Dean Brown started off this morning’s COVID Management call with a thank you to those who have, as she says, “stepped up at a time that is, in some ways, even harder than last spring.” But she also noted that we need more volunteers and it’s a difficult ask. As she said, “The adrenaline is gone. You are taking care of the usual number of patients, but they’re even sicker. As we face this second wave, people are tired. And yet we need to, once again, ask you to consider taking on another shift, or two – which I say with full recognition that it’s really hard to do."
Though the Pfizer and Moderna announcements brighten our long-term outlook, we anticipate a few intense weeks. The YNHH census this morning was 1,337, including 183 COVID patients – a population that increases by about 10/day. Our data give us every reason to expect this rate of growth to continue for several weeks, with hope it will subside in early December. I respectfully add my voice to that of Dean Brown, Dr. Gary Desir, Dr. Lynn Tanoue and the others working to staff our floors, in requesting your additional support. It’s more important than ever that we work collaboratively and support one another in caring for our community.
Here’s a rundown of all you need to know today, Wednesday, November 18, 2020:
Volunteers Urgently Needed
Dr. Gary Desir reports that the Hospitalist and MICU services are under enormous pressure as they try to meet the growing demands of caring for the surge of COVID patients, in addition to an already full census. Expressing gratitude to the 27 faculty (plus a cadre of APPs) who’ve already stepped up to support the department, Dr. Desir notes that “as the number of patients admitted to YNHH continues to rise, our resources are substantially stressed.” As noted in previous communications, volunteers will be compensated for their time. If you can help, please inform your chair – and know how much your support is and will be appreciated.
Physician Guidance on Daily Health Check
I write to clarify the recent announcement that a Daily Health Check email will be sent out by the YSM Office of Communications. Physicians are exempted from daily reporting requirements other than what is in place for your department. The daily health email is a proactive tool to track symptoms associated with the workforce and is meant for YSM staff and faculty who need to be on campus, whether daily or occasionally. It should be viewed as a mechanism to facilitate compliance with the University-wide requirement.
Shifting to Telehealth, from Face-to-Face Visits
On the ambulatory side, telehealth remains not only a useful tool to help manage the delivery of patient care – but also, often, the safest option for both patients and providers. Our focus is simultaneously on maintaining our practice volume and managing the needs of COVID patients, which is – of course – challenging. Even as we continue to build our telehealth capacity by hiring more support personnel, we encourage physicians to utilize telehealth where appropriate, always keeping in mind what is the best model of care for each patient, given concerns around safety and patient flow. Our goal is to conduct at least 30% of visits via telehealth.
Important Reminders Regarding Residency Requirements
While meeting staffing requirements is paramount, Dr. Steve Huot noted that there are several important considerations relating to accreditation and graduation requirements for residents and fellows that should be kept in mind for workforce planning.
- First, within a given specialty, individuals can be reassigned if needed from one setting to another (such as, for Medicine, outpatient to ICU or a floor rotation) but the move must be documented by the program director, and should be done in ways that minimize disruption to core educational goals.
- Second, it’s vital to keep procedural and case volume minimums in mind to ensure that spring 2021 graduates are able to meet the requirements. “We need to avoid creating personally difficult situations for people who expect to be looking for jobs next summer and could find themselves short of key board-eligibility requirements,” he said.
He added that, given changes implemented by ACGME this summer following the spring surge, YSM does not currently qualify for pandemic disaster accreditation status as we did earlier in the year. There is ongoing conversation about this with the ACGME and it is likely that we will have new guidance in the next couple of weeks.
How We’re Doing with All This Stress
As you know, we have been sending out Stress Self-Assessments since last spring. At this morning’s meeting, Dr. John Krystal, representing the COVID Mental Health Support Task Force, shared analyses of nearly 7,000 responses from physicians and nurses. (An additional 1,000+ survey results have been received and will be reported on in coming weeks). These Self-Assessments are intended, first and foremost, to give people in our community a tool to obtain feedback on their stress levels. Upon completing this self-assessment, people are referred to sites where they can connect to support resources, including a free, confidential, one-to-one assessment-and-support contact with a mental health professional. However, the survey data also enable us to take the “stress temperature” of our community.
Key findings include:
Themes most commonly referenced around COVID include illness, exposure, infection and work stress and, on the personal front, family, economic pressures and social pressures. “This is a very stressful time in peoples’ work lives, their family lives and, most particularly, the balance of work and family,” says Dr. Krystal.
The most common stress-related symptom, present in the majority of both doctors and nurses who completed the self-assessment, is feeling tired, exhausted, fatigued. “This is quite a striking finding in that it speaks to how draining the burden of stress and work can be,” Dr. Krystal says.
Each of us can (and should) regularly evaluate our own stress levels by filling out the Stress Self-Assessment, an anonymous tool that provides an immediate measure of your stress level.
It’s helpful to make an effort to balance work with self-care, including paying attention to nutrition, exercise, meditation, spirituality, etc. Some may also want to seek support from other sources, that may include EAPs, the One-to-One program or any of the many other resources listed on the Care for the Caregivers website.
Finally, emphasizes Dr. Krystal, “we need to make sure that we are looking out for and supporting one another.” He suggests joining team meetings, participating in huddles, and attending town hall meetings as a way to share your concerns with others facing similar challenges.
Special DNR Policy Reactivated
The special resuscitation protocol put in place during last spring’s wave has been reactivated, with two minor changes. The policy allows two physicians, together, to change code status to DNR for patients with low survivability of an in-hospital code. (See the full policy statement here.) The two changes are as follows:
- This version of the protocol supports only do-not-resuscitate status, not do-not-intubate.
- Emergency Medicine physicians can invoke this protocol only for patients with suspected or confirmed COVID-19, which aligns it with the inpatient protocol. The previous version allowed its use for any patient with low survivability of an in-hospital code.
Paul Taheri, MD, MBA
Deputy Dean for Clinical Affairs, YSM
CEO, Yale Medicine