finally, decisions in busy, chaotic and time-pressured healthcare systems with disrupted and/or newly designed care processes will be error prone.¹

Based on emerging literature and collaborative discussions across the globe, we propose a new typology of diagnostic errors of concern in the COVID-19 era (Table). These errors span the entire continuum of care and have both systems-based and cognitive origins. While some errors arise from previously described clinical reasoning fallacies, others are unique to the pandemic. We provide a user-friendly nomenclature while describing eight types of diagnostic errors and highlight mitigation strategies to reduce potential preventable harm caused by those errors.

The classic COVID-19 presentation of a febrile respiratory illness warrants confirmatory testing, but testing may not be available or produce a false-negative result, leading to an error we termed “Classic.” In the United States, efforts to develop and implement testing protocols are still evolving. There is wide local and regional variation in type and availability of tests, as well as accessibility of information regarding test performance characteristics or diagnostic yield.³ Test results that are false negatives or testing that is not performed can lead to delayed diagnosis of the disease, as well as continued spread.

Testing is similarly relevant when patients present with unusual or nonrespiratory symptoms. Both predominantly olfactory⁴ and gastrointestinal manifestations⁵ have now been described, and mysterious new associations, such as multisystem inflammatory syndromes, continue to emerge. A failure to recognize atypical presentations and associations, either because of testing problems or knowledge gaps, could lead to overlooking underlying COVID-19 diagnosis, an error we termed “Anomalous.”

Another error emerging in the pandemic is mislabeling patients who do not have COVID-19 as having the disease, particularly those with respiratory symptoms. This usually occurs in absence of testing in an overwhelmed health system with limited capacity to test or treat (eg, clinicians just assume it must be COVID-19 when the test is not available). This type of labeling error, called “Anchor,” introduces the risk of missing other respiratory infections such as bacterial sinusitis and pneumonia, as well as nonrespiratory conditions.

In patients with known COVID-19, a second underlying or concurrent condition may be missed, an error we termed “Secondary.” For instance, reports of coagulopathy-related pulmonary embolism⁶ and strokes in young patients with minimal symptoms⁷ have emerged just recently. Respiratory compromise may be mistakenly attributed to COVID-19 rather than looking for a new source of worsening, such as pulmonary embolism. Similarly, clinicians may not recognize subtle stroke symptoms in patients who were otherwise feeling well at home. Such cognitive errors will likely increase as it becomes harder for clinicians or health systems to keep up with new knowledge.

Collateral effects of the COVID-19 pandemic are also emerging. For instance, patients with symptoms of new acute conditions may be unwilling to visit acute care for evaluation because of infection risk, an error we termed “Acute Collateral.” Concerns are already being raised that patients with acute myocardial infarction⁸ and stroke⁹ are not coming in for evaluation. Similarly, there may be delays in diagnosis of important ambulatory conditions, including cancer,¹⁰ when appointments or elective procedures are canceled (“Chronic Collateral”). In the United Kingdom, referrals under the 2-week wait system–in which suspected cancer patients referred by general practitioners are seen within 2-weeks–fell by 70% over March to April, 2020.

Diagnosis of non–COVID-19 patients coming into the hospital may also be affected because of the understandably heightened state of attention to COVID-19 patients, capacity, and staffing issues, an error we termed “Strain.” Physicians, including surgeons, pediatricians, and radiologists, have been “redeployed” into acute care medical specialties. Cognitive errors increase when clinicians in new roles face unfamiliar situations and disease manifestations. Although these clinicians may be highly experienced previously, they may have insufficient skills and experience in their new roles and may not feel comfortable asking for guidance.¹¹

Lastly, clinicians are increasingly using intermediary mechanisms, such as PPE and telemedicine technologies, to interact with patients. This is new for both parties and could introduce new types of errors, which we termed “Unintended.” Furthermore, interactions mediated via telemedicine technologies or PPE, as well as PPE conservation measures such as reduced room entries and e-consultation, may reduce the ability of even well-trained clinicians to take effective histories, perform physical exams, and monitor symptoms. In fact, infection-prevention isolation has been shown to put patients at risk of preventable adverse events in hospitalized patients.¹²

There are many strategies that health systems could deploy to try to minimize these eight types of diagnostic errors. We organize mitigation strategies using the Safer Dx framework, which proposes sociotechnical approaches (ie, both technology and other systems-based approaches) to reduce diagnostic error.¹³

Technology for Cognitive Support

Up-to-date electronic decision support is needed to optimize test interpretation. Technology can also help scale and facilitate rapid adoption of standardized safety practices and protocols to address emerging risks areas. For instance, there are early efforts to create, implement, and disseminate smart algorithms to predict risks of non–COVID-19 diagnoses such as venous thromboembolism, patient transfer protocols on how best to reduce the burden at overstressed hospitals, protocols to triage rescheduling of elective procedures based on potential risk as determined from data in the electronic health record, new rules for creating outreach to patients who have missed appointments to prevent delays in their evaluation and diagnosis, and triage protocols and follow-up systems to optimize telemedicine.¹⁴

Optimized Workflow and Communication

When in-person contact is limited, specific practices (eg, providing patients with iPads, use of reflective listening, and use of optimal nonverbal communication strategies such as eye-contact) can still facilitate comprehensive discussions with patients and families about symptoms and encourage them to speak up if and when they have concerns.¹⁵ For patients reached through telemedicine, follow-up appointments and surveys should be done to ensure that symptoms and concerns have been addressed. For clinicians working in new clinical areas unfamiliar to them (eg, surgeons on medical floors, hospitalists in ICUs), buddy systems can pair these clinicians with more experienced clinicians to make it easier for them to ask for help. Visual aids, decision support, and reliable error-prevention resources can also be helpful.¹⁶

People-Focused Interventions

Some clinicians are used to practicing solo, but this is the time to start “diagnostic huddles” for discussion of challenging cases with symptoms that are unusual or not improving as expected or for determining whether anything has been missed. In addition to encouraging patients to use reliable digital tools for self-triage, outreach to patients and the public must also advise them (with the help of public health authorities and the media) to seek medical assistance for certain important conditions such as acute myocardial infarction and stroke.

Organizational Strategies

Fundamental safety strategies must be ensured. First, it is critical to have a strong safety culture in which staff feel empowered to speak up, ask questions or ask for help, and report concerns without fear of repercussions or judgement. Culture can take years to develop, but due to rapidly changing circumstances in a crisis, there are ways for healthcare leaders to create changes more quickly. In addition to having daily huddles, leaders should be visible and communicate clearly about the behaviors and norms they are supporting. In particular, frequent leadership rounding (either virtually or in person)—during which leaders ask questions and encourage discussions of concerns in a supportive way—can foster the kind of culture that is needed. All organizations should implement peer support, counseling, limits on hours worked, and other support strategies for all clinicians to minimize the fatigue, stress, and anxiety that can impair cognitive function.¹⁷

Organizations must also be able to identify these errors to help understand root causes and prioritize interventions.¹⁸ For example, streamlined reporting systems that use apps and hotlines could be developed quickly to ensure that clinicians and patients/families can easily report these errors. Electronic triggers can help detect specific situations indicative of error or delay (eg, patient not on precautions gets switched to precautions during a hospitalization; absence of follow-up on abnormal tests).¹⁹

Learning systems—both within and across hospitals—should continue to share diagnostic challenges, the most up-to-date information, and best practices/protocols, and identify opportunities for improvement together. Many hospitals are having virtual grand rounds, journals are rapidly sharing new information via open access, regional and national cross-organizational and multidisciplinary learning networks of various groups have emerged (such as networks of oncologists, infectious disease specialists, and hospitalists), and new and transparent communication channels have developed between state and local health departments, government leaders, health systems, and the public. These forums should discuss emerging knowledge on diagnosis and strategies for risk reduction, many of which will unfold over the next few months.

State/Federal Policies and Regulations

While there is progress, additional challenges with accessibility, accuracy and performance of testing should be addressed at a national level. Guidance is needed on which asymptomatic people should be tested, both within and outside hospitals. Standardized metrics should be developed to monitor diagnostic performance and outcomes and evaluate how COVID-19 diagnosis errors affect different demographics. For instance, black and Hispanic individuals are disproportionately represented in COVID-19 cases and deaths, so metrics could be further stratified by race and ethnicity to ensure that we can understand and eliminate inequities, such as lack of access to care or testing.²⁰

Clinicians must be provided with both cognitive and system support so they can do what they do best—diagnose and treat patients and save lives. Intermittent epidemic spikes based on location and season, including a potentially bigger spike of cases later this year, are now projected. Risks and recommendations discussed herein should therefore be rapidly shared to help redesign and strengthen the work system and protect patients from preventable diagnosis-related harm.

The views expressed in this article do not represent the views of the U.S. Department of Veterans Affairs or the United States government.

As the death toll from the coronavirus disease 2019 (COVID-19) pandemic rapidly increases, the need to make a timely and accurate diagnosis has never been greater. Even before the pandemic, diagnostic errors (ie, missed, delayed, and incorrect diagnoses) had been one of the leading contributors to harm in health care.¹ The COVID-19 pandemic is likely to increase the risk of such errors for several reasons. The disease itself is new and knowledge of its clinical manifestations is still evolving. Both physical and psychological safety of clinicians and health system capacity are compromised and can affect clinical decision-making.² Situational factors such as staffing shortages and workarounds are more common, and clinicians in certain geographic areas are experiencing epic levels of stress, fatigue, and burnout. Finally, decisions in busy, chaotic and time-pressured healthcare systems with disrupted and/or newly designed care processes will be error prone.¹

Based on emerging literature and collaborative discussions across the globe, we propose a new typology of diagnostic errors of concern in the COVID-19 era (Table). These errors span the entire continuum of care and have both systems-based and cognitive origins. While some errors arise from previously described clinical reasoning fallacies, others are unique to the pandemic. We provide a user-friendly nomenclature while describing eight types of diagnostic errors and highlight mitigation strategies to reduce potential preventable harm caused by those errors.

The classic COVID-19 presentation of a febrile respiratory illness warrants confirmatory testing, but testing may not be available or produce a false-negative result, leading to an error we termed “Classic.” In the United States, efforts to develop and implement testing protocols are still evolving. There is wide local and regional variation in type and availability of tests, as well as accessibility of information regarding test performance characteristics or diagnostic yield.³ Test results that are false negatives or testing that is not performed can lead to delayed diagnosis of the disease, as well as continued spread.

Testing is similarly relevant when patients present with unusual or nonrespiratory symptoms. Both predominantly olfactory⁴ and gastrointestinal manifestations⁵ have now been described, and mysterious new associations, such as multisystem inflammatory syndromes, continue to emerge. A failure to recognize atypical presentations and associations, either because of testing problems or knowledge gaps, could lead to overlooking underlying COVID-19 diagnosis, an error we termed “Anomalous.”

Another error emerging in the pandemic is mislabeling patients who do not have COVID-19 as having the disease, particularly those with respiratory symptoms. This usually occurs in absence of testing in an overwhelmed health system with limited capacity to test or treat (eg, clinicians just assume it must be COVID-19 when the test is not available). This type of labeling error, called “Anchor,” introduces the risk of missing other respiratory infections such as bacterial sinusitis and pneumonia, as well as nonrespiratory conditions.

In patients with known COVID-19, a second underlying or concurrent condition may be missed, an error we termed “Secondary.” For instance, reports of coagulopathy-related pulmonary embolism⁶ and strokes in young patients with minimal symptoms⁷ have emerged just recently. Respiratory compromise may be mistakenly attributed to COVID-19 rather than looking for a new source of worsening, such as pulmonary embolism. Similarly, clinicians may not recognize subtle stroke symptoms in patients who were otherwise feeling well at home. Such cognitive errors will likely increase as it becomes harder for clinicians or health systems to keep up with new knowledge.

Collateral effects of the COVID-19 pandemic are also emerging. For instance, patients with symptoms of new acute conditions may be unwilling to visit acute care for evaluation because of infection risk, an error we termed “Acute Collateral.” Concerns are already being raised that patients with acute myocardial infarction⁸ and stroke⁹ are not coming in for evaluation. Similarly, there may be delays in diagnosis of important ambulatory conditions, including cancer,¹⁰ when appointments or elective procedures are canceled (“Chronic Collateral”). In the United Kingdom, referrals under the 2-week wait system–in which suspected cancer patients referred by general practitioners are seen within 2-weeks–fell by 70% over March to April, 2020.

Diagnosis of non–COVID-19 patients coming into the hospital may also be affected because of the understandably heightened state of attention to COVID-19 patients, capacity, and staffing issues, an error we termed “Strain.” Physicians, including surgeons, pediatricians, and radiologists, have been “redeployed” into acute care medical specialties. Cognitive errors increase when clinicians in new roles face unfamiliar situations and disease manifestations. Although these clinicians may be highly experienced previously, they may have insufficient skills and experience in their new roles and may not feel comfortable asking for guidance.¹¹

Lastly, clinicians are increasingly using intermediary mechanisms, such as PPE and telemedicine technologies, to interact with patients. This is new for both parties and could introduce new types of errors, which we termed “Unintended.” Furthermore, interactions mediated via telemedicine technologies or PPE, as well as PPE conservation measures such as reduced room entries and e-consultation, may reduce the ability of even well-trained clinicians to take effective histories, perform physical exams, and monitor symptoms. In fact, infection-prevention isolation has been shown to put patients at risk of preventable adverse events in hospitalized patients.¹²

There are many strategies that health systems could deploy to try to minimize these eight types of diagnostic errors. We organize mitigation strategies using the Safer Dx framework, which proposes sociotechnical approaches (ie, both technology and other systems-based approaches) to reduce diagnostic error.¹³

Technology for Cognitive Support

Up-to-date electronic decision support is needed to optimize test interpretation. Technology can also help scale and facilitate rapid adoption of standardized safety practices and protocols to address emerging risks areas. For instance, there are early efforts to create, implement, and disseminate smart algorithms to predict risks of non–COVID-19 diagnoses such as venous thromboembolism, patient transfer protocols on how best to reduce the burden at overstressed hospitals, protocols to triage rescheduling of elective procedures based on potential risk as determined from data in the electronic health record, new rules for creating outreach to patients who have missed appointments to prevent delays in their evaluation and diagnosis, and triage protocols and follow-up systems to optimize telemedicine.¹⁴

Optimized Workflow and Communication

When in-person contact is limited, specific practices (eg, providing patients with iPads, use of reflective listening, and use of optimal nonverbal communication strategies such as eye-contact) can still facilitate comprehensive discussions with patients and families about symptoms and encourage them to speak up if and when they have concerns.¹⁵ For patients reached through telemedicine, follow-up appointments and surveys should be done to ensure that symptoms and concerns have been addressed. For clinicians working in new clinical areas unfamiliar to them (eg, surgeons on medical floors, hospitalists in ICUs), buddy systems can pair these clinicians with more experienced clinicians to make it easier for them to ask for help. Visual aids, decision support, and reliable error-prevention resources can also be helpful.¹⁶

People-Focused Interventions

Some clinicians are used to practicing solo, but this is the time to start “diagnostic huddles” for discussion of challenging cases with symptoms that are unusual or not improving as expected or for determining whether anything has been missed. In addition to encouraging patients to use reliable digital tools for self-triage, outreach to patients and the public must also advise them (with the help of public health authorities and the media) to seek medical assistance for certain important conditions such as acute myocardial infarction and stroke.

Organizational Strategies

Fundamental safety strategies must be ensured. First, it is critical to have a strong safety culture in which staff feel empowered to speak up, ask questions or ask for help, and report concerns without fear of repercussions or judgement. Culture can take years to develop, but due to rapidly changing circumstances in a crisis, there are ways for healthcare leaders to create changes more quickly. In addition to having daily huddles, leaders should be visible and communicate clearly about the behaviors and norms they are supporting. In particular, frequent leadership rounding (either virtually or in person)—during which leaders ask questions and encourage discussions of concerns in a supportive way—can foster the kind of culture that is needed. All organizations should implement peer support, counseling, limits on hours worked, and other support strategies for all clinicians to minimize the fatigue, stress, and anxiety that can impair cognitive function.¹⁷

Organizations must also be able to identify these errors to help understand root causes and prioritize interventions.¹⁸ For example, streamlined reporting systems that use apps and hotlines could be developed quickly to ensure that clinicians and patients/families can easily report these errors. Electronic triggers can help detect specific situations indicative of error or delay (eg, patient not on precautions gets switched to precautions during a hospitalization; absence of follow-up on abnormal tests).¹⁹

Learning systems—both within and across hospitals—should continue to share diagnostic challenges, the most up-to-date information, and best practices/protocols, and identify opportunities for improvement together. Many hospitals are having virtual grand rounds, journals are rapidly sharing new information via open access, regional and national cross-organizational and multidisciplinary learning networks of various groups have emerged (such as networks of oncologists, infectious disease specialists, and hospitalists), and new and transparent communication channels have developed between state and local health departments, government leaders, health systems, and the public. These forums should discuss emerging knowledge on diagnosis and strategies for risk reduction, many of which will unfold over the next few months.

State/Federal Policies and Regulations

While there is progress, additional challenges with accessibility, accuracy and performance of testing should be addressed at a national level. Guidance is needed on which asymptomatic people should be tested, both within and outside hospitals. Standardized metrics should be developed to monitor diagnostic performance and outcomes and evaluate how COVID-19 diagnosis errors affect different demographics. For instance, black and Hispanic individuals are disproportionately represented in COVID-19 cases and deaths, so metrics could be further stratified by race and ethnicity to ensure that we can understand and eliminate inequities, such as lack of access to care or testing.²⁰

Clinicians must be provided with both cognitive and system support so they can do what they do best—diagnose and treat patients and save lives. Intermittent epidemic spikes based on location and season, including a potentially bigger spike of cases later this year, are now projected. Risks and recommendations discussed herein should therefore be rapidly shared to help redesign and strengthen the work system and protect patients from preventable diagnosis-related harm.

The views expressed in this article do not represent the views of the U.S. Department of Veterans Affairs or the United States government.

As the death toll from the coronavirus disease 2019 (COVID-19) pandemic rapidly increases, the need to make a timely and accurate diagnosis has never been greater. Even before the pandemic, diagnostic errors (ie, missed, delayed, and incorrect diagnoses) had been one of the leading contributors to harm in health care.¹ The COVID-19 pandemic is likely to increase the risk of such errors for several reasons. The disease itself is new and knowledge of its clinical manifestations is still evolving. Both physical and psychological safety of clinicians and health system capacity are compromised and can affect clinical decision-making.² Situational factors such as staffing shortages and workarounds are more common, and clinicians in certain geographic areas are experiencing epic levels of stress, fatigue, and burnout. Finally, decisions in busy, chaotic and time-pressured healthcare systems with disrupted and/or newly designed care processes will be error prone.¹

Based on emerging literature and collaborative discussions across the globe, we propose a new typology of diagnostic errors of concern in the COVID-19 era (Table). These errors span the entire continuum of care and have both systems-based and cognitive origins. While some errors arise from previously described clinical reasoning fallacies, others are unique to the pandemic. We provide a user-friendly nomenclature while describing eight types of diagnostic errors and highlight mitigation strategies to reduce potential preventable harm caused by those errors.

The classic COVID-19 presentation of a febrile respiratory illness warrants confirmatory testing, but testing may not be available or produce a false-negative result, leading to an error we termed “Classic.” In the United States, efforts to develop and implement testing protocols are still evolving. There is wide local and regional variation in type and availability of tests, as well as accessibility of information regarding test performance characteristics or diagnostic yield.³ Test results that are false negatives or testing that is not performed can lead to delayed diagnosis of the disease, as well as continued spread.

Testing is similarly relevant when patients present with unusual or nonrespiratory symptoms. Both predominantly olfactory⁴ and gastrointestinal manifestations⁵ have now been described, and mysterious new associations, such as multisystem inflammatory syndromes, continue to emerge. A failure to recognize atypical presentations and associations, either because of testing problems or knowledge gaps, could lead to overlooking underlying COVID-19 diagnosis, an error we termed “Anomalous.”

Another error emerging in the pandemic is mislabeling patients who do not have COVID-19 as having the disease, particularly those with respiratory symptoms. This usually occurs in absence of testing in an overwhelmed health system with limited capacity to test or treat (eg, clinicians just assume it must be COVID-19 when the test is not available). This type of labeling error, called “Anchor,” introduces the risk of missing other respiratory infections such as bacterial sinusitis and pneumonia, as well as nonrespiratory conditions.

In patients with known COVID-19, a second underlying or concurrent condition may be missed, an error we termed “Secondary.” For instance, reports of coagulopathy-related pulmonary embolism⁶ and strokes in young patients with minimal symptoms⁷ have emerged just recently. Respiratory compromise may be mistakenly attributed to COVID-19 rather than looking for a new source of worsening, such as pulmonary embolism. Similarly, clinicians may not recognize subtle stroke symptoms in patients who were otherwise feeling well at home. Such cognitive errors will likely increase as it becomes harder for clinicians or health systems to keep up with new knowledge.

Collateral effects of the COVID-19 pandemic are also emerging. For instance, patients with symptoms of new acute conditions may be unwilling to visit acute care for evaluation because of infection risk, an error we termed “Acute Collateral.” Concerns are already being raised that patients with acute myocardial infarction⁸ and stroke⁹ are not coming in for evaluation. Similarly, there may be delays in diagnosis of important ambulatory conditions, including cancer,¹⁰ when appointments or elective procedures are canceled (“Chronic Collateral”). In the United Kingdom, referrals under the 2-week wait system–in which suspected cancer patients referred by general practitioners are seen within 2-weeks–fell by 70% over March to April, 2020.

Diagnosis of non–COVID-19 patients coming into the hospital may also be affected because of the understandably heightened state of attention to COVID-19 patients, capacity, and staffing issues, an error we termed “Strain.” Physicians, including surgeons, pediatricians, and radiologists, have been “redeployed” into acute care medical specialties. Cognitive errors increase when clinicians in new roles face unfamiliar situations and disease manifestations. Although these clinicians may be highly experienced previously, they may have insufficient skills and experience in their new roles and may not feel comfortable asking for guidance.¹¹

Lastly, clinicians are increasingly using intermediary mechanisms, such as PPE and telemedicine technologies, to interact with patients. This is new for both parties and could introduce new types of errors, which we termed “Unintended.” Furthermore, interactions mediated via telemedicine technologies or PPE, as well as PPE conservation measures such as reduced room entries and e-consultation, may reduce the ability of even well-trained clinicians to take effective histories, perform physical exams, and monitor symptoms. In fact, infection-prevention isolation has been shown to put patients at risk of preventable adverse events in hospitalized patients.¹²

There are many strategies that health systems could deploy to try to minimize these eight types of diagnostic errors. We organize mitigation strategies using the Safer Dx framework, which proposes sociotechnical approaches (ie, both technology and other systems-based approaches) to reduce diagnostic error.¹³

Technology for Cognitive Support

Up-to-date electronic decision support is needed to optimize test interpretation. Technology can also help scale and facilitate rapid adoption of standardized safety practices and protocols to address emerging risks areas. For instance, there are early efforts to create, implement, and disseminate smart algorithms to predict risks of non–COVID-19 diagnoses such as venous thromboembolism, patient transfer protocols on how best to reduce the burden at overstressed hospitals, protocols to triage rescheduling of elective procedures based on potential risk as determined from data in the electronic health record, new rules for creating outreach to patients who have missed appointments to prevent delays in their evaluation and diagnosis, and triage protocols and follow-up systems to optimize telemedicine.¹⁴

Optimized Workflow and Communication

When in-person contact is limited, specific practices (eg, providing patients with iPads, use of reflective listening, and use of optimal nonverbal communication strategies such as eye-contact) can still facilitate comprehensive discussions with patients and families about symptoms and encourage them to speak up if and when they have concerns.¹⁵ For patients reached through telemedicine, follow-up appointments and surveys should be done to ensure that symptoms and concerns have been addressed. For clinicians working in new clinical areas unfamiliar to them (eg, surgeons on medical floors, hospitalists in ICUs), buddy systems can pair these clinicians with more experienced clinicians to make it easier for them to ask for help. Visual aids, decision support, and reliable error-prevention resources can also be helpful.¹⁶

People-Focused Interventions

Some clinicians are used to practicing solo, but this is the time to start “diagnostic huddles” for discussion of challenging cases with symptoms that are unusual or not improving as expected or for determining whether anything has been missed. In addition to encouraging patients to use reliable digital tools for self-triage, outreach to patients and the public must also advise them (with the help of public health authorities and the media) to seek medical assistance for certain important conditions such as acute myocardial infarction and stroke.

Organizational Strategies

Fundamental safety strategies must be ensured. First, it is critical to have a strong safety culture in which staff feel empowered to speak up, ask questions or ask for help, and report concerns without fear of repercussions or judgement. Culture can take years to develop, but due to rapidly changing circumstances in a crisis, there are ways for healthcare leaders to create changes more quickly. In addition to having daily huddles, leaders should be visible and communicate clearly about the behaviors and norms they are supporting. In particular, frequent leadership rounding (either virtually or in person)—during which leaders ask questions and encourage discussions of concerns in a supportive way—can foster the kind of culture that is needed. All organizations should implement peer support, counseling, limits on hours worked, and other support strategies for all clinicians to minimize the fatigue, stress, and anxiety that can impair cognitive function.¹⁷

Organizations must also be able to identify these errors to help understand root causes and prioritize interventions.¹⁸ For example, streamlined reporting systems that use apps and hotlines could be developed quickly to ensure that clinicians and patients/families can easily report these errors. Electronic triggers can help detect specific situations indicative of error or delay (eg, patient not on precautions gets switched to precautions during a hospitalization; absence of follow-up on abnormal tests).¹⁹

Learning systems—both within and across hospitals—should continue to share diagnostic challenges, the most up-to-date information, and best practices/protocols, and identify opportunities for improvement together. Many hospitals are having virtual grand rounds, journals are rapidly sharing new information via open access, regional and national cross-organizational and multidisciplinary learning networks of various groups have emerged (such as networks of oncologists, infectious disease specialists, and hospitalists), and new and transparent communication channels have developed between state and local health departments, government leaders, health systems, and the public. These forums should discuss emerging knowledge on diagnosis and strategies for risk reduction, many of which will unfold over the next few months.

State/Federal Policies and Regulations

While there is progress, additional challenges with accessibility, accuracy and performance of testing should be addressed at a national level. Guidance is needed on which asymptomatic people should be tested, both within and outside hospitals. Standardized metrics should be developed to monitor diagnostic performance and outcomes and evaluate how COVID-19 diagnosis errors affect different demographics. For instance, black and Hispanic individuals are disproportionately represented in COVID-19 cases and deaths, so metrics could be further stratified by race and ethnicity to ensure that we can understand and eliminate inequities, such as lack of access to care or testing.²⁰

Clinicians must be provided with both cognitive and system support so they can do what they do best—diagnose and treat patients and save lives. Intermittent epidemic spikes based on location and season, including a potentially bigger spike of cases later this year, are now projected. Risks and recommendations discussed herein should therefore be rapidly shared to help redesign and strengthen the work system and protect patients from preventable diagnosis-related harm.

The views expressed in this article do not represent the views of the U.S. Department of Veterans Affairs or the United States government.

The coronavirus disease of 2019 (COVID-19) pandemic has strained the healthcare system by rapidly depleting multiple resources including hospital space, medications, ventilators, personal protective equipment (PPE), clinical revenue, and morale. One of the most essential at-risk resources is healthcare providers. Healthcare providers have been overwhelmed as hospital systems have experienced local surges in COVID-19 patients. Compounding this is the fact that providers are more likely to contract COVID-19, which could sideline portions of an already taxed workforce.

Multiple “surge” interventions have been planned or implemented to mitigate a current or anticipated dearth of physicians. Some institutions are reallocating subspecialists and surgeons to general ward and intensive care unit (ICU) roles, often with support from hospitalists and ICU physicians.¹ Others have used telemedicine to reduce personnel exposure and conserve PPE.² A novel and perhaps paradigm-shifting solution arose in March 2020 when several medical schools around the world announced they would graduate final year students early to allow them to join the workforce during the COVID-19 surge.^3-7 In the United States, fourth-year medical students at multiple institutions in cities such as New York, Boston, Phoenix, Tucson, Newark, Portland, and Bethesda were offered the opportunity to graduate in April rather than in May or June. The Liaison Committee on Medical Education stated that for students to graduate early, they must have already met all curricular requirements and be deemed ready by an evaluations and promotions committee.⁸ What these early graduates do with their “gap time” before residency is neither standardized nor prescribed. The Accreditation Council for Graduate Medical Education has discouraged individuals from joining their newly matched residency programs early.⁹ Some early graduates who wish to bolster the workforce have signed temporary training agreements with local healthcare systems to work for a 1- to 2-month period before moving on to their matched residency program. Some institutions have already been working with local and state officials to rapidly grant provisional temporary licenses for this purpose.¹⁰

Early medical school graduation in times of international crisis is not without precedent. When faced with physician shortages during World War II, the United States federal government urged medical colleges to graduate trainees in 3 years.¹¹ The national medical education milieu was different then, with standardized medical school training still crystalizing merely 30 years following the Flexner report. However, there was pressure from the federal government during World War II, whereas decisions around early graduation today are driven by institutional and local officials. While a few accelerated programs persist today, there has not been an urgent, unplanned early release of graduates to meet a public health need on such a large scale in recent history. The seasonal timing of the pandemic surge in the United States may have been a key factor in deciding to graduate students early. With a late winter and early spring peak, final year students are graduating only 2 to 3 months early. But what if another peak occurs in late summer or early fall, and some students are graduated even earlier? With which aspects of patient care would hospitalists trust these graduates, and with what level of supervision? Whether now or with a future COVID-19 peak, we describe how trust develops with learners and provide hospitalists with a framework for deliberate entrustment if and when they are asked to integrate early medical school graduates into their workforce.

The degree of supervision that is provided to a learner is linked to how much a supervisor trusts the learner, as well as the specific context. Trust has many forms, often depending on what type of information informs it. Presumptive trust is trust based on credentials, without any actual interaction with the learner.¹² Healthcare systems typically assume that medical school graduates are ready to perform intern-level tasks based on their medical degree. This presumptive trust may be bolstered by the assumption that a residency program director has vetted a learner’s credentials during the match process. On meeting a learner, we develop initial trust, which is based on first impressions and snap-judgment. Over time, presumptive and initial trust can be replaced by grounded trust, or trust based on demonstrated performance after prolonged experience with a learner. Under normal circumstances, supervisors use observations of learner performance in the clinical environment to develop grounded trust. With early graduates, especially those who sign temporary work agreements, the usual progression of trust may be compressed. Hospitalists may have less presumptive trust because these students graduated early and little time to develop grounded trust before integrating new graduates into patient care. How should hospitalists navigate supervision in this setting?

Missing a few months at the end of medical school likely does not significantly affect competence and, therefore, should not affect presumptive trust. The value of the fourth year of medical school has been questioned because, after fulfilling graduation requirements, students often spend significant amounts of time interviewing, traveling, taking electives with lighter workloads, or exploring nonclinical interests late in the year.¹³ More intense “subintern” rotations, which are important for the residency application process, occur earlier in the academic year. It is therefore reasonable to presume that most students graduating in April are not less prepared than those graduating in June.

Additionally, there is significant interlearner variability in rates of competence attainment.¹⁴ This means that there is no magic point in time at which students are fully ready for resident-­level responsibilities. Some students are likely competent to be interns without a fourth year at all, while others are still facing challenges in their development at the end of medical school. As Englander and Carraccio wrote, “The notion that every medical student across the nation has somehow achieved all the competencies necessary to start residency training on July 1 of their graduation year is magical thinking.”¹⁵ Since there is no universal, time-based finish line for competence, we should not be thrown by a slight change in the arbitrary line currently drawn in June. Whether students graduate in April or June, it remains true that some will be more ready than others.

With compressed timelines, hospitalists may default to initial trust, relying heavily on first impressions to determine how much supervision an early graduate requires. For example, a graduate who is extroverted, assertive, and articulate may give off an air of confidence, which could entice a supervising hospitalist to give a “longer leash” with higher-risk patient care tasks. It is easy to fall prey to the “confidence equals competence” heuristic, but this has been shown to be unreliable.¹⁶ Initial trust is influenced by both social biases (eg, gender, race, age) and cognitive biases (eg, halo effect) that have little or nothing to do with the actual abilities of learners. While initial trust and accompanying biases often develop unconsciously, it is important to reflect on how unfounded first impressions can influence trust and supervision decisions.

Hospitalists must be deliberate with entrustment decisions, especially in a pandemic environment. There are useful guides for making these decisions that can be used in a point-of-care manner.¹⁷ First, it is important to acknowledge that entrustment is based in part on the perceived trustworthiness of a person. Kennedy and colleagues have described four components of trustworthiness, all of which can be assessed by hospitalists in the moment of care delivery: (1) knowledge and skill (Does the trainee possess the requisite knowledge and skill to perform the task?), (2) conscientiousness (Does the trainee follow through on tasks? Are they thorough and dependable?), (3) discernment (Does the trainee recognize personal limitations and seek help when needed?), and (4) truthfulness (Does the trainee tell the truth?).¹⁷

Entrustment decisions also depend on the specific task being observed (eg, high risk vs low risk) and context (eg, severity of illness of the patient, acuity of the setting).¹⁸ Trust is linked with perceived risk and benefits.¹⁹ More entrustment (less supervision) may be given when perceived risk is low, such as prescribing acetaminophen on a stable patient or taking an initial history. Less entrustment (more supervision) may be given when perceived risk is high, such as with managing septic shock or inserting a central venous catheter. However, the duress of the COVID-19 pandemic may tilt the risk/benefit balance toward less-than-usual supervision if an early graduate is the only provider available for some higher-risk tasks. This underscores the importance of direct observation leading to grounded trust with progressively higher-risk tasks as dictated by the local pandemic environment.

As much as possible, trust should be determined based on direct observation, not fallible first impressions or inference. Supervisors often use inference when assuming that performance on one task reflects performance on others. For example, if learners are observed to be competent when interpreting electrocardiograms, one might infer they also know how to manage tachyarrhythmias. If they can manage tachyarrhythmias, one might infer they also know how to manage acute coronary syndrome. These inferences are not the way to build grounded trust because competence is task and context dependent.

Direct observation can include watching patient interactions, being present for procedures, think-alouds during didactics, cognitive autopsies, reviewing notes, and informal conversations. Being deliberate with direct observation and entrustment decision-making can be challenging because of the high cognitive load of caring for sick and complex patients, maintaining proper PPE practices, and simultaneously assessing an early graduate’s performance. However, maintaining a level of supervision that is appropriate for trainee competence is paramount for patient safety. It may be valuable to identify tasks needing to be performed by early graduates and using focused simulation to generate a significant number of observations over a short period of time. Trust should be gained once competence is observed, not inferred or assumed. Instead of “trust, but verify,” we should “observe, then trust.”

There is a moral obligation to patients to avoid placing trainees in situations for which they are ill prepared based on their current abilities. We must balance the risk that exists both in leaving early graduates on the sidelines (overprotecting them as learners) and in asking them to perform tasks for which they are not prepared (overextending them as a workforce). Focusing on grounded trust derived from direct observation of performance while also balancing the risks and benefits inherent in the local pandemic context can help hospitalists calibrate supervision to a level that helps extend the workforce in a time of crisis while maintaining patient safety.

The coronavirus disease of 2019 (COVID-19) pandemic has strained the healthcare system by rapidly depleting multiple resources including hospital space, medications, ventilators, personal protective equipment (PPE), clinical revenue, and morale. One of the most essential at-risk resources is healthcare providers. Healthcare providers have been overwhelmed as hospital systems have experienced local surges in COVID-19 patients. Compounding this is the fact that providers are more likely to contract COVID-19, which could sideline portions of an already taxed workforce.

Multiple “surge” interventions have been planned or implemented to mitigate a current or anticipated dearth of physicians. Some institutions are reallocating subspecialists and surgeons to general ward and intensive care unit (ICU) roles, often with support from hospitalists and ICU physicians.¹ Others have used telemedicine to reduce personnel exposure and conserve PPE.² A novel and perhaps paradigm-shifting solution arose in March 2020 when several medical schools around the world announced they would graduate final year students early to allow them to join the workforce during the COVID-19 surge.^3-7 In the United States, fourth-year medical students at multiple institutions in cities such as New York, Boston, Phoenix, Tucson, Newark, Portland, and Bethesda were offered the opportunity to graduate in April rather than in May or June. The Liaison Committee on Medical Education stated that for students to graduate early, they must have already met all curricular requirements and be deemed ready by an evaluations and promotions committee.⁸ What these early graduates do with their “gap time” before residency is neither standardized nor prescribed. The Accreditation Council for Graduate Medical Education has discouraged individuals from joining their newly matched residency programs early.⁹ Some early graduates who wish to bolster the workforce have signed temporary training agreements with local healthcare systems to work for a 1- to 2-month period before moving on to their matched residency program. Some institutions have already been working with local and state officials to rapidly grant provisional temporary licenses for this purpose.¹⁰

Early medical school graduation in times of international crisis is not without precedent. When faced with physician shortages during World War II, the United States federal government urged medical colleges to graduate trainees in 3 years.¹¹ The national medical education milieu was different then, with standardized medical school training still crystalizing merely 30 years following the Flexner report. However, there was pressure from the federal government during World War II, whereas decisions around early graduation today are driven by institutional and local officials. While a few accelerated programs persist today, there has not been an urgent, unplanned early release of graduates to meet a public health need on such a large scale in recent history. The seasonal timing of the pandemic surge in the United States may have been a key factor in deciding to graduate students early. With a late winter and early spring peak, final year students are graduating only 2 to 3 months early. But what if another peak occurs in late summer or early fall, and some students are graduated even earlier? With which aspects of patient care would hospitalists trust these graduates, and with what level of supervision? Whether now or with a future COVID-19 peak, we describe how trust develops with learners and provide hospitalists with a framework for deliberate entrustment if and when they are asked to integrate early medical school graduates into their workforce.

The degree of supervision that is provided to a learner is linked to how much a supervisor trusts the learner, as well as the specific context. Trust has many forms, often depending on what type of information informs it. Presumptive trust is trust based on credentials, without any actual interaction with the learner.¹² Healthcare systems typically assume that medical school graduates are ready to perform intern-level tasks based on their medical degree. This presumptive trust may be bolstered by the assumption that a residency program director has vetted a learner’s credentials during the match process. On meeting a learner, we develop initial trust, which is based on first impressions and snap-judgment. Over time, presumptive and initial trust can be replaced by grounded trust, or trust based on demonstrated performance after prolonged experience with a learner. Under normal circumstances, supervisors use observations of learner performance in the clinical environment to develop grounded trust. With early graduates, especially those who sign temporary work agreements, the usual progression of trust may be compressed. Hospitalists may have less presumptive trust because these students graduated early and little time to develop grounded trust before integrating new graduates into patient care. How should hospitalists navigate supervision in this setting?

Missing a few months at the end of medical school likely does not significantly affect competence and, therefore, should not affect presumptive trust. The value of the fourth year of medical school has been questioned because, after fulfilling graduation requirements, students often spend significant amounts of time interviewing, traveling, taking electives with lighter workloads, or exploring nonclinical interests late in the year.¹³ More intense “subintern” rotations, which are important for the residency application process, occur earlier in the academic year. It is therefore reasonable to presume that most students graduating in April are not less prepared than those graduating in June.

Additionally, there is significant interlearner variability in rates of competence attainment.¹⁴ This means that there is no magic point in time at which students are fully ready for resident-­level responsibilities. Some students are likely competent to be interns without a fourth year at all, while others are still facing challenges in their development at the end of medical school. As Englander and Carraccio wrote, “The notion that every medical student across the nation has somehow achieved all the competencies necessary to start residency training on July 1 of their graduation year is magical thinking.”¹⁵ Since there is no universal, time-based finish line for competence, we should not be thrown by a slight change in the arbitrary line currently drawn in June. Whether students graduate in April or June, it remains true that some will be more ready than others.

With compressed timelines, hospitalists may default to initial trust, relying heavily on first impressions to determine how much supervision an early graduate requires. For example, a graduate who is extroverted, assertive, and articulate may give off an air of confidence, which could entice a supervising hospitalist to give a “longer leash” with higher-risk patient care tasks. It is easy to fall prey to the “confidence equals competence” heuristic, but this has been shown to be unreliable.¹⁶ Initial trust is influenced by both social biases (eg, gender, race, age) and cognitive biases (eg, halo effect) that have little or nothing to do with the actual abilities of learners. While initial trust and accompanying biases often develop unconsciously, it is important to reflect on how unfounded first impressions can influence trust and supervision decisions.

Hospitalists must be deliberate with entrustment decisions, especially in a pandemic environment. There are useful guides for making these decisions that can be used in a point-of-care manner.¹⁷ First, it is important to acknowledge that entrustment is based in part on the perceived trustworthiness of a person. Kennedy and colleagues have described four components of trustworthiness, all of which can be assessed by hospitalists in the moment of care delivery: (1) knowledge and skill (Does the trainee possess the requisite knowledge and skill to perform the task?), (2) conscientiousness (Does the trainee follow through on tasks? Are they thorough and dependable?), (3) discernment (Does the trainee recognize personal limitations and seek help when needed?), and (4) truthfulness (Does the trainee tell the truth?).¹⁷

Entrustment decisions also depend on the specific task being observed (eg, high risk vs low risk) and context (eg, severity of illness of the patient, acuity of the setting).¹⁸ Trust is linked with perceived risk and benefits.¹⁹ More entrustment (less supervision) may be given when perceived risk is low, such as prescribing acetaminophen on a stable patient or taking an initial history. Less entrustment (more supervision) may be given when perceived risk is high, such as with managing septic shock or inserting a central venous catheter. However, the duress of the COVID-19 pandemic may tilt the risk/benefit balance toward less-than-usual supervision if an early graduate is the only provider available for some higher-risk tasks. This underscores the importance of direct observation leading to grounded trust with progressively higher-risk tasks as dictated by the local pandemic environment.

As much as possible, trust should be determined based on direct observation, not fallible first impressions or inference. Supervisors often use inference when assuming that performance on one task reflects performance on others. For example, if learners are observed to be competent when interpreting electrocardiograms, one might infer they also know how to manage tachyarrhythmias. If they can manage tachyarrhythmias, one might infer they also know how to manage acute coronary syndrome. These inferences are not the way to build grounded trust because competence is task and context dependent.

Direct observation can include watching patient interactions, being present for procedures, think-alouds during didactics, cognitive autopsies, reviewing notes, and informal conversations. Being deliberate with direct observation and entrustment decision-making can be challenging because of the high cognitive load of caring for sick and complex patients, maintaining proper PPE practices, and simultaneously assessing an early graduate’s performance. However, maintaining a level of supervision that is appropriate for trainee competence is paramount for patient safety. It may be valuable to identify tasks needing to be performed by early graduates and using focused simulation to generate a significant number of observations over a short period of time. Trust should be gained once competence is observed, not inferred or assumed. Instead of “trust, but verify,” we should “observe, then trust.”

There is a moral obligation to patients to avoid placing trainees in situations for which they are ill prepared based on their current abilities. We must balance the risk that exists both in leaving early graduates on the sidelines (overprotecting them as learners) and in asking them to perform tasks for which they are not prepared (overextending them as a workforce). Focusing on grounded trust derived from direct observation of performance while also balancing the risks and benefits inherent in the local pandemic context can help hospitalists calibrate supervision to a level that helps extend the workforce in a time of crisis while maintaining patient safety.

The coronavirus disease of 2019 (COVID-19) pandemic has strained the healthcare system by rapidly depleting multiple resources including hospital space, medications, ventilators, personal protective equipment (PPE), clinical revenue, and morale. One of the most essential at-risk resources is healthcare providers. Healthcare providers have been overwhelmed as hospital systems have experienced local surges in COVID-19 patients. Compounding this is the fact that providers are more likely to contract COVID-19, which could sideline portions of an already taxed workforce.

Multiple “surge” interventions have been planned or implemented to mitigate a current or anticipated dearth of physicians. Some institutions are reallocating subspecialists and surgeons to general ward and intensive care unit (ICU) roles, often with support from hospitalists and ICU physicians.¹ Others have used telemedicine to reduce personnel exposure and conserve PPE.² A novel and perhaps paradigm-shifting solution arose in March 2020 when several medical schools around the world announced they would graduate final year students early to allow them to join the workforce during the COVID-19 surge.^3-7 In the United States, fourth-year medical students at multiple institutions in cities such as New York, Boston, Phoenix, Tucson, Newark, Portland, and Bethesda were offered the opportunity to graduate in April rather than in May or June. The Liaison Committee on Medical Education stated that for students to graduate early, they must have already met all curricular requirements and be deemed ready by an evaluations and promotions committee.⁸ What these early graduates do with their “gap time” before residency is neither standardized nor prescribed. The Accreditation Council for Graduate Medical Education has discouraged individuals from joining their newly matched residency programs early.⁹ Some early graduates who wish to bolster the workforce have signed temporary training agreements with local healthcare systems to work for a 1- to 2-month period before moving on to their matched residency program. Some institutions have already been working with local and state officials to rapidly grant provisional temporary licenses for this purpose.¹⁰

Early medical school graduation in times of international crisis is not without precedent. When faced with physician shortages during World War II, the United States federal government urged medical colleges to graduate trainees in 3 years.¹¹ The national medical education milieu was different then, with standardized medical school training still crystalizing merely 30 years following the Flexner report. However, there was pressure from the federal government during World War II, whereas decisions around early graduation today are driven by institutional and local officials. While a few accelerated programs persist today, there has not been an urgent, unplanned early release of graduates to meet a public health need on such a large scale in recent history. The seasonal timing of the pandemic surge in the United States may have been a key factor in deciding to graduate students early. With a late winter and early spring peak, final year students are graduating only 2 to 3 months early. But what if another peak occurs in late summer or early fall, and some students are graduated even earlier? With which aspects of patient care would hospitalists trust these graduates, and with what level of supervision? Whether now or with a future COVID-19 peak, we describe how trust develops with learners and provide hospitalists with a framework for deliberate entrustment if and when they are asked to integrate early medical school graduates into their workforce.

The degree of supervision that is provided to a learner is linked to how much a supervisor trusts the learner, as well as the specific context. Trust has many forms, often depending on what type of information informs it. Presumptive trust is trust based on credentials, without any actual interaction with the learner.¹² Healthcare systems typically assume that medical school graduates are ready to perform intern-level tasks based on their medical degree. This presumptive trust may be bolstered by the assumption that a residency program director has vetted a learner’s credentials during the match process. On meeting a learner, we develop initial trust, which is based on first impressions and snap-judgment. Over time, presumptive and initial trust can be replaced by grounded trust, or trust based on demonstrated performance after prolonged experience with a learner. Under normal circumstances, supervisors use observations of learner performance in the clinical environment to develop grounded trust. With early graduates, especially those who sign temporary work agreements, the usual progression of trust may be compressed. Hospitalists may have less presumptive trust because these students graduated early and little time to develop grounded trust before integrating new graduates into patient care. How should hospitalists navigate supervision in this setting?

Missing a few months at the end of medical school likely does not significantly affect competence and, therefore, should not affect presumptive trust. The value of the fourth year of medical school has been questioned because, after fulfilling graduation requirements, students often spend significant amounts of time interviewing, traveling, taking electives with lighter workloads, or exploring nonclinical interests late in the year.¹³ More intense “subintern” rotations, which are important for the residency application process, occur earlier in the academic year. It is therefore reasonable to presume that most students graduating in April are not less prepared than those graduating in June.

Additionally, there is significant interlearner variability in rates of competence attainment.¹⁴ This means that there is no magic point in time at which students are fully ready for resident-­level responsibilities. Some students are likely competent to be interns without a fourth year at all, while others are still facing challenges in their development at the end of medical school. As Englander and Carraccio wrote, “The notion that every medical student across the nation has somehow achieved all the competencies necessary to start residency training on July 1 of their graduation year is magical thinking.”¹⁵ Since there is no universal, time-based finish line for competence, we should not be thrown by a slight change in the arbitrary line currently drawn in June. Whether students graduate in April or June, it remains true that some will be more ready than others.

With compressed timelines, hospitalists may default to initial trust, relying heavily on first impressions to determine how much supervision an early graduate requires. For example, a graduate who is extroverted, assertive, and articulate may give off an air of confidence, which could entice a supervising hospitalist to give a “longer leash” with higher-risk patient care tasks. It is easy to fall prey to the “confidence equals competence” heuristic, but this has been shown to be unreliable.¹⁶ Initial trust is influenced by both social biases (eg, gender, race, age) and cognitive biases (eg, halo effect) that have little or nothing to do with the actual abilities of learners. While initial trust and accompanying biases often develop unconsciously, it is important to reflect on how unfounded first impressions can influence trust and supervision decisions.

Hospitalists must be deliberate with entrustment decisions, especially in a pandemic environment. There are useful guides for making these decisions that can be used in a point-of-care manner.¹⁷ First, it is important to acknowledge that entrustment is based in part on the perceived trustworthiness of a person. Kennedy and colleagues have described four components of trustworthiness, all of which can be assessed by hospitalists in the moment of care delivery: (1) knowledge and skill (Does the trainee possess the requisite knowledge and skill to perform the task?), (2) conscientiousness (Does the trainee follow through on tasks? Are they thorough and dependable?), (3) discernment (Does the trainee recognize personal limitations and seek help when needed?), and (4) truthfulness (Does the trainee tell the truth?).¹⁷

Entrustment decisions also depend on the specific task being observed (eg, high risk vs low risk) and context (eg, severity of illness of the patient, acuity of the setting).¹⁸ Trust is linked with perceived risk and benefits.¹⁹ More entrustment (less supervision) may be given when perceived risk is low, such as prescribing acetaminophen on a stable patient or taking an initial history. Less entrustment (more supervision) may be given when perceived risk is high, such as with managing septic shock or inserting a central venous catheter. However, the duress of the COVID-19 pandemic may tilt the risk/benefit balance toward less-than-usual supervision if an early graduate is the only provider available for some higher-risk tasks. This underscores the importance of direct observation leading to grounded trust with progressively higher-risk tasks as dictated by the local pandemic environment.

As much as possible, trust should be determined based on direct observation, not fallible first impressions or inference. Supervisors often use inference when assuming that performance on one task reflects performance on others. For example, if learners are observed to be competent when interpreting electrocardiograms, one might infer they also know how to manage tachyarrhythmias. If they can manage tachyarrhythmias, one might infer they also know how to manage acute coronary syndrome. These inferences are not the way to build grounded trust because competence is task and context dependent.

Direct observation can include watching patient interactions, being present for procedures, think-alouds during didactics, cognitive autopsies, reviewing notes, and informal conversations. Being deliberate with direct observation and entrustment decision-making can be challenging because of the high cognitive load of caring for sick and complex patients, maintaining proper PPE practices, and simultaneously assessing an early graduate’s performance. However, maintaining a level of supervision that is appropriate for trainee competence is paramount for patient safety. It may be valuable to identify tasks needing to be performed by early graduates and using focused simulation to generate a significant number of observations over a short period of time. Trust should be gained once competence is observed, not inferred or assumed. Instead of “trust, but verify,” we should “observe, then trust.”

There is a moral obligation to patients to avoid placing trainees in situations for which they are ill prepared based on their current abilities. We must balance the risk that exists both in leaving early graduates on the sidelines (overprotecting them as learners) and in asking them to perform tasks for which they are not prepared (overextending them as a workforce). Focusing on grounded trust derived from direct observation of performance while also balancing the risks and benefits inherent in the local pandemic context can help hospitalists calibrate supervision to a level that helps extend the workforce in a time of crisis while maintaining patient safety.

During the severe acute respiratory syndrome (SARS) outbreak in 2003, Taiwan reported 346 confirmed cases and 73 deaths.¹ Of all known infections, 94% were transmitted inside hospitals. Nine major hospitals were fully or partially shut down, and many doctors and nurses quit for fear of becoming infected. The Taipei Municipal Ho-Ping Hospital was most severely affected. Its index patient, a 42-year-old undocumented hospital laundry worker who interacted with staff and patients for 6 days before being hospitalized, became a superspreader, infecting at least 20 other patients and 10 staff members.^2,3 The entire 450-bed hospital was ordered to shut down, and all 930 staff and 240 patients were quarantined within the hospital. The central government appointed the previous Minister of Health as head of the Anti-SARS Taskforce. Ultimately the hospital was evacuated; the outbreak resulted in 26 deaths.² Events surrounding the hospital’s evacuation offer important lessons for hospitals struggling to cope with the COVID-19 pandemic, which has been caused by spread of a similar coronavirus.

Flexibility about case definition is important, as is use of clinical criteria for diagnosis when reliable laboratory tests are not available.

The laundry worker of Ho-Ping Hospital was initially misdiagnosed with infectious enteritis, which delayed proper management and, crucially, isolation from other patients. The low index of suspicion for SARS reflected the initial World Health Organization diagnostic criteria for SARS, which included travel to or residence in an area with recent local transmission of SARS within 10 days of symptom onset.⁴ The laundry worker did not have a recent travel history.³ Additionally, SARS manifested as a lower respiratory tract infection, so many patients were hospitalized for pneumonia before being diagnosed with SARS. Similarly, the Wuhan Municipal Health Commission initially issued diagnostic criteria for COVID-19 that, in addition to fever and symptoms of respiratory infections, emphasized direct exposure to the Huanan Seafood Wholesale Market.⁵ As a result, many cases of COVID-19 were not identified.

Diagnosing SARS was challenging. Early symptoms such as fever and malaise were nonspecific. Polymerase chain reaction tests, although available, were unreliable especially in early stages of the disease and had a high false-negative rate. As cases of SARS increased rapidly, Taiwan began using fever alone for early detection.⁶ Patients and hospital staff received temperature measurements twice daily. Despite the late start to SARS screening, the fever criterion identified many suspected patients, which ensured widespread detection and containment.

For COVID-19, symptoms such as fever, dry cough, and shortness of breath can be used as clinical criteria to triage patients for quarantine in endemic areas when reliable diagnostic tests are not readily available, but all frontline clinical staff should receive daily temperature checks and/or COVID-19 tests, if available, to protect their families and the public.

Ineffective coordination between central and local governments can delay response, but this can be remedied.

During the SARS outbreak, the Taipei City Government and the Taiwan central government were controlled by opposing political parties. Responses to SARS were initially impeded by political skirmishes, which hindered implementation of policies regarding criteria for diagnosis, tracking of suspected cases and their contacts, duration of quarantine, and allocation of resources and facilities for confirmed cases. To avoid further delays, the central government acted swiftly to create the nonpartisan Anti-SARS Taskforce and appointed leaders who could work cordially with both local and central government agencies. To help to deal with the crisis, the central government also designated a new Minister of Health, an epidemiologist, who became the first nonphysician to hold this position.

Treatment in place vs evacuation during hospital infections is a critical decision.

The surge of SARS cases at Ho-Ping Hospital led to confusion and panic among patients and hospital staff. Whether to treat its SARS patients on site or to evacuate the hospital was a complex decision and reflected many concerns, including the following: How many wards had been infected? Was there sufficient equipment (eg, respirators) to monitor or treat infected patients? How many isolation beds were available? How many hospital staff were already infected and quarantined? Were they in different wards? Were there neighboring facilities (eg, hospitals, military camps, dorms) available for quarantine?

If a hospital has sufficient capacity to isolate persons under investigation and to treat confirmed patients, on-site treatment is possible. However, evacuation should be considered when there is widespread infection involving different hospital wards and hospital staff. In such cases, patients should be transferred to different facilities based on clinical severity: Patients with new onset fever or respiratory symptoms but who are relatively healthy should be sent to community or regional hospitals with isolation rooms for monitoring; sicker infected patients should be sent to medical centers; and other hospitalized patients (eg, admitted for heart failure) without infection risk or symptoms should seek care elsewhere.

So far, there has been only one instance of hospital-based COVID-19 infections in Taiwan, and the spread of infection was quickly contained within one ward. All nine confirmed cases (including the index patient, one patient in the same ward but a different room, three nurses, one laundry worker, and three members of patients’ families) and their known contacts were identified, then isolated or quarantined individually. Because the affected hospital is part of a complex with more than 3,000 beds, it was big enough to accommodate all infected patients and no evacuation measures were needed. To further reduce potential nodes in the chain of transmission, interns and many other healthcare workers were temporarily relieved of their duties, elective surgeries were canceled, and hospital visitation was limited to immediate family members. The clear communication of intervention measures ensured rapid cooperation and staved off both social panic and further spread of the disease.

Hospitals should establish different flows for different patients.

Having learned from the SARS experience in 2003, hospitals in Taiwan have designated specific pathways to manage patient flow during the COVID-19 outbreak, in addition to checking all patients for travel history and fever: Patients with fever were quickly triaged to a designated fever clinic so they did not mingle with other patients, patients visiting the hospital to obtain chronic disease medications were directed to a “drive-through” lane, patients needing emergent care went through the emergency department, all other regular outpatients were seen in outpatient departments, and visitors of patients were restricted to one visitor per patient at a given time.

Healthcare providers should be organized into blocks and modular teams to avoid hospital-wide infection.

After SARS, Taiwan learned that one way to reduce the spread of something like COVID-19 among healthcare providers and from providers to patients is to divide providers’ work areas into discrete blocks and organize providers into modular teams. This approach was inspired by the design of watertight compartments in ships: Should the hull be breached, flooding is restricted to the breached compartments. Under this organizational strategy, movements of physicians and nurses would be restricted to their designated locations: They would be routinely exposed only to other staff and patients within their division. Doctors and nurses would be asked to practice in modular teams within their blocked locations, reducing the likelihood that infection in one team would spread to another, which could lead to hospital-wide infections. Movement of senior hospital executives would be similarly restricted. Common areas such as cafeterias where people mingle would be closed. Owing to these stringent initiatives, aside from the hospital-­based infection mentioned in Lesson 3, no other hospital-­based infections have been reported in Taiwan so far.

Lessons from previous hospital-based coronavirus infections can be used to minimize future infections.

The authors would like to thank Dr Lee Ming-Liang, former Health Minister of Taiwan and director of that central government’s Anti-SARS Taskforce during the 2003 outbreak, for providing valuable recommendations to this work.

During the severe acute respiratory syndrome (SARS) outbreak in 2003, Taiwan reported 346 confirmed cases and 73 deaths.¹ Of all known infections, 94% were transmitted inside hospitals. Nine major hospitals were fully or partially shut down, and many doctors and nurses quit for fear of becoming infected. The Taipei Municipal Ho-Ping Hospital was most severely affected. Its index patient, a 42-year-old undocumented hospital laundry worker who interacted with staff and patients for 6 days before being hospitalized, became a superspreader, infecting at least 20 other patients and 10 staff members.^2,3 The entire 450-bed hospital was ordered to shut down, and all 930 staff and 240 patients were quarantined within the hospital. The central government appointed the previous Minister of Health as head of the Anti-SARS Taskforce. Ultimately the hospital was evacuated; the outbreak resulted in 26 deaths.² Events surrounding the hospital’s evacuation offer important lessons for hospitals struggling to cope with the COVID-19 pandemic, which has been caused by spread of a similar coronavirus.

Flexibility about case definition is important, as is use of clinical criteria for diagnosis when reliable laboratory tests are not available.

The laundry worker of Ho-Ping Hospital was initially misdiagnosed with infectious enteritis, which delayed proper management and, crucially, isolation from other patients. The low index of suspicion for SARS reflected the initial World Health Organization diagnostic criteria for SARS, which included travel to or residence in an area with recent local transmission of SARS within 10 days of symptom onset.⁴ The laundry worker did not have a recent travel history.³ Additionally, SARS manifested as a lower respiratory tract infection, so many patients were hospitalized for pneumonia before being diagnosed with SARS. Similarly, the Wuhan Municipal Health Commission initially issued diagnostic criteria for COVID-19 that, in addition to fever and symptoms of respiratory infections, emphasized direct exposure to the Huanan Seafood Wholesale Market.⁵ As a result, many cases of COVID-19 were not identified.

Diagnosing SARS was challenging. Early symptoms such as fever and malaise were nonspecific. Polymerase chain reaction tests, although available, were unreliable especially in early stages of the disease and had a high false-negative rate. As cases of SARS increased rapidly, Taiwan began using fever alone for early detection.⁶ Patients and hospital staff received temperature measurements twice daily. Despite the late start to SARS screening, the fever criterion identified many suspected patients, which ensured widespread detection and containment.

For COVID-19, symptoms such as fever, dry cough, and shortness of breath can be used as clinical criteria to triage patients for quarantine in endemic areas when reliable diagnostic tests are not readily available, but all frontline clinical staff should receive daily temperature checks and/or COVID-19 tests, if available, to protect their families and the public.

Ineffective coordination between central and local governments can delay response, but this can be remedied.

During the SARS outbreak, the Taipei City Government and the Taiwan central government were controlled by opposing political parties. Responses to SARS were initially impeded by political skirmishes, which hindered implementation of policies regarding criteria for diagnosis, tracking of suspected cases and their contacts, duration of quarantine, and allocation of resources and facilities for confirmed cases. To avoid further delays, the central government acted swiftly to create the nonpartisan Anti-SARS Taskforce and appointed leaders who could work cordially with both local and central government agencies. To help to deal with the crisis, the central government also designated a new Minister of Health, an epidemiologist, who became the first nonphysician to hold this position.

Treatment in place vs evacuation during hospital infections is a critical decision.

The surge of SARS cases at Ho-Ping Hospital led to confusion and panic among patients and hospital staff. Whether to treat its SARS patients on site or to evacuate the hospital was a complex decision and reflected many concerns, including the following: How many wards had been infected? Was there sufficient equipment (eg, respirators) to monitor or treat infected patients? How many isolation beds were available? How many hospital staff were already infected and quarantined? Were they in different wards? Were there neighboring facilities (eg, hospitals, military camps, dorms) available for quarantine?

If a hospital has sufficient capacity to isolate persons under investigation and to treat confirmed patients, on-site treatment is possible. However, evacuation should be considered when there is widespread infection involving different hospital wards and hospital staff. In such cases, patients should be transferred to different facilities based on clinical severity: Patients with new onset fever or respiratory symptoms but who are relatively healthy should be sent to community or regional hospitals with isolation rooms for monitoring; sicker infected patients should be sent to medical centers; and other hospitalized patients (eg, admitted for heart failure) without infection risk or symptoms should seek care elsewhere.

So far, there has been only one instance of hospital-based COVID-19 infections in Taiwan, and the spread of infection was quickly contained within one ward. All nine confirmed cases (including the index patient, one patient in the same ward but a different room, three nurses, one laundry worker, and three members of patients’ families) and their known contacts were identified, then isolated or quarantined individually. Because the affected hospital is part of a complex with more than 3,000 beds, it was big enough to accommodate all infected patients and no evacuation measures were needed. To further reduce potential nodes in the chain of transmission, interns and many other healthcare workers were temporarily relieved of their duties, elective surgeries were canceled, and hospital visitation was limited to immediate family members. The clear communication of intervention measures ensured rapid cooperation and staved off both social panic and further spread of the disease.

Hospitals should establish different flows for different patients.

Having learned from the SARS experience in 2003, hospitals in Taiwan have designated specific pathways to manage patient flow during the COVID-19 outbreak, in addition to checking all patients for travel history and fever: Patients with fever were quickly triaged to a designated fever clinic so they did not mingle with other patients, patients visiting the hospital to obtain chronic disease medications were directed to a “drive-through” lane, patients needing emergent care went through the emergency department, all other regular outpatients were seen in outpatient departments, and visitors of patients were restricted to one visitor per patient at a given time.

Healthcare providers should be organized into blocks and modular teams to avoid hospital-wide infection.

After SARS, Taiwan learned that one way to reduce the spread of something like COVID-19 among healthcare providers and from providers to patients is to divide providers’ work areas into discrete blocks and organize providers into modular teams. This approach was inspired by the design of watertight compartments in ships: Should the hull be breached, flooding is restricted to the breached compartments. Under this organizational strategy, movements of physicians and nurses would be restricted to their designated locations: They would be routinely exposed only to other staff and patients within their division. Doctors and nurses would be asked to practice in modular teams within their blocked locations, reducing the likelihood that infection in one team would spread to another, which could lead to hospital-wide infections. Movement of senior hospital executives would be similarly restricted. Common areas such as cafeterias where people mingle would be closed. Owing to these stringent initiatives, aside from the hospital-­based infection mentioned in Lesson 3, no other hospital-­based infections have been reported in Taiwan so far.

Lessons from previous hospital-based coronavirus infections can be used to minimize future infections.

The authors would like to thank Dr Lee Ming-Liang, former Health Minister of Taiwan and director of that central government’s Anti-SARS Taskforce during the 2003 outbreak, for providing valuable recommendations to this work.

During the severe acute respiratory syndrome (SARS) outbreak in 2003, Taiwan reported 346 confirmed cases and 73 deaths.¹ Of all known infections, 94% were transmitted inside hospitals. Nine major hospitals were fully or partially shut down, and many doctors and nurses quit for fear of becoming infected. The Taipei Municipal Ho-Ping Hospital was most severely affected. Its index patient, a 42-year-old undocumented hospital laundry worker who interacted with staff and patients for 6 days before being hospitalized, became a superspreader, infecting at least 20 other patients and 10 staff members.^2,3 The entire 450-bed hospital was ordered to shut down, and all 930 staff and 240 patients were quarantined within the hospital. The central government appointed the previous Minister of Health as head of the Anti-SARS Taskforce. Ultimately the hospital was evacuated; the outbreak resulted in 26 deaths.² Events surrounding the hospital’s evacuation offer important lessons for hospitals struggling to cope with the COVID-19 pandemic, which has been caused by spread of a similar coronavirus.

Flexibility about case definition is important, as is use of clinical criteria for diagnosis when reliable laboratory tests are not available.

The laundry worker of Ho-Ping Hospital was initially misdiagnosed with infectious enteritis, which delayed proper management and, crucially, isolation from other patients. The low index of suspicion for SARS reflected the initial World Health Organization diagnostic criteria for SARS, which included travel to or residence in an area with recent local transmission of SARS within 10 days of symptom onset.⁴ The laundry worker did not have a recent travel history.³ Additionally, SARS manifested as a lower respiratory tract infection, so many patients were hospitalized for pneumonia before being diagnosed with SARS. Similarly, the Wuhan Municipal Health Commission initially issued diagnostic criteria for COVID-19 that, in addition to fever and symptoms of respiratory infections, emphasized direct exposure to the Huanan Seafood Wholesale Market.⁵ As a result, many cases of COVID-19 were not identified.

Diagnosing SARS was challenging. Early symptoms such as fever and malaise were nonspecific. Polymerase chain reaction tests, although available, were unreliable especially in early stages of the disease and had a high false-negative rate. As cases of SARS increased rapidly, Taiwan began using fever alone for early detection.⁶ Patients and hospital staff received temperature measurements twice daily. Despite the late start to SARS screening, the fever criterion identified many suspected patients, which ensured widespread detection and containment.

For COVID-19, symptoms such as fever, dry cough, and shortness of breath can be used as clinical criteria to triage patients for quarantine in endemic areas when reliable diagnostic tests are not readily available, but all frontline clinical staff should receive daily temperature checks and/or COVID-19 tests, if available, to protect their families and the public.

Ineffective coordination between central and local governments can delay response, but this can be remedied.

During the SARS outbreak, the Taipei City Government and the Taiwan central government were controlled by opposing political parties. Responses to SARS were initially impeded by political skirmishes, which hindered implementation of policies regarding criteria for diagnosis, tracking of suspected cases and their contacts, duration of quarantine, and allocation of resources and facilities for confirmed cases. To avoid further delays, the central government acted swiftly to create the nonpartisan Anti-SARS Taskforce and appointed leaders who could work cordially with both local and central government agencies. To help to deal with the crisis, the central government also designated a new Minister of Health, an epidemiologist, who became the first nonphysician to hold this position.

Treatment in place vs evacuation during hospital infections is a critical decision.

The surge of SARS cases at Ho-Ping Hospital led to confusion and panic among patients and hospital staff. Whether to treat its SARS patients on site or to evacuate the hospital was a complex decision and reflected many concerns, including the following: How many wards had been infected? Was there sufficient equipment (eg, respirators) to monitor or treat infected patients? How many isolation beds were available? How many hospital staff were already infected and quarantined? Were they in different wards? Were there neighboring facilities (eg, hospitals, military camps, dorms) available for quarantine?

If a hospital has sufficient capacity to isolate persons under investigation and to treat confirmed patients, on-site treatment is possible. However, evacuation should be considered when there is widespread infection involving different hospital wards and hospital staff. In such cases, patients should be transferred to different facilities based on clinical severity: Patients with new onset fever or respiratory symptoms but who are relatively healthy should be sent to community or regional hospitals with isolation rooms for monitoring; sicker infected patients should be sent to medical centers; and other hospitalized patients (eg, admitted for heart failure) without infection risk or symptoms should seek care elsewhere.

So far, there has been only one instance of hospital-based COVID-19 infections in Taiwan, and the spread of infection was quickly contained within one ward. All nine confirmed cases (including the index patient, one patient in the same ward but a different room, three nurses, one laundry worker, and three members of patients’ families) and their known contacts were identified, then isolated or quarantined individually. Because the affected hospital is part of a complex with more than 3,000 beds, it was big enough to accommodate all infected patients and no evacuation measures were needed. To further reduce potential nodes in the chain of transmission, interns and many other healthcare workers were temporarily relieved of their duties, elective surgeries were canceled, and hospital visitation was limited to immediate family members. The clear communication of intervention measures ensured rapid cooperation and staved off both social panic and further spread of the disease.

Hospitals should establish different flows for different patients.

Having learned from the SARS experience in 2003, hospitals in Taiwan have designated specific pathways to manage patient flow during the COVID-19 outbreak, in addition to checking all patients for travel history and fever: Patients with fever were quickly triaged to a designated fever clinic so they did not mingle with other patients, patients visiting the hospital to obtain chronic disease medications were directed to a “drive-through” lane, patients needing emergent care went through the emergency department, all other regular outpatients were seen in outpatient departments, and visitors of patients were restricted to one visitor per patient at a given time.

Healthcare providers should be organized into blocks and modular teams to avoid hospital-wide infection.

After SARS, Taiwan learned that one way to reduce the spread of something like COVID-19 among healthcare providers and from providers to patients is to divide providers’ work areas into discrete blocks and organize providers into modular teams. This approach was inspired by the design of watertight compartments in ships: Should the hull be breached, flooding is restricted to the breached compartments. Under this organizational strategy, movements of physicians and nurses would be restricted to their designated locations: They would be routinely exposed only to other staff and patients within their division. Doctors and nurses would be asked to practice in modular teams within their blocked locations, reducing the likelihood that infection in one team would spread to another, which could lead to hospital-wide infections. Movement of senior hospital executives would be similarly restricted. Common areas such as cafeterias where people mingle would be closed. Owing to these stringent initiatives, aside from the hospital-­based infection mentioned in Lesson 3, no other hospital-­based infections have been reported in Taiwan so far.

Lessons from previous hospital-based coronavirus infections can be used to minimize future infections.

The authors would like to thank Dr Lee Ming-Liang, former Health Minister of Taiwan and director of that central government’s Anti-SARS Taskforce during the 2003 outbreak, for providing valuable recommendations to this work.

My colleague asked, “Do you remember that patient?” I froze because, like most emergency physicians, this phrase haunts me. It was the early days of the COVID-19 epidemic, and the story that followed was upsetting. A patient who looked comfortable when I admitted him was intubated hours later by the rapid response team who was called to the floor. All I could think was, “But he looked so comfortable when I admitted him; he was just on a couple of liters of oxygen. Why was he intubated?”

In the days after COVID-19 arrived in our region, there were many such stories of patients sent to the floor from the Emergency Department who were intubated shortly after admission. Many of those patients subsequently endured prolonged and complicated courses on the ventilator. While we would typically use noninvasive modalities such as high-flow nasal cannula (HFNC) or noninvasive ventilation (NIV) for acute respiratory failure, our quickness to intubate was driven by two factors: (1) early reports that noninvasive modalities posed a high risk of failure and subsequent intubation and (2) fear that HFNC and NIV would aerosolize SARS-CoV-2 and unnecessarily expose the heath care team.¹ We would soon find out that our thinking was flawed on both accounts.

When we dug into the evidence for early intubation, we realized that these recommendations were based on a 12-patient series in which 5 patients were trialed on NIV but ultimately intubated and placed on invasive mechanical ventilation (IMV). As the pandemic progressed, more case series and small studies were published, revealing a different picture.² Sun and colleagues reported a multifaceted intervention of 610 inpatients, of whom 10% were critically ill, that identified at-risk patients and used NIV or HFNC and awake proning. Reportedly, fewer than 1% required IMV.³ Similarly, a small study found intubation was avoided in 85% of patients with severe acute respiratory failure caused by COVID-19 with use of HFNC and NIV.⁴ Early findings from New York University in New York, New York, where only 8.5% of patients undergoing IMV were extubated by the time of outcome reporting, suggest early IMV could lead to poor outcomes.⁵

Still, we had concerns about use of HFNC and NIV because of worries about the health and safety of other patients and particularly that of healthcare workers (HCWs) because they have been disproportionately affected by the disease.⁶ Fortunately, we identified emerging data that revealed that HFNC is no more aerosolizing than low-flow nasal cannula or a non­rebreather mask and droplet spread is reduced with a surgical mask.^7,8 In light of these new studies and our own developing experience with the disease, we felt that there was insufficient evidence to continue following the “early intubation” protocol in patients with COVID-19. It was time for a new paradigm.

In order to effectively and quickly change our respiratory pathway for these patients, we initially sought out protocols from other institutions through social media. These protocols, supported by early data from those sites, informed our process. We considered data from various sources, including emergency medicine, hospital medicine, and critical care. We then assembled stakeholders within our organization from emergency medicine, hospital medicine, critical care, and respiratory therapy because our protocol would need endorsement from all key players within our organization who cared for these patients across the potential spectrum of care. We made sure that all stakeholders understood that the quality of the evidence for treatment of this novel disease was much lower than our typical threshold to change practice, but that we aimed to reflect the best evidence to date. We also were careful to identify pathways that would be amenable to near-immediate implementation.

Our group reached consensus within 48 hours and quickly disseminated our first draft of the protocol (Appendix Figure). Dubbed the “Early Intervention Respiratory Protocol,” it differed from usual management in several ways. First, we had consistently observed (and confirmed from the literature) a phenotype of patients with “silent hypoxemia”⁹ (that is, a subset of patients who presented with profound hypoxemia but minimally increased work of breathing). The protocol encouraged tolerance of lower oxygen saturations than is usually seen on inpatient units. This required ensuring all stakeholders were comfortable with a target oxygen saturation of 88%. Second, the protocol leveraged early “awake” proning by patients. Historically, proning is used in mechanically ventilated patients with acute respiratory distress syndrome (ARDS) to improve ventilation-perfusion matching, promote more uniform ventilation, and increase end-expiratory lung volume.¹⁰ Prior literature was limited to the use of awake proning in small case series of ARDS, but given our limitations in terms of ICU capacity, we agreed to trial awake proning in a sizable proportion of our COVID-19 patients outside the ICU.^11,12 Finally, we clarified safe practices regarding the risk of aerosolization with noninvasive modalities. Local infection control determined that HFNC wa not aerosol generating, and use of surgical masks was added for further protection from respiratory droplets. In addition, airborne personal protective equipment was to be worn on the inpatient ward, and we used NIV sparingly and preferentially placed these patients in negative pressure rooms, if available.¹³

Implementation of the protocol involved aggressive dissemination and education (Table). A single-page protocol was designed for ease of use at the bedside that included anticipatory guidance regarding aerosolization and addressed potential resistance to awake proning because of concerns regarding safety and hassle. Departmental leaders disseminated the protocol throughout the institution with tailored education on the rationale and acknowledgment of a reversal in approach. In addition to email, we used text messaging (WhatsApp) and a comprehensive living document (Google Drive) to reach clinicians.

For ease of monitoring and safety, we designated a COVID-19 intermediate care unit. We partnered with the unit medical director, nurse educator, and a focused group of hospitalists, conducting individual train-the-trainer sessions. This training was carried forward, and all nurses, respiratory therapists, and clinicians were trained on the early aggressive respiratory protocol within 12 hours of protocol approval. In addition, the rapid response and critical care teams agreed to round on the COVID-19 intermediate care unit daily.

As a result of these efforts, adoption of the protocol was essentially immediate across the institution. We had shifted the mindset of a diverse group of clinicians regarding how to support the respiratory status of these patients, but also detected reductions in the proportion of patients undergoing IMV and ICU admission (we are planning to report these results separately).

The COVID-19 pandemic has highlighted the importance of having cognitive flexibility when the evidence base is rapidly changing and there is a need for rapid dissemination of knowledge. Even in clinical scenarios with an abundance of high-quality evidence, a gap in knowledge translation on the order of a decade often exists. In contrast, a pandemic involving a novel virus highlights an urgent need for adaptive knowledge translation in the present moment rather than a decade later. In the absence of robust evidence regarding SARS-CoV-2, early management of COVID-19 was based on expert recommendations and experience with other disease processes. Even so, we should anticipate that management paradigms may shift, and we should constantly seek out emerging evidence to adjust our mindset (and protocols like this) accordingly. Our original protocol was based on nearly nonexistent evidence, but we anticipated that, in a pandemic, data would accumulate quickly, so we prioritized rapid translation of new information into practice. In fact, further evidence has emerged regarding the improvement in oxygenation in COVID-19 patients with self-proning.¹⁴

The final step is evaluating the success of both clinical and implementation outcomes. We are attempting to identify changes in intubation, length of stay, days on ventilator, and days in ICU. In addition, we will measure feasibility and adaptability. We are also attempting, in real time, to identify barriers to its use, including conducting qualitative interviews to understand whether there were unintended consequences to use of the protocol. This endeavor highlights how the COVID-19 pandemic, for all its tragedy, may represent an important era for implementation science: a time when emerging literature from a variety of sources can be implemented in days rather than years.

My colleague asked, “Do you remember that patient?” I froze because, like most emergency physicians, this phrase haunts me. It was the early days of the COVID-19 epidemic, and the story that followed was upsetting. A patient who looked comfortable when I admitted him was intubated hours later by the rapid response team who was called to the floor. All I could think was, “But he looked so comfortable when I admitted him; he was just on a couple of liters of oxygen. Why was he intubated?”

In the days after COVID-19 arrived in our region, there were many such stories of patients sent to the floor from the Emergency Department who were intubated shortly after admission. Many of those patients subsequently endured prolonged and complicated courses on the ventilator. While we would typically use noninvasive modalities such as high-flow nasal cannula (HFNC) or noninvasive ventilation (NIV) for acute respiratory failure, our quickness to intubate was driven by two factors: (1) early reports that noninvasive modalities posed a high risk of failure and subsequent intubation and (2) fear that HFNC and NIV would aerosolize SARS-CoV-2 and unnecessarily expose the heath care team.¹ We would soon find out that our thinking was flawed on both accounts.

When we dug into the evidence for early intubation, we realized that these recommendations were based on a 12-patient series in which 5 patients were trialed on NIV but ultimately intubated and placed on invasive mechanical ventilation (IMV). As the pandemic progressed, more case series and small studies were published, revealing a different picture.² Sun and colleagues reported a multifaceted intervention of 610 inpatients, of whom 10% were critically ill, that identified at-risk patients and used NIV or HFNC and awake proning. Reportedly, fewer than 1% required IMV.³ Similarly, a small study found intubation was avoided in 85% of patients with severe acute respiratory failure caused by COVID-19 with use of HFNC and NIV.⁴ Early findings from New York University in New York, New York, where only 8.5% of patients undergoing IMV were extubated by the time of outcome reporting, suggest early IMV could lead to poor outcomes.⁵

Still, we had concerns about use of HFNC and NIV because of worries about the health and safety of other patients and particularly that of healthcare workers (HCWs) because they have been disproportionately affected by the disease.⁶ Fortunately, we identified emerging data that revealed that HFNC is no more aerosolizing than low-flow nasal cannula or a non­rebreather mask and droplet spread is reduced with a surgical mask.^7,8 In light of these new studies and our own developing experience with the disease, we felt that there was insufficient evidence to continue following the “early intubation” protocol in patients with COVID-19. It was time for a new paradigm.

In order to effectively and quickly change our respiratory pathway for these patients, we initially sought out protocols from other institutions through social media. These protocols, supported by early data from those sites, informed our process. We considered data from various sources, including emergency medicine, hospital medicine, and critical care. We then assembled stakeholders within our organization from emergency medicine, hospital medicine, critical care, and respiratory therapy because our protocol would need endorsement from all key players within our organization who cared for these patients across the potential spectrum of care. We made sure that all stakeholders understood that the quality of the evidence for treatment of this novel disease was much lower than our typical threshold to change practice, but that we aimed to reflect the best evidence to date. We also were careful to identify pathways that would be amenable to near-immediate implementation.

Our group reached consensus within 48 hours and quickly disseminated our first draft of the protocol (Appendix Figure). Dubbed the “Early Intervention Respiratory Protocol,” it differed from usual management in several ways. First, we had consistently observed (and confirmed from the literature) a phenotype of patients with “silent hypoxemia”⁹ (that is, a subset of patients who presented with profound hypoxemia but minimally increased work of breathing). The protocol encouraged tolerance of lower oxygen saturations than is usually seen on inpatient units. This required ensuring all stakeholders were comfortable with a target oxygen saturation of 88%. Second, the protocol leveraged early “awake” proning by patients. Historically, proning is used in mechanically ventilated patients with acute respiratory distress syndrome (ARDS) to improve ventilation-perfusion matching, promote more uniform ventilation, and increase end-expiratory lung volume.¹⁰ Prior literature was limited to the use of awake proning in small case series of ARDS, but given our limitations in terms of ICU capacity, we agreed to trial awake proning in a sizable proportion of our COVID-19 patients outside the ICU.^11,12 Finally, we clarified safe practices regarding the risk of aerosolization with noninvasive modalities. Local infection control determined that HFNC wa not aerosol generating, and use of surgical masks was added for further protection from respiratory droplets. In addition, airborne personal protective equipment was to be worn on the inpatient ward, and we used NIV sparingly and preferentially placed these patients in negative pressure rooms, if available.¹³

Implementation of the protocol involved aggressive dissemination and education (Table). A single-page protocol was designed for ease of use at the bedside that included anticipatory guidance regarding aerosolization and addressed potential resistance to awake proning because of concerns regarding safety and hassle. Departmental leaders disseminated the protocol throughout the institution with tailored education on the rationale and acknowledgment of a reversal in approach. In addition to email, we used text messaging (WhatsApp) and a comprehensive living document (Google Drive) to reach clinicians.

For ease of monitoring and safety, we designated a COVID-19 intermediate care unit. We partnered with the unit medical director, nurse educator, and a focused group of hospitalists, conducting individual train-the-trainer sessions. This training was carried forward, and all nurses, respiratory therapists, and clinicians were trained on the early aggressive respiratory protocol within 12 hours of protocol approval. In addition, the rapid response and critical care teams agreed to round on the COVID-19 intermediate care unit daily.

As a result of these efforts, adoption of the protocol was essentially immediate across the institution. We had shifted the mindset of a diverse group of clinicians regarding how to support the respiratory status of these patients, but also detected reductions in the proportion of patients undergoing IMV and ICU admission (we are planning to report these results separately).

The COVID-19 pandemic has highlighted the importance of having cognitive flexibility when the evidence base is rapidly changing and there is a need for rapid dissemination of knowledge. Even in clinical scenarios with an abundance of high-quality evidence, a gap in knowledge translation on the order of a decade often exists. In contrast, a pandemic involving a novel virus highlights an urgent need for adaptive knowledge translation in the present moment rather than a decade later. In the absence of robust evidence regarding SARS-CoV-2, early management of COVID-19 was based on expert recommendations and experience with other disease processes. Even so, we should anticipate that management paradigms may shift, and we should constantly seek out emerging evidence to adjust our mindset (and protocols like this) accordingly. Our original protocol was based on nearly nonexistent evidence, but we anticipated that, in a pandemic, data would accumulate quickly, so we prioritized rapid translation of new information into practice. In fact, further evidence has emerged regarding the improvement in oxygenation in COVID-19 patients with self-proning.¹⁴

The final step is evaluating the success of both clinical and implementation outcomes. We are attempting to identify changes in intubation, length of stay, days on ventilator, and days in ICU. In addition, we will measure feasibility and adaptability. We are also attempting, in real time, to identify barriers to its use, including conducting qualitative interviews to understand whether there were unintended consequences to use of the protocol. This endeavor highlights how the COVID-19 pandemic, for all its tragedy, may represent an important era for implementation science: a time when emerging literature from a variety of sources can be implemented in days rather than years.

My colleague asked, “Do you remember that patient?” I froze because, like most emergency physicians, this phrase haunts me. It was the early days of the COVID-19 epidemic, and the story that followed was upsetting. A patient who looked comfortable when I admitted him was intubated hours later by the rapid response team who was called to the floor. All I could think was, “But he looked so comfortable when I admitted him; he was just on a couple of liters of oxygen. Why was he intubated?”

In the days after COVID-19 arrived in our region, there were many such stories of patients sent to the floor from the Emergency Department who were intubated shortly after admission. Many of those patients subsequently endured prolonged and complicated courses on the ventilator. While we would typically use noninvasive modalities such as high-flow nasal cannula (HFNC) or noninvasive ventilation (NIV) for acute respiratory failure, our quickness to intubate was driven by two factors: (1) early reports that noninvasive modalities posed a high risk of failure and subsequent intubation and (2) fear that HFNC and NIV would aerosolize SARS-CoV-2 and unnecessarily expose the heath care team.¹ We would soon find out that our thinking was flawed on both accounts.

When we dug into the evidence for early intubation, we realized that these recommendations were based on a 12-patient series in which 5 patients were trialed on NIV but ultimately intubated and placed on invasive mechanical ventilation (IMV). As the pandemic progressed, more case series and small studies were published, revealing a different picture.² Sun and colleagues reported a multifaceted intervention of 610 inpatients, of whom 10% were critically ill, that identified at-risk patients and used NIV or HFNC and awake proning. Reportedly, fewer than 1% required IMV.³ Similarly, a small study found intubation was avoided in 85% of patients with severe acute respiratory failure caused by COVID-19 with use of HFNC and NIV.⁴ Early findings from New York University in New York, New York, where only 8.5% of patients undergoing IMV were extubated by the time of outcome reporting, suggest early IMV could lead to poor outcomes.⁵

Still, we had concerns about use of HFNC and NIV because of worries about the health and safety of other patients and particularly that of healthcare workers (HCWs) because they have been disproportionately affected by the disease.⁶ Fortunately, we identified emerging data that revealed that HFNC is no more aerosolizing than low-flow nasal cannula or a non­rebreather mask and droplet spread is reduced with a surgical mask.^7,8 In light of these new studies and our own developing experience with the disease, we felt that there was insufficient evidence to continue following the “early intubation” protocol in patients with COVID-19. It was time for a new paradigm.

In order to effectively and quickly change our respiratory pathway for these patients, we initially sought out protocols from other institutions through social media. These protocols, supported by early data from those sites, informed our process. We considered data from various sources, including emergency medicine, hospital medicine, and critical care. We then assembled stakeholders within our organization from emergency medicine, hospital medicine, critical care, and respiratory therapy because our protocol would need endorsement from all key players within our organization who cared for these patients across the potential spectrum of care. We made sure that all stakeholders understood that the quality of the evidence for treatment of this novel disease was much lower than our typical threshold to change practice, but that we aimed to reflect the best evidence to date. We also were careful to identify pathways that would be amenable to near-immediate implementation.

Our group reached consensus within 48 hours and quickly disseminated our first draft of the protocol (Appendix Figure). Dubbed the “Early Intervention Respiratory Protocol,” it differed from usual management in several ways. First, we had consistently observed (and confirmed from the literature) a phenotype of patients with “silent hypoxemia”⁹ (that is, a subset of patients who presented with profound hypoxemia but minimally increased work of breathing). The protocol encouraged tolerance of lower oxygen saturations than is usually seen on inpatient units. This required ensuring all stakeholders were comfortable with a target oxygen saturation of 88%. Second, the protocol leveraged early “awake” proning by patients. Historically, proning is used in mechanically ventilated patients with acute respiratory distress syndrome (ARDS) to improve ventilation-perfusion matching, promote more uniform ventilation, and increase end-expiratory lung volume.¹⁰ Prior literature was limited to the use of awake proning in small case series of ARDS, but given our limitations in terms of ICU capacity, we agreed to trial awake proning in a sizable proportion of our COVID-19 patients outside the ICU.^11,12 Finally, we clarified safe practices regarding the risk of aerosolization with noninvasive modalities. Local infection control determined that HFNC wa not aerosol generating, and use of surgical masks was added for further protection from respiratory droplets. In addition, airborne personal protective equipment was to be worn on the inpatient ward, and we used NIV sparingly and preferentially placed these patients in negative pressure rooms, if available.¹³

Implementation of the protocol involved aggressive dissemination and education (Table). A single-page protocol was designed for ease of use at the bedside that included anticipatory guidance regarding aerosolization and addressed potential resistance to awake proning because of concerns regarding safety and hassle. Departmental leaders disseminated the protocol throughout the institution with tailored education on the rationale and acknowledgment of a reversal in approach. In addition to email, we used text messaging (WhatsApp) and a comprehensive living document (Google Drive) to reach clinicians.

For ease of monitoring and safety, we designated a COVID-19 intermediate care unit. We partnered with the unit medical director, nurse educator, and a focused group of hospitalists, conducting individual train-the-trainer sessions. This training was carried forward, and all nurses, respiratory therapists, and clinicians were trained on the early aggressive respiratory protocol within 12 hours of protocol approval. In addition, the rapid response and critical care teams agreed to round on the COVID-19 intermediate care unit daily.

As a result of these efforts, adoption of the protocol was essentially immediate across the institution. We had shifted the mindset of a diverse group of clinicians regarding how to support the respiratory status of these patients, but also detected reductions in the proportion of patients undergoing IMV and ICU admission (we are planning to report these results separately).

The COVID-19 pandemic has highlighted the importance of having cognitive flexibility when the evidence base is rapidly changing and there is a need for rapid dissemination of knowledge. Even in clinical scenarios with an abundance of high-quality evidence, a gap in knowledge translation on the order of a decade often exists. In contrast, a pandemic involving a novel virus highlights an urgent need for adaptive knowledge translation in the present moment rather than a decade later. In the absence of robust evidence regarding SARS-CoV-2, early management of COVID-19 was based on expert recommendations and experience with other disease processes. Even so, we should anticipate that management paradigms may shift, and we should constantly seek out emerging evidence to adjust our mindset (and protocols like this) accordingly. Our original protocol was based on nearly nonexistent evidence, but we anticipated that, in a pandemic, data would accumulate quickly, so we prioritized rapid translation of new information into practice. In fact, further evidence has emerged regarding the improvement in oxygenation in COVID-19 patients with self-proning.¹⁴

The final step is evaluating the success of both clinical and implementation outcomes. We are attempting to identify changes in intubation, length of stay, days on ventilator, and days in ICU. In addition, we will measure feasibility and adaptability. We are also attempting, in real time, to identify barriers to its use, including conducting qualitative interviews to understand whether there were unintended consequences to use of the protocol. This endeavor highlights how the COVID-19 pandemic, for all its tragedy, may represent an important era for implementation science: a time when emerging literature from a variety of sources can be implemented in days rather than years.

In 2015, and in response to the Ebola virus outbreak in West Africa, the United States Department of Health and Human Services (HHS) designated 10 health departments and associated partner hospitals to become regional treatment centers for patients with highly infectious diseases, such as the Ebola virus and other highly infectious special pathogens (HISPs), and reinforce the nation’s infectious disease response capability. These efforts catalyzed the creation and/or expansion of a network of biocontainment units (BCUs) to safely care for patients diagnosed with highly infectious diseases. These units are designed as special care units with environmental/engineering controls, laboratory capabilities, simple imaging testing, and dedicated staff to allow for the uninterrupted care of patients.^1,2 The HHS approach closely resembled the tiered structure of trauma center levels familiar to the healthcare system. The regional framework identified four types of facilities (frontline healthcare facilities, assessment hospitals, treatment centers, and regional Ebola and other special pathogens treatment centers [RESPTCs]) with increasing levels of capabilities and responsibilities.

There are over 4,845 frontline healthcare facilities across the United States, which are able to identify and isolate a patient suspected of a HISP infection and inform local and state partners. The facility provides stabilizing treatment while coordinating the transport of the patient to a specialized center. An assessment hospital can identify and isolate a patient with a HISP, inform partnering agencies, and provide care at the facility for up to 96 hours. There are over 217 hospitals with this designation in the United States. Treatment centers are designated as state or jurisdiction treatment centers and have the capacity to care for HISP-infected patients for the entirety of their care plan, as well as serve as a partner in caring for a potential surge in high-risk patients if their partner RESPTC is unable to care for a patient because of capacity limits. Patients may receive care at a treatment center if and when it is determined to be more appropriate (eg, clinical purview, logistics, resources) than sending them to a RESPTC. There are currently 63 designated treatment centers in the United States.

As outlined by HHS, the RESPTCs³ must be ready to receive a HISP-infected patient within their HHS region, domestically, or internationally within 8 hours. RESPTCs provide care for the entirety of the patient care plan. The 10 regional Departments of Public Health representatives are: Massachusetts (Region 1); New York (Region 2); Maryland (Region 3); Georgia (Region 4); Minnesota (Region 5); Texas (Region 6); Nebraska (Region 7); Colorado in partnership with Denver Health Hospital Authority (DHHA; Region 8); California (Region 9); and Washington State (Region 10).

Most RESPCTs BCUs are staffed by a self-selected group of core providers with expertise in infectious diseases (ID) and critical care (CC). Teams are interdisciplinary and committed to a culture of safety.^4-7 ID physicians are experts in HISP disease processes and epidemiology, which enables expert guidance on patient care and infection control. CC physicians are trained to provide care to patients requiring life-saving interventions.

As specialized units are shifting to include high-risk infectious diseases beyond Ebola, hospitals are developing innovative ways to manage a potential surge of patients with respiratory pathogens, expanding care far beyond the biocontainment unit. With the potential for an influx of HISPs in the healthcare setting, identifying stakeholders uniquely equipped to provide care in all areas of the hospital is ideal. At DHHA, the BCU physician staffing model transitioned from ID and CC physicians to a selected group of ten hospitalists as the primary managing service in 2018.

When DHHA received the RESPTC nomination, it developed a fully voluntary multidisciplinary high-risk infection team (HITeam; Table) with specialized training in personal protective equipment (PPE) donning and doffing, as well as BCU protocols. Our HITeam members participate in every-6-weeks mandatory team drills that involve practicing team dynamics and dexterity while wearing PPE. Team members participate in regular hospital and/or BCU-focused exercises to simulate and practice real-world experiences. They also participate in HISP Journal Club, where members from different disciplines discuss pertinent articles in the field, as well as every-other-month team-building meetings. Our unit’s main challenges included maintaining competencies and staff retention. We developed a unique staffing model aimed at mitigating some of these challenges through a multidisciplinary team approach utilizing different levels of physician involvement. The first group comprises physicians providing primary, direct care to patients, which which consists our specially trained group of 10 hospitalists—including 2 pediatricians, as well as 3 CC and 4 ID consultants. The second group involves consultants from specialties such as nephrology, anesthesia, general surgery, radiology and gynecology; just–in-time training is available for them.

Hospitalists are uniquely positioned to care for this distinctive set of patients because they are comfortable with the care of acutely ill patients, many maintain bedside procedural skills, and many have acquired point-of-care-ultrasonography (POCUS) skills. Furthermore, hospitalists usually outnumber available specialists who may be needed to maintain consultative and critical care services for non-BCU patients. We were able to develop a feasible physician staffing model, as described below, and validate hospital medicine’s commitment in addressing institutional needs.

In order to provide ideal unit coverage, 2 hospitalists are scheduled daily and available to respond in case of unit activation. BCU hospitalists are scheduled to cover the BCU when already scheduled to work a clinical shift. In the very infrequent event of BCU activation, BCU hospitalists would move their clinical work to the BCU and a back-up hospitalist would be called in to cover the “other” clinical shift; by overlapping coverage, we ensure BCU hospitalists’ work-life balance and job satisfaction remain intact. Because of expected postexposure monitoring, individual physician’s planned international travel is considered while generating the call schedule. When the unit is activated, the hospital provides payment for extra hours worked by both the BCU hospitalist and the back-up hospitalist, with anticipated revenue recapture through critical care billing by the BCU hospitalist. There are 10 HITeam hospitalists, who are trained and credentialed in bedside procedures and with different levels of POCUS expertise (from literacy to expert level). Team members are expected to attend training in bedside procedures while in PPE 2 times a year. The hospital also provides financial support for hospitalists seeking to further their BCU-related skills and training. It is anticipated that hospitalists will require consultative services from CC and ID in some selected cases to provide a well-rounded care approach to the biocontained patient.

Eligibility criteria for HITeam hospitalists include complete initial and quarterly maintenance PPE training; possession of active bedside procedure credentials for at least central line, paracentesis, thoracentesis, and arterial line; demonstration of basic POCUS skills, such as having enough POCUS verbiage literacy to be able to follow a radiologist’s instructions on probe management (ie, a radiologist outside anteroom); and possibility of completing additional training and credentialing on conscious sedation and/or advanced airway management.

Similarly, hospitalists who join the team commit to attendance of at least one National Ebola Training and Education Center (NETEC) provider’s course, representing the Region 8 RESPTC for educational presentations and research at regional and national levels, participation in quarterly HISP multidisciplinary meetings, attendance at quarterly donning and doffing sessions, as well as HITeam training sessions and drills, and active participation in the every-other-month HISP Journal Club/Grand Rounds to maintain competence and knowledge on management of many different pathogens, including Ebola and other filoviruses, MERS-CoV, SARS-CoV, Arenaviruses causing hemorrhagic fevers, Hantavirus, and novel influenzas or coronaviruses.

All of these commitments provide HITeam hospitalists with multiple opportunities for professional growth and development, such as augmenting scholarship venues by participating in collaborative national research projects, participating in national topic networks discussion groups and committees, becoming topic experts, and engaging in diversified training such as advanced airway training and conscious sedation. A new bedside ultrasound machine was purchased for the unit and housed within the division of hospital medicine with the intent to provide hospitalists the means necessary to achieve POCUS proficiency. Above all, by fostering a highly motivated and collegial multidisciplinary team, our model helps develop lasting partnerships at an institutional, regional, and national level.

This multidisciplinary team—with its skillfully trained and engaged nurses, physicians, respiratory therapists, pharmacists, infection control and laboratory specialists—works, learns, trains, and thrives collectively with the aim of providing excellent clinical care to our patients while assuring the safety of the team. DHHA has pioneered a RESPTC physician staffing model led by hospitalists.

We live in an ever-changing landscape of emerging diseases with blurred borders of disease geography. Hospitalists are versatile, capable of managing patients of varying acuity, able to perform many bedside procedures and POCUS; they are champions of interdisciplinary and teamwork disposition. By utilizing the resourcefulness of hospital medicine while helping to ease some of the burden that might otherwise be placed on a smaller numbers of physician groups, this approach provides a unique, cost-effective, and viable physician staffing model, which could be implemented in other BCUs in the United States.

In 2015, and in response to the Ebola virus outbreak in West Africa, the United States Department of Health and Human Services (HHS) designated 10 health departments and associated partner hospitals to become regional treatment centers for patients with highly infectious diseases, such as the Ebola virus and other highly infectious special pathogens (HISPs), and reinforce the nation’s infectious disease response capability. These efforts catalyzed the creation and/or expansion of a network of biocontainment units (BCUs) to safely care for patients diagnosed with highly infectious diseases. These units are designed as special care units with environmental/engineering controls, laboratory capabilities, simple imaging testing, and dedicated staff to allow for the uninterrupted care of patients.^1,2 The HHS approach closely resembled the tiered structure of trauma center levels familiar to the healthcare system. The regional framework identified four types of facilities (frontline healthcare facilities, assessment hospitals, treatment centers, and regional Ebola and other special pathogens treatment centers [RESPTCs]) with increasing levels of capabilities and responsibilities.

There are over 4,845 frontline healthcare facilities across the United States, which are able to identify and isolate a patient suspected of a HISP infection and inform local and state partners. The facility provides stabilizing treatment while coordinating the transport of the patient to a specialized center. An assessment hospital can identify and isolate a patient with a HISP, inform partnering agencies, and provide care at the facility for up to 96 hours. There are over 217 hospitals with this designation in the United States. Treatment centers are designated as state or jurisdiction treatment centers and have the capacity to care for HISP-infected patients for the entirety of their care plan, as well as serve as a partner in caring for a potential surge in high-risk patients if their partner RESPTC is unable to care for a patient because of capacity limits. Patients may receive care at a treatment center if and when it is determined to be more appropriate (eg, clinical purview, logistics, resources) than sending them to a RESPTC. There are currently 63 designated treatment centers in the United States.

As outlined by HHS, the RESPTCs³ must be ready to receive a HISP-infected patient within their HHS region, domestically, or internationally within 8 hours. RESPTCs provide care for the entirety of the patient care plan. The 10 regional Departments of Public Health representatives are: Massachusetts (Region 1); New York (Region 2); Maryland (Region 3); Georgia (Region 4); Minnesota (Region 5); Texas (Region 6); Nebraska (Region 7); Colorado in partnership with Denver Health Hospital Authority (DHHA; Region 8); California (Region 9); and Washington State (Region 10).

Most RESPCTs BCUs are staffed by a self-selected group of core providers with expertise in infectious diseases (ID) and critical care (CC). Teams are interdisciplinary and committed to a culture of safety.^4-7 ID physicians are experts in HISP disease processes and epidemiology, which enables expert guidance on patient care and infection control. CC physicians are trained to provide care to patients requiring life-saving interventions.

As specialized units are shifting to include high-risk infectious diseases beyond Ebola, hospitals are developing innovative ways to manage a potential surge of patients with respiratory pathogens, expanding care far beyond the biocontainment unit. With the potential for an influx of HISPs in the healthcare setting, identifying stakeholders uniquely equipped to provide care in all areas of the hospital is ideal. At DHHA, the BCU physician staffing model transitioned from ID and CC physicians to a selected group of ten hospitalists as the primary managing service in 2018.

When DHHA received the RESPTC nomination, it developed a fully voluntary multidisciplinary high-risk infection team (HITeam; Table) with specialized training in personal protective equipment (PPE) donning and doffing, as well as BCU protocols. Our HITeam members participate in every-6-weeks mandatory team drills that involve practicing team dynamics and dexterity while wearing PPE. Team members participate in regular hospital and/or BCU-focused exercises to simulate and practice real-world experiences. They also participate in HISP Journal Club, where members from different disciplines discuss pertinent articles in the field, as well as every-other-month team-building meetings. Our unit’s main challenges included maintaining competencies and staff retention. We developed a unique staffing model aimed at mitigating some of these challenges through a multidisciplinary team approach utilizing different levels of physician involvement. The first group comprises physicians providing primary, direct care to patients, which which consists our specially trained group of 10 hospitalists—including 2 pediatricians, as well as 3 CC and 4 ID consultants. The second group involves consultants from specialties such as nephrology, anesthesia, general surgery, radiology and gynecology; just–in-time training is available for them.

Hospitalists are uniquely positioned to care for this distinctive set of patients because they are comfortable with the care of acutely ill patients, many maintain bedside procedural skills, and many have acquired point-of-care-ultrasonography (POCUS) skills. Furthermore, hospitalists usually outnumber available specialists who may be needed to maintain consultative and critical care services for non-BCU patients. We were able to develop a feasible physician staffing model, as described below, and validate hospital medicine’s commitment in addressing institutional needs.

In order to provide ideal unit coverage, 2 hospitalists are scheduled daily and available to respond in case of unit activation. BCU hospitalists are scheduled to cover the BCU when already scheduled to work a clinical shift. In the very infrequent event of BCU activation, BCU hospitalists would move their clinical work to the BCU and a back-up hospitalist would be called in to cover the “other” clinical shift; by overlapping coverage, we ensure BCU hospitalists’ work-life balance and job satisfaction remain intact. Because of expected postexposure monitoring, individual physician’s planned international travel is considered while generating the call schedule. When the unit is activated, the hospital provides payment for extra hours worked by both the BCU hospitalist and the back-up hospitalist, with anticipated revenue recapture through critical care billing by the BCU hospitalist. There are 10 HITeam hospitalists, who are trained and credentialed in bedside procedures and with different levels of POCUS expertise (from literacy to expert level). Team members are expected to attend training in bedside procedures while in PPE 2 times a year. The hospital also provides financial support for hospitalists seeking to further their BCU-related skills and training. It is anticipated that hospitalists will require consultative services from CC and ID in some selected cases to provide a well-rounded care approach to the biocontained patient.

Eligibility criteria for HITeam hospitalists include complete initial and quarterly maintenance PPE training; possession of active bedside procedure credentials for at least central line, paracentesis, thoracentesis, and arterial line; demonstration of basic POCUS skills, such as having enough POCUS verbiage literacy to be able to follow a radiologist’s instructions on probe management (ie, a radiologist outside anteroom); and possibility of completing additional training and credentialing on conscious sedation and/or advanced airway management.

Similarly, hospitalists who join the team commit to attendance of at least one National Ebola Training and Education Center (NETEC) provider’s course, representing the Region 8 RESPTC for educational presentations and research at regional and national levels, participation in quarterly HISP multidisciplinary meetings, attendance at quarterly donning and doffing sessions, as well as HITeam training sessions and drills, and active participation in the every-other-month HISP Journal Club/Grand Rounds to maintain competence and knowledge on management of many different pathogens, including Ebola and other filoviruses, MERS-CoV, SARS-CoV, Arenaviruses causing hemorrhagic fevers, Hantavirus, and novel influenzas or coronaviruses.

All of these commitments provide HITeam hospitalists with multiple opportunities for professional growth and development, such as augmenting scholarship venues by participating in collaborative national research projects, participating in national topic networks discussion groups and committees, becoming topic experts, and engaging in diversified training such as advanced airway training and conscious sedation. A new bedside ultrasound machine was purchased for the unit and housed within the division of hospital medicine with the intent to provide hospitalists the means necessary to achieve POCUS proficiency. Above all, by fostering a highly motivated and collegial multidisciplinary team, our model helps develop lasting partnerships at an institutional, regional, and national level.

This multidisciplinary team—with its skillfully trained and engaged nurses, physicians, respiratory therapists, pharmacists, infection control and laboratory specialists—works, learns, trains, and thrives collectively with the aim of providing excellent clinical care to our patients while assuring the safety of the team. DHHA has pioneered a RESPTC physician staffing model led by hospitalists.

We live in an ever-changing landscape of emerging diseases with blurred borders of disease geography. Hospitalists are versatile, capable of managing patients of varying acuity, able to perform many bedside procedures and POCUS; they are champions of interdisciplinary and teamwork disposition. By utilizing the resourcefulness of hospital medicine while helping to ease some of the burden that might otherwise be placed on a smaller numbers of physician groups, this approach provides a unique, cost-effective, and viable physician staffing model, which could be implemented in other BCUs in the United States.

In 2015, and in response to the Ebola virus outbreak in West Africa, the United States Department of Health and Human Services (HHS) designated 10 health departments and associated partner hospitals to become regional treatment centers for patients with highly infectious diseases, such as the Ebola virus and other highly infectious special pathogens (HISPs), and reinforce the nation’s infectious disease response capability. These efforts catalyzed the creation and/or expansion of a network of biocontainment units (BCUs) to safely care for patients diagnosed with highly infectious diseases. These units are designed as special care units with environmental/engineering controls, laboratory capabilities, simple imaging testing, and dedicated staff to allow for the uninterrupted care of patients.^1,2 The HHS approach closely resembled the tiered structure of trauma center levels familiar to the healthcare system. The regional framework identified four types of facilities (frontline healthcare facilities, assessment hospitals, treatment centers, and regional Ebola and other special pathogens treatment centers [RESPTCs]) with increasing levels of capabilities and responsibilities.

There are over 4,845 frontline healthcare facilities across the United States, which are able to identify and isolate a patient suspected of a HISP infection and inform local and state partners. The facility provides stabilizing treatment while coordinating the transport of the patient to a specialized center. An assessment hospital can identify and isolate a patient with a HISP, inform partnering agencies, and provide care at the facility for up to 96 hours. There are over 217 hospitals with this designation in the United States. Treatment centers are designated as state or jurisdiction treatment centers and have the capacity to care for HISP-infected patients for the entirety of their care plan, as well as serve as a partner in caring for a potential surge in high-risk patients if their partner RESPTC is unable to care for a patient because of capacity limits. Patients may receive care at a treatment center if and when it is determined to be more appropriate (eg, clinical purview, logistics, resources) than sending them to a RESPTC. There are currently 63 designated treatment centers in the United States.

As outlined by HHS, the RESPTCs³ must be ready to receive a HISP-infected patient within their HHS region, domestically, or internationally within 8 hours. RESPTCs provide care for the entirety of the patient care plan. The 10 regional Departments of Public Health representatives are: Massachusetts (Region 1); New York (Region 2); Maryland (Region 3); Georgia (Region 4); Minnesota (Region 5); Texas (Region 6); Nebraska (Region 7); Colorado in partnership with Denver Health Hospital Authority (DHHA; Region 8); California (Region 9); and Washington State (Region 10).

Most RESPCTs BCUs are staffed by a self-selected group of core providers with expertise in infectious diseases (ID) and critical care (CC). Teams are interdisciplinary and committed to a culture of safety.^4-7 ID physicians are experts in HISP disease processes and epidemiology, which enables expert guidance on patient care and infection control. CC physicians are trained to provide care to patients requiring life-saving interventions.

As specialized units are shifting to include high-risk infectious diseases beyond Ebola, hospitals are developing innovative ways to manage a potential surge of patients with respiratory pathogens, expanding care far beyond the biocontainment unit. With the potential for an influx of HISPs in the healthcare setting, identifying stakeholders uniquely equipped to provide care in all areas of the hospital is ideal. At DHHA, the BCU physician staffing model transitioned from ID and CC physicians to a selected group of ten hospitalists as the primary managing service in 2018.

When DHHA received the RESPTC nomination, it developed a fully voluntary multidisciplinary high-risk infection team (HITeam; Table) with specialized training in personal protective equipment (PPE) donning and doffing, as well as BCU protocols. Our HITeam members participate in every-6-weeks mandatory team drills that involve practicing team dynamics and dexterity while wearing PPE. Team members participate in regular hospital and/or BCU-focused exercises to simulate and practice real-world experiences. They also participate in HISP Journal Club, where members from different disciplines discuss pertinent articles in the field, as well as every-other-month team-building meetings. Our unit’s main challenges included maintaining competencies and staff retention. We developed a unique staffing model aimed at mitigating some of these challenges through a multidisciplinary team approach utilizing different levels of physician involvement. The first group comprises physicians providing primary, direct care to patients, which which consists our specially trained group of 10 hospitalists—including 2 pediatricians, as well as 3 CC and 4 ID consultants. The second group involves consultants from specialties such as nephrology, anesthesia, general surgery, radiology and gynecology; just–in-time training is available for them.

Hospitalists are uniquely positioned to care for this distinctive set of patients because they are comfortable with the care of acutely ill patients, many maintain bedside procedural skills, and many have acquired point-of-care-ultrasonography (POCUS) skills. Furthermore, hospitalists usually outnumber available specialists who may be needed to maintain consultative and critical care services for non-BCU patients. We were able to develop a feasible physician staffing model, as described below, and validate hospital medicine’s commitment in addressing institutional needs.

In order to provide ideal unit coverage, 2 hospitalists are scheduled daily and available to respond in case of unit activation. BCU hospitalists are scheduled to cover the BCU when already scheduled to work a clinical shift. In the very infrequent event of BCU activation, BCU hospitalists would move their clinical work to the BCU and a back-up hospitalist would be called in to cover the “other” clinical shift; by overlapping coverage, we ensure BCU hospitalists’ work-life balance and job satisfaction remain intact. Because of expected postexposure monitoring, individual physician’s planned international travel is considered while generating the call schedule. When the unit is activated, the hospital provides payment for extra hours worked by both the BCU hospitalist and the back-up hospitalist, with anticipated revenue recapture through critical care billing by the BCU hospitalist. There are 10 HITeam hospitalists, who are trained and credentialed in bedside procedures and with different levels of POCUS expertise (from literacy to expert level). Team members are expected to attend training in bedside procedures while in PPE 2 times a year. The hospital also provides financial support for hospitalists seeking to further their BCU-related skills and training. It is anticipated that hospitalists will require consultative services from CC and ID in some selected cases to provide a well-rounded care approach to the biocontained patient.

Eligibility criteria for HITeam hospitalists include complete initial and quarterly maintenance PPE training; possession of active bedside procedure credentials for at least central line, paracentesis, thoracentesis, and arterial line; demonstration of basic POCUS skills, such as having enough POCUS verbiage literacy to be able to follow a radiologist’s instructions on probe management (ie, a radiologist outside anteroom); and possibility of completing additional training and credentialing on conscious sedation and/or advanced airway management.

Similarly, hospitalists who join the team commit to attendance of at least one National Ebola Training and Education Center (NETEC) provider’s course, representing the Region 8 RESPTC for educational presentations and research at regional and national levels, participation in quarterly HISP multidisciplinary meetings, attendance at quarterly donning and doffing sessions, as well as HITeam training sessions and drills, and active participation in the every-other-month HISP Journal Club/Grand Rounds to maintain competence and knowledge on management of many different pathogens, including Ebola and other filoviruses, MERS-CoV, SARS-CoV, Arenaviruses causing hemorrhagic fevers, Hantavirus, and novel influenzas or coronaviruses.

All of these commitments provide HITeam hospitalists with multiple opportunities for professional growth and development, such as augmenting scholarship venues by participating in collaborative national research projects, participating in national topic networks discussion groups and committees, becoming topic experts, and engaging in diversified training such as advanced airway training and conscious sedation. A new bedside ultrasound machine was purchased for the unit and housed within the division of hospital medicine with the intent to provide hospitalists the means necessary to achieve POCUS proficiency. Above all, by fostering a highly motivated and collegial multidisciplinary team, our model helps develop lasting partnerships at an institutional, regional, and national level.

This multidisciplinary team—with its skillfully trained and engaged nurses, physicians, respiratory therapists, pharmacists, infection control and laboratory specialists—works, learns, trains, and thrives collectively with the aim of providing excellent clinical care to our patients while assuring the safety of the team. DHHA has pioneered a RESPTC physician staffing model led by hospitalists.

We live in an ever-changing landscape of emerging diseases with blurred borders of disease geography. Hospitalists are versatile, capable of managing patients of varying acuity, able to perform many bedside procedures and POCUS; they are champions of interdisciplinary and teamwork disposition. By utilizing the resourcefulness of hospital medicine while helping to ease some of the burden that might otherwise be placed on a smaller numbers of physician groups, this approach provides a unique, cost-effective, and viable physician staffing model, which could be implemented in other BCUs in the United States.

Over the past two decades, physicians and nurses practicing in hospital settings have faced an onslaught of challenges in communication, an area frequently cited as critical to providing safe and effective care to patients.^1-3 Communication needs have increased significantly as hospitalized patients have become more acute, complex, and technology-dependent, requiring larger healthcare teams comprising subspecialists across multiple disciplines spread across increasingly larger inpatient facilities.⁴ During this same period, the evolution of mobile phones has led to dramatic shifts in personal communication patterns, with asynchronous text messaging replacing verbal communication.^5-7

In response to both the changing communication needs of clinicians and shifting cultural conventions, healthcare systems and providers alike have viewed text messaging as a solution to these growing communication problems. In fact, an entire industry has developed around “secure” and “Health Insurance Portability and Accountability Act (HIPAA)-compliant” text messaging platforms, which we will refer to below as secure text messaging systems (STMS). These systems offer benefits over carrier-based text messaging given their focus on the healthcare environment and HIPAA compliance. However, hospitals’ rapid adoption of these systems has outpaced our abilities to surveil, recognize, and understand the unintended consequences of transitioning to STMS communication in the hospital setting where failures in communication can be catastrophic. Below, we highlight three critical areas of concern encountered at our institutions and offer five potential mitigating strategies (Table).

Text Messaging is a Form of Alarm Fatigue

Text messaging renders clinicians vulnerable to a unique form of alarm fatigue. The burden of alarm fatigue has been well described in the literature and applies to interruptions to workflow in the electronic medical record and sensory alerts in clinical settings.^8,9 Text messaging serves as yet another interruption for healthcare providers. Without a framework to triage urgent versus nonurgent messages, a clinician can become inundated with information and miss critical messages. This can lead to delayed or incorrect responses and impede patient care. System design and implementation can also contribute to this phenomenon. For example, a text message analysis at one center identified how system and workflow design resulted in all messages to an intensive care unit team being routed to a single physician’s phone.¹⁰ This design left the singular physician at risk of information and task overload and at the mercy of endless interruptive alerts. Although this can occur with any communication system, it has been well demonstrated that adopting STMS correlates with an increased frequency of messaging, leading to an increase in interruptive alerts, which may have implications for patient safety.¹¹ This type of systems failure is silent unless proactively identified or revealed through a retrospective review of a resulting safety event.

Text Messaging Inappropriately Replaces Critical Communications that Should Happen in Person or by Phone

Text messaging has de-emphasized interpersonal communication skills and behaviors critical for quality and safety in hospital-based care. This concern emerges alongside evidence suggesting that new generations of physician trainees have profoundly different communication habits, preferences, and skillsets based on their experience in a text-heavy, asynchronous world of communication.¹² There is reason to worry that reliance on text messaging in healthcare leads to similar alterations in relationships and collaboration as it has in our broader cultural context.¹³ Academic medical centers in particular should attempt to mitigate the loss of profound and formative learning that occurs during face-to-face encounters between providers of different disciplines, experience levels, and specialties.

Text Messaging Increases the Risk of Communication Error

Finally, text messaging appears to be highly vulnerable to communication errors in the healthcare setting. Prior work emphasizes the importance of nonverbal communication in face-to-face and even voice-to-voice interactions, highlighting the loss of fidelity when using text-only methods to communicate.¹ Furthermore, the asynchronous nature of text messaging grants little room for clarification of minor misunderstandings that often arise in text-only communication through minor alterations in punctuation or automatic spelling corrections, a frequent occurrence when using medical terminology. Although a seasoned physician may be able to piece together the issues that deserve further clarification, young residents may be more hesitant to ask clarifying questions and determine the right course of action due to clinical inexperience.

Deliberate Design and Implementation

A recent systematic review identified a lack of high-quality evidence evaluating the impact of mobile technologies on communication and teamwork in hospital settings.¹⁴ This paucity of understanding renders communication via STMS in the healthcare setting uniquely vulnerable to latent safety threats unless the design and implementation of these systems are purposeful and proactive.

These concerns led us to postulate that deliberate and proactive implementation of these systems, rather than passive adoption, is needed in the healthcare environment. We propose a number of approaches and interventions that may guide institutions as they seek to implement STMS or redesign communication in the inpatient setting. At the core of these proposals lies an important tension: can implementation of STMS occur in isolation or should the arrival of these systems prompt an overhaul of an institution’s clinical communication system and culture?¹⁵

Proactive Surveillance

Surveillance is one proactive method for healthcare systems to understand where and how the implementation of STMS might lead to safety threats. From a quantitative standpoint, understanding the burden of messaging for each user across the system can reveal the clinical roles in the system that are particularly vulnerable to alert fatigue or information overload. Quality assurance monitoring of critical roles in the hospital (ie, airway emergency team, rapid response teams) could be conducted to ensure accurate directory listings at all times. Associating conversations with events, from serious safety events to near misses, could help leaders understand when and how text messaging contributes to safety events and create actionable learnings for safety learning systems.

Standardized Communication

A standardized language eliminates the burden of individuals to parse and translate each individual text message. A standardized algorithm for language, urgency, and expectations (ie, response before escalation) would help define the interaction in the clinical setting.¹⁶ Moving toward standardized, meaningful “quick messages,” one of our centers has implemented a campaign to “stick to the FACS,” where the following four standard quick messages are available for users: (1) “FYI no response needed,” (2) “ACTION needed within X min,” (3) “CONCERN can we talk or meet,” and (4) “STAT immediate response required.” These quick messages, developed with frontline stakeholders, represent the majority of requests exchanged by providers, and help standardize expectations and task prioritization.

Targeted Training

Targeted training and culture change efforts might help institutions counteract the broader impact of asynchronous messaging on communication skills and behaviors. Highlighting the contrast between clinical and casual communication with an emphasis on examples, scenarios, or role-playing has the potential to emphasize why and how clinical communication with STMS requires a careful, deliberate approach. For instance, safety culture training at one of our institutions features a scenario that illustrates the potential for miscommunication and missed connection between a nurse and a physician on the wards. The scenario gives way to discussion between participants about the shortcomings of text messaging and allows the facilitator to segue into the “dos and don’ts” of text messaging and when a phone call might be more appropriate.

Innovate

Finally, creatively harnessing the technology and data underlying these STMS may uncover methods to identify and mitigate communication errors in real time. For instance, using trigger methods to create a “ripple in the pond,” whereby a floor nurse reaching out with an urgent text automatically loops in the charge nurse of the unit. Building a chatbot or a virtual assistant functionality by leveraging user behavior patterns and natural language processing to provide text-based guidance to users might help busy clinicians connect to the key decision-makers on their team. For example, in response to an unanswered text, a virtual assistant might reach out to the waiting provider as follows: “you texted the resident 20 minutes ago and they haven’t replied, would you like to call the fellow instead?” The data-rich nature of these systems implies that they are ripe for automated solutions that can respond to behavioral- or text-based patterns to augment the existing operation and safety infrastructure.

The transition of healthcare communication systems toward STMS is already well underway. These systems, despite their flaws, are undoubtedly an improvement over legacy paging systems and, if properly implemented, offer several benefits to large healthcare systems. However, the communication needs in the healthcare setting are vastly different from the personal communication needs in everyday text messaging. As clinicians at the forefront of these transitions, we have the opportunity to critically assess the unique communication requirements in our hospital settings and help shape the way STMS are implemented in our hospitals. Pausing to deliberate about the limitations and the vulnerabilities of the current messaging systems for our acute clinical needs, including how they impact training and education, will allow us to proactively design and implement better communication systems that improve patient safety.

Over the past two decades, physicians and nurses practicing in hospital settings have faced an onslaught of challenges in communication, an area frequently cited as critical to providing safe and effective care to patients.^1-3 Communication needs have increased significantly as hospitalized patients have become more acute, complex, and technology-dependent, requiring larger healthcare teams comprising subspecialists across multiple disciplines spread across increasingly larger inpatient facilities.⁴ During this same period, the evolution of mobile phones has led to dramatic shifts in personal communication patterns, with asynchronous text messaging replacing verbal communication.^5-7

In response to both the changing communication needs of clinicians and shifting cultural conventions, healthcare systems and providers alike have viewed text messaging as a solution to these growing communication problems. In fact, an entire industry has developed around “secure” and “Health Insurance Portability and Accountability Act (HIPAA)-compliant” text messaging platforms, which we will refer to below as secure text messaging systems (STMS). These systems offer benefits over carrier-based text messaging given their focus on the healthcare environment and HIPAA compliance. However, hospitals’ rapid adoption of these systems has outpaced our abilities to surveil, recognize, and understand the unintended consequences of transitioning to STMS communication in the hospital setting where failures in communication can be catastrophic. Below, we highlight three critical areas of concern encountered at our institutions and offer five potential mitigating strategies (Table).

Text Messaging is a Form of Alarm Fatigue

Text messaging renders clinicians vulnerable to a unique form of alarm fatigue. The burden of alarm fatigue has been well described in the literature and applies to interruptions to workflow in the electronic medical record and sensory alerts in clinical settings.^8,9 Text messaging serves as yet another interruption for healthcare providers. Without a framework to triage urgent versus nonurgent messages, a clinician can become inundated with information and miss critical messages. This can lead to delayed or incorrect responses and impede patient care. System design and implementation can also contribute to this phenomenon. For example, a text message analysis at one center identified how system and workflow design resulted in all messages to an intensive care unit team being routed to a single physician’s phone.¹⁰ This design left the singular physician at risk of information and task overload and at the mercy of endless interruptive alerts. Although this can occur with any communication system, it has been well demonstrated that adopting STMS correlates with an increased frequency of messaging, leading to an increase in interruptive alerts, which may have implications for patient safety.¹¹ This type of systems failure is silent unless proactively identified or revealed through a retrospective review of a resulting safety event.

Text Messaging Inappropriately Replaces Critical Communications that Should Happen in Person or by Phone

Text messaging has de-emphasized interpersonal communication skills and behaviors critical for quality and safety in hospital-based care. This concern emerges alongside evidence suggesting that new generations of physician trainees have profoundly different communication habits, preferences, and skillsets based on their experience in a text-heavy, asynchronous world of communication.¹² There is reason to worry that reliance on text messaging in healthcare leads to similar alterations in relationships and collaboration as it has in our broader cultural context.¹³ Academic medical centers in particular should attempt to mitigate the loss of profound and formative learning that occurs during face-to-face encounters between providers of different disciplines, experience levels, and specialties.

Text Messaging Increases the Risk of Communication Error

Finally, text messaging appears to be highly vulnerable to communication errors in the healthcare setting. Prior work emphasizes the importance of nonverbal communication in face-to-face and even voice-to-voice interactions, highlighting the loss of fidelity when using text-only methods to communicate.¹ Furthermore, the asynchronous nature of text messaging grants little room for clarification of minor misunderstandings that often arise in text-only communication through minor alterations in punctuation or automatic spelling corrections, a frequent occurrence when using medical terminology. Although a seasoned physician may be able to piece together the issues that deserve further clarification, young residents may be more hesitant to ask clarifying questions and determine the right course of action due to clinical inexperience.

Deliberate Design and Implementation

A recent systematic review identified a lack of high-quality evidence evaluating the impact of mobile technologies on communication and teamwork in hospital settings.¹⁴ This paucity of understanding renders communication via STMS in the healthcare setting uniquely vulnerable to latent safety threats unless the design and implementation of these systems are purposeful and proactive.

These concerns led us to postulate that deliberate and proactive implementation of these systems, rather than passive adoption, is needed in the healthcare environment. We propose a number of approaches and interventions that may guide institutions as they seek to implement STMS or redesign communication in the inpatient setting. At the core of these proposals lies an important tension: can implementation of STMS occur in isolation or should the arrival of these systems prompt an overhaul of an institution’s clinical communication system and culture?¹⁵

Proactive Surveillance

Surveillance is one proactive method for healthcare systems to understand where and how the implementation of STMS might lead to safety threats. From a quantitative standpoint, understanding the burden of messaging for each user across the system can reveal the clinical roles in the system that are particularly vulnerable to alert fatigue or information overload. Quality assurance monitoring of critical roles in the hospital (ie, airway emergency team, rapid response teams) could be conducted to ensure accurate directory listings at all times. Associating conversations with events, from serious safety events to near misses, could help leaders understand when and how text messaging contributes to safety events and create actionable learnings for safety learning systems.

Standardized Communication

A standardized language eliminates the burden of individuals to parse and translate each individual text message. A standardized algorithm for language, urgency, and expectations (ie, response before escalation) would help define the interaction in the clinical setting.¹⁶ Moving toward standardized, meaningful “quick messages,” one of our centers has implemented a campaign to “stick to the FACS,” where the following four standard quick messages are available for users: (1) “FYI no response needed,” (2) “ACTION needed within X min,” (3) “CONCERN can we talk or meet,” and (4) “STAT immediate response required.” These quick messages, developed with frontline stakeholders, represent the majority of requests exchanged by providers, and help standardize expectations and task prioritization.

Targeted Training

Targeted training and culture change efforts might help institutions counteract the broader impact of asynchronous messaging on communication skills and behaviors. Highlighting the contrast between clinical and casual communication with an emphasis on examples, scenarios, or role-playing has the potential to emphasize why and how clinical communication with STMS requires a careful, deliberate approach. For instance, safety culture training at one of our institutions features a scenario that illustrates the potential for miscommunication and missed connection between a nurse and a physician on the wards. The scenario gives way to discussion between participants about the shortcomings of text messaging and allows the facilitator to segue into the “dos and don’ts” of text messaging and when a phone call might be more appropriate.

Innovate

Finally, creatively harnessing the technology and data underlying these STMS may uncover methods to identify and mitigate communication errors in real time. For instance, using trigger methods to create a “ripple in the pond,” whereby a floor nurse reaching out with an urgent text automatically loops in the charge nurse of the unit. Building a chatbot or a virtual assistant functionality by leveraging user behavior patterns and natural language processing to provide text-based guidance to users might help busy clinicians connect to the key decision-makers on their team. For example, in response to an unanswered text, a virtual assistant might reach out to the waiting provider as follows: “you texted the resident 20 minutes ago and they haven’t replied, would you like to call the fellow instead?” The data-rich nature of these systems implies that they are ripe for automated solutions that can respond to behavioral- or text-based patterns to augment the existing operation and safety infrastructure.

The transition of healthcare communication systems toward STMS is already well underway. These systems, despite their flaws, are undoubtedly an improvement over legacy paging systems and, if properly implemented, offer several benefits to large healthcare systems. However, the communication needs in the healthcare setting are vastly different from the personal communication needs in everyday text messaging. As clinicians at the forefront of these transitions, we have the opportunity to critically assess the unique communication requirements in our hospital settings and help shape the way STMS are implemented in our hospitals. Pausing to deliberate about the limitations and the vulnerabilities of the current messaging systems for our acute clinical needs, including how they impact training and education, will allow us to proactively design and implement better communication systems that improve patient safety.

Over the past two decades, physicians and nurses practicing in hospital settings have faced an onslaught of challenges in communication, an area frequently cited as critical to providing safe and effective care to patients.^1-3 Communication needs have increased significantly as hospitalized patients have become more acute, complex, and technology-dependent, requiring larger healthcare teams comprising subspecialists across multiple disciplines spread across increasingly larger inpatient facilities.⁴ During this same period, the evolution of mobile phones has led to dramatic shifts in personal communication patterns, with asynchronous text messaging replacing verbal communication.^5-7

In response to both the changing communication needs of clinicians and shifting cultural conventions, healthcare systems and providers alike have viewed text messaging as a solution to these growing communication problems. In fact, an entire industry has developed around “secure” and “Health Insurance Portability and Accountability Act (HIPAA)-compliant” text messaging platforms, which we will refer to below as secure text messaging systems (STMS). These systems offer benefits over carrier-based text messaging given their focus on the healthcare environment and HIPAA compliance. However, hospitals’ rapid adoption of these systems has outpaced our abilities to surveil, recognize, and understand the unintended consequences of transitioning to STMS communication in the hospital setting where failures in communication can be catastrophic. Below, we highlight three critical areas of concern encountered at our institutions and offer five potential mitigating strategies (Table).

Text Messaging is a Form of Alarm Fatigue

Text messaging renders clinicians vulnerable to a unique form of alarm fatigue. The burden of alarm fatigue has been well described in the literature and applies to interruptions to workflow in the electronic medical record and sensory alerts in clinical settings.^8,9 Text messaging serves as yet another interruption for healthcare providers. Without a framework to triage urgent versus nonurgent messages, a clinician can become inundated with information and miss critical messages. This can lead to delayed or incorrect responses and impede patient care. System design and implementation can also contribute to this phenomenon. For example, a text message analysis at one center identified how system and workflow design resulted in all messages to an intensive care unit team being routed to a single physician’s phone.¹⁰ This design left the singular physician at risk of information and task overload and at the mercy of endless interruptive alerts. Although this can occur with any communication system, it has been well demonstrated that adopting STMS correlates with an increased frequency of messaging, leading to an increase in interruptive alerts, which may have implications for patient safety.¹¹ This type of systems failure is silent unless proactively identified or revealed through a retrospective review of a resulting safety event.

Text Messaging Inappropriately Replaces Critical Communications that Should Happen in Person or by Phone

Text messaging has de-emphasized interpersonal communication skills and behaviors critical for quality and safety in hospital-based care. This concern emerges alongside evidence suggesting that new generations of physician trainees have profoundly different communication habits, preferences, and skillsets based on their experience in a text-heavy, asynchronous world of communication.¹² There is reason to worry that reliance on text messaging in healthcare leads to similar alterations in relationships and collaboration as it has in our broader cultural context.¹³ Academic medical centers in particular should attempt to mitigate the loss of profound and formative learning that occurs during face-to-face encounters between providers of different disciplines, experience levels, and specialties.

Text Messaging Increases the Risk of Communication Error

Finally, text messaging appears to be highly vulnerable to communication errors in the healthcare setting. Prior work emphasizes the importance of nonverbal communication in face-to-face and even voice-to-voice interactions, highlighting the loss of fidelity when using text-only methods to communicate.¹ Furthermore, the asynchronous nature of text messaging grants little room for clarification of minor misunderstandings that often arise in text-only communication through minor alterations in punctuation or automatic spelling corrections, a frequent occurrence when using medical terminology. Although a seasoned physician may be able to piece together the issues that deserve further clarification, young residents may be more hesitant to ask clarifying questions and determine the right course of action due to clinical inexperience.

Deliberate Design and Implementation

A recent systematic review identified a lack of high-quality evidence evaluating the impact of mobile technologies on communication and teamwork in hospital settings.¹⁴ This paucity of understanding renders communication via STMS in the healthcare setting uniquely vulnerable to latent safety threats unless the design and implementation of these systems are purposeful and proactive.

These concerns led us to postulate that deliberate and proactive implementation of these systems, rather than passive adoption, is needed in the healthcare environment. We propose a number of approaches and interventions that may guide institutions as they seek to implement STMS or redesign communication in the inpatient setting. At the core of these proposals lies an important tension: can implementation of STMS occur in isolation or should the arrival of these systems prompt an overhaul of an institution’s clinical communication system and culture?¹⁵

Proactive Surveillance

Surveillance is one proactive method for healthcare systems to understand where and how the implementation of STMS might lead to safety threats. From a quantitative standpoint, understanding the burden of messaging for each user across the system can reveal the clinical roles in the system that are particularly vulnerable to alert fatigue or information overload. Quality assurance monitoring of critical roles in the hospital (ie, airway emergency team, rapid response teams) could be conducted to ensure accurate directory listings at all times. Associating conversations with events, from serious safety events to near misses, could help leaders understand when and how text messaging contributes to safety events and create actionable learnings for safety learning systems.

Standardized Communication

A standardized language eliminates the burden of individuals to parse and translate each individual text message. A standardized algorithm for language, urgency, and expectations (ie, response before escalation) would help define the interaction in the clinical setting.¹⁶ Moving toward standardized, meaningful “quick messages,” one of our centers has implemented a campaign to “stick to the FACS,” where the following four standard quick messages are available for users: (1) “FYI no response needed,” (2) “ACTION needed within X min,” (3) “CONCERN can we talk or meet,” and (4) “STAT immediate response required.” These quick messages, developed with frontline stakeholders, represent the majority of requests exchanged by providers, and help standardize expectations and task prioritization.

Targeted Training

Targeted training and culture change efforts might help institutions counteract the broader impact of asynchronous messaging on communication skills and behaviors. Highlighting the contrast between clinical and casual communication with an emphasis on examples, scenarios, or role-playing has the potential to emphasize why and how clinical communication with STMS requires a careful, deliberate approach. For instance, safety culture training at one of our institutions features a scenario that illustrates the potential for miscommunication and missed connection between a nurse and a physician on the wards. The scenario gives way to discussion between participants about the shortcomings of text messaging and allows the facilitator to segue into the “dos and don’ts” of text messaging and when a phone call might be more appropriate.

Innovate

Finally, creatively harnessing the technology and data underlying these STMS may uncover methods to identify and mitigate communication errors in real time. For instance, using trigger methods to create a “ripple in the pond,” whereby a floor nurse reaching out with an urgent text automatically loops in the charge nurse of the unit. Building a chatbot or a virtual assistant functionality by leveraging user behavior patterns and natural language processing to provide text-based guidance to users might help busy clinicians connect to the key decision-makers on their team. For example, in response to an unanswered text, a virtual assistant might reach out to the waiting provider as follows: “you texted the resident 20 minutes ago and they haven’t replied, would you like to call the fellow instead?” The data-rich nature of these systems implies that they are ripe for automated solutions that can respond to behavioral- or text-based patterns to augment the existing operation and safety infrastructure.

The transition of healthcare communication systems toward STMS is already well underway. These systems, despite their flaws, are undoubtedly an improvement over legacy paging systems and, if properly implemented, offer several benefits to large healthcare systems. However, the communication needs in the healthcare setting are vastly different from the personal communication needs in everyday text messaging. As clinicians at the forefront of these transitions, we have the opportunity to critically assess the unique communication requirements in our hospital settings and help shape the way STMS are implemented in our hospitals. Pausing to deliberate about the limitations and the vulnerabilities of the current messaging systems for our acute clinical needs, including how they impact training and education, will allow us to proactively design and implement better communication systems that improve patient safety.

As an appealing, physiologically plausible treatment, humidified oxygen delivery via high-flow nasal cannula (HFNC) has been rapidly adopted for the treatment of bronchiolitis despite weak evidence supporting its routine and early use in hypoxemic infants.¹ Although HFNC use has been associated with decreased work of breathing and lower rates of progression to invasive ventilation in some studies, the one large trial published on the topic found no difference between early HFNC and standard oxygen therapy on length of stay in hospital, duration of oxygen therapy, or rates of intubation.^2,3 No adequately powered studies have examined the effect of ward-based HFNC initiation on ICU transfer, an outcome that it is designed to prevent.

In this month’s issue of the Journal of Hospital Medicine, Coon et al examine the association between the implementation of ward-based HFNC initiation protocols and subsequent ICU transfer rates.⁴ Hospitals enrolled in the Pediatric Health Information System database were surveyed about their HFNC use and protocol implementation, with 41 (93% response rate) hospitals replying, 12 of which implemented ward-based HFNC initiation protocols during 2010 to 2016. Administrative data for bronchiolitis encounters were obtained with use of International Classification of Diseases, 9th and 10th Revisions, coding of children aged 3 to 24 months discharged during the respiratory seasons of the study period. The authors used an interrupted time series analysis to study the association between ward-based HFNC protocol initiation and several outcomes, revealing a small but significant increase in ICU transfers (absolute difference, 3.1%; 95% CI, 2.8%-3.4%) and ICU length of stay (absolute difference, 9.1 days per 100 patients; 95% CI 5.1-13.2), but not overall length of stay or use of mechanical ventilation. Modifications to the analysis that account for a learning period during the first season of implementation at each hospital, and for trends among nonadopting hospitals, did not substantially affect the findings.

The authors acknowledged many of the study’s limitations, including its retrospective design, presumption of bronchiolitis discharge code validity, restriction to tertiary care hospitals, and analysis of hospital-level rather than patient-level variables and outcomes. Because the data source does not capture patient-­level HFNC use, the number and characteristics of patients receiving HFNC at the centers are unknown. It is also important to note that the 12 included protocols are quite heterogeneous, with differing exclusion criteria, maximum flow rates, and indications for ICU transfer. Given the rapid evolution of ward-based HFNC use for bronchiolitis, these protocols from 2010 to 2016 are already out of date. All of the protocols allowed much lower maximum flow rates (4-10 L/min) than would typically be expected today (usually 2 L/kg per minute, which translates to 10 L/min of flow for a 5-kg child or 20 L/min for a 10-kg child). Many also had time-based criteria prompting ICU transfer (eg, 24 hours without improvement) that are not typically included in more recent protocols. Few had instructions for weaning or discontinuation of HFNC.

In spite of the above limitations, the results of this large, multicenter study advance our understanding of the consequences of ward-based protocols for HFNC initiation. However, it is important to contextualize this work as an examination of the implementation of a technology to a broad population in a specific era, not necessarily a study of the effectiveness of the technology itself.

The pediatric hospital medicine community has long recognized the need for more evidence regarding HFNC use.^5-7 Coon et al have highlighted possible unintended consequences, notably increased ICU use, that may be associated with ward-based HFNC implementation on a population basis. This finding mirrors evidence from a recent similarly designed study analyzing Canadian tertiary care centers implementing HFNC administration during 2009 to 2014, though not specifically limited to ward use.⁸

More recently there has been discussion of how we might deimplement ward-based HFNC protocols. Although it is increasingly clear that HFNC is not a panacea for bronchiolitis, there is not necessarily a problem with the technology; the problem that this study so clearly demonstrates is how we have applied it. We need pragmatic trials of HFNC protocols to understand what parameters should guide HFNC initiation as a rescue treatment; what oxygen and flow settings might prevent ICU transfer; how it should be used in populations that have been largely excluded from trials (ie, children with medical complexity); and how to optimally wean it. With that information we could construct evidence-based, utilitarian HFNC initiation and treatment protocols to maximize benefit and minimize harm and cost.

It is understandable that our desire to help patients has led us to hear the “siren’s call” for this therapy, and indeed we should work on putting some of the “horses back in the barn.”^5,6 Until new evidence guides how to best use this technology, institutional practice guidelines for HFNC initiation in ward settings should target children for whom ICU transfer seems very likely (eg, having oxygen saturations not maintained on maximum low-flow oxygen therapy) so that HFNC is not used routinely and that we maximize its cost to benefit ratio. It is important to approach this shift in a thoughtful manner to prevent a pendulum swing to premature universal deimplementation.

As an appealing, physiologically plausible treatment, humidified oxygen delivery via high-flow nasal cannula (HFNC) has been rapidly adopted for the treatment of bronchiolitis despite weak evidence supporting its routine and early use in hypoxemic infants.¹ Although HFNC use has been associated with decreased work of breathing and lower rates of progression to invasive ventilation in some studies, the one large trial published on the topic found no difference between early HFNC and standard oxygen therapy on length of stay in hospital, duration of oxygen therapy, or rates of intubation.^2,3 No adequately powered studies have examined the effect of ward-based HFNC initiation on ICU transfer, an outcome that it is designed to prevent.

In this month’s issue of the Journal of Hospital Medicine, Coon et al examine the association between the implementation of ward-based HFNC initiation protocols and subsequent ICU transfer rates.⁴ Hospitals enrolled in the Pediatric Health Information System database were surveyed about their HFNC use and protocol implementation, with 41 (93% response rate) hospitals replying, 12 of which implemented ward-based HFNC initiation protocols during 2010 to 2016. Administrative data for bronchiolitis encounters were obtained with use of International Classification of Diseases, 9th and 10th Revisions, coding of children aged 3 to 24 months discharged during the respiratory seasons of the study period. The authors used an interrupted time series analysis to study the association between ward-based HFNC protocol initiation and several outcomes, revealing a small but significant increase in ICU transfers (absolute difference, 3.1%; 95% CI, 2.8%-3.4%) and ICU length of stay (absolute difference, 9.1 days per 100 patients; 95% CI 5.1-13.2), but not overall length of stay or use of mechanical ventilation. Modifications to the analysis that account for a learning period during the first season of implementation at each hospital, and for trends among nonadopting hospitals, did not substantially affect the findings.

The authors acknowledged many of the study’s limitations, including its retrospective design, presumption of bronchiolitis discharge code validity, restriction to tertiary care hospitals, and analysis of hospital-level rather than patient-level variables and outcomes. Because the data source does not capture patient-­level HFNC use, the number and characteristics of patients receiving HFNC at the centers are unknown. It is also important to note that the 12 included protocols are quite heterogeneous, with differing exclusion criteria, maximum flow rates, and indications for ICU transfer. Given the rapid evolution of ward-based HFNC use for bronchiolitis, these protocols from 2010 to 2016 are already out of date. All of the protocols allowed much lower maximum flow rates (4-10 L/min) than would typically be expected today (usually 2 L/kg per minute, which translates to 10 L/min of flow for a 5-kg child or 20 L/min for a 10-kg child). Many also had time-based criteria prompting ICU transfer (eg, 24 hours without improvement) that are not typically included in more recent protocols. Few had instructions for weaning or discontinuation of HFNC.

In spite of the above limitations, the results of this large, multicenter study advance our understanding of the consequences of ward-based protocols for HFNC initiation. However, it is important to contextualize this work as an examination of the implementation of a technology to a broad population in a specific era, not necessarily a study of the effectiveness of the technology itself.

The pediatric hospital medicine community has long recognized the need for more evidence regarding HFNC use.^5-7 Coon et al have highlighted possible unintended consequences, notably increased ICU use, that may be associated with ward-based HFNC implementation on a population basis. This finding mirrors evidence from a recent similarly designed study analyzing Canadian tertiary care centers implementing HFNC administration during 2009 to 2014, though not specifically limited to ward use.⁸

More recently there has been discussion of how we might deimplement ward-based HFNC protocols. Although it is increasingly clear that HFNC is not a panacea for bronchiolitis, there is not necessarily a problem with the technology; the problem that this study so clearly demonstrates is how we have applied it. We need pragmatic trials of HFNC protocols to understand what parameters should guide HFNC initiation as a rescue treatment; what oxygen and flow settings might prevent ICU transfer; how it should be used in populations that have been largely excluded from trials (ie, children with medical complexity); and how to optimally wean it. With that information we could construct evidence-based, utilitarian HFNC initiation and treatment protocols to maximize benefit and minimize harm and cost.

It is understandable that our desire to help patients has led us to hear the “siren’s call” for this therapy, and indeed we should work on putting some of the “horses back in the barn.”^5,6 Until new evidence guides how to best use this technology, institutional practice guidelines for HFNC initiation in ward settings should target children for whom ICU transfer seems very likely (eg, having oxygen saturations not maintained on maximum low-flow oxygen therapy) so that HFNC is not used routinely and that we maximize its cost to benefit ratio. It is important to approach this shift in a thoughtful manner to prevent a pendulum swing to premature universal deimplementation.

As an appealing, physiologically plausible treatment, humidified oxygen delivery via high-flow nasal cannula (HFNC) has been rapidly adopted for the treatment of bronchiolitis despite weak evidence supporting its routine and early use in hypoxemic infants.¹ Although HFNC use has been associated with decreased work of breathing and lower rates of progression to invasive ventilation in some studies, the one large trial published on the topic found no difference between early HFNC and standard oxygen therapy on length of stay in hospital, duration of oxygen therapy, or rates of intubation.^2,3 No adequately powered studies have examined the effect of ward-based HFNC initiation on ICU transfer, an outcome that it is designed to prevent.

In this month’s issue of the Journal of Hospital Medicine, Coon et al examine the association between the implementation of ward-based HFNC initiation protocols and subsequent ICU transfer rates.⁴ Hospitals enrolled in the Pediatric Health Information System database were surveyed about their HFNC use and protocol implementation, with 41 (93% response rate) hospitals replying, 12 of which implemented ward-based HFNC initiation protocols during 2010 to 2016. Administrative data for bronchiolitis encounters were obtained with use of International Classification of Diseases, 9th and 10th Revisions, coding of children aged 3 to 24 months discharged during the respiratory seasons of the study period. The authors used an interrupted time series analysis to study the association between ward-based HFNC protocol initiation and several outcomes, revealing a small but significant increase in ICU transfers (absolute difference, 3.1%; 95% CI, 2.8%-3.4%) and ICU length of stay (absolute difference, 9.1 days per 100 patients; 95% CI 5.1-13.2), but not overall length of stay or use of mechanical ventilation. Modifications to the analysis that account for a learning period during the first season of implementation at each hospital, and for trends among nonadopting hospitals, did not substantially affect the findings.

The authors acknowledged many of the study’s limitations, including its retrospective design, presumption of bronchiolitis discharge code validity, restriction to tertiary care hospitals, and analysis of hospital-level rather than patient-level variables and outcomes. Because the data source does not capture patient-­level HFNC use, the number and characteristics of patients receiving HFNC at the centers are unknown. It is also important to note that the 12 included protocols are quite heterogeneous, with differing exclusion criteria, maximum flow rates, and indications for ICU transfer. Given the rapid evolution of ward-based HFNC use for bronchiolitis, these protocols from 2010 to 2016 are already out of date. All of the protocols allowed much lower maximum flow rates (4-10 L/min) than would typically be expected today (usually 2 L/kg per minute, which translates to 10 L/min of flow for a 5-kg child or 20 L/min for a 10-kg child). Many also had time-based criteria prompting ICU transfer (eg, 24 hours without improvement) that are not typically included in more recent protocols. Few had instructions for weaning or discontinuation of HFNC.

In spite of the above limitations, the results of this large, multicenter study advance our understanding of the consequences of ward-based protocols for HFNC initiation. However, it is important to contextualize this work as an examination of the implementation of a technology to a broad population in a specific era, not necessarily a study of the effectiveness of the technology itself.

The pediatric hospital medicine community has long recognized the need for more evidence regarding HFNC use.^5-7 Coon et al have highlighted possible unintended consequences, notably increased ICU use, that may be associated with ward-based HFNC implementation on a population basis. This finding mirrors evidence from a recent similarly designed study analyzing Canadian tertiary care centers implementing HFNC administration during 2009 to 2014, though not specifically limited to ward use.⁸

More recently there has been discussion of how we might deimplement ward-based HFNC protocols. Although it is increasingly clear that HFNC is not a panacea for bronchiolitis, there is not necessarily a problem with the technology; the problem that this study so clearly demonstrates is how we have applied it. We need pragmatic trials of HFNC protocols to understand what parameters should guide HFNC initiation as a rescue treatment; what oxygen and flow settings might prevent ICU transfer; how it should be used in populations that have been largely excluded from trials (ie, children with medical complexity); and how to optimally wean it. With that information we could construct evidence-based, utilitarian HFNC initiation and treatment protocols to maximize benefit and minimize harm and cost.

It is understandable that our desire to help patients has led us to hear the “siren’s call” for this therapy, and indeed we should work on putting some of the “horses back in the barn.”^5,6 Until new evidence guides how to best use this technology, institutional practice guidelines for HFNC initiation in ward settings should target children for whom ICU transfer seems very likely (eg, having oxygen saturations not maintained on maximum low-flow oxygen therapy) so that HFNC is not used routinely and that we maximize its cost to benefit ratio. It is important to approach this shift in a thoughtful manner to prevent a pendulum swing to premature universal deimplementation.