The Hospitalist

Background: Studies have shown improved hospital outcomes in patients who ambulate regularly. Many assisted mobility protocols aimed at ambulating patients multiple times daily are nurse centered. However, implementation is difficult because of the large number of nursing duties and difficulty finding time away from other competing responsibilities.

Dr. Nelson is a hospitalist at Ochsner Health System, New Orleans.

Background: Studies have shown improved hospital outcomes in patients who ambulate regularly. Many assisted mobility protocols aimed at ambulating patients multiple times daily are nurse centered. However, implementation is difficult because of the large number of nursing duties and difficulty finding time away from other competing responsibilities.

Dr. Nelson is a hospitalist at Ochsner Health System, New Orleans.

Background: Studies have shown improved hospital outcomes in patients who ambulate regularly. Many assisted mobility protocols aimed at ambulating patients multiple times daily are nurse centered. However, implementation is difficult because of the large number of nursing duties and difficulty finding time away from other competing responsibilities.

Dr. Nelson is a hospitalist at Ochsner Health System, New Orleans.

When officials closed U.S. schools in March to limit the spread of COVID-19, they may have prevented more than 1 million cases over a 26-day period, a new estimate published online July 29 in JAMA suggests.

But school closures also left blind spots in understanding how children and schools affect disease transmission.

“School closures early in pandemic responses thwarted larger-scale investigations of schools as a source of community transmission,” researchers noted in a separate study, published online July 30 in JAMA Pediatrics, that examined levels of viral RNA in children and adults with COVID-19.

“Our analyses suggest children younger than 5 years with mild to moderate COVID-19 have high amounts of SARS-CoV-2 viral RNA in their nasopharynx, compared with older children and adults,” reported Taylor Heald-Sargent, MD, PhD, and colleagues. “Thus, young children can potentially be important drivers of SARS-CoV-2 spread in the general population, as has been demonstrated with respiratory syncytial virus, where children with high viral loads are more likely to transmit.”

Although the study “was not designed to prove that younger children spread COVID-19 as much as adults,” it is a possibility, Dr. Heald-Sargent, a pediatric infectious diseases specialist at Ann and Robert H. Lurie Children’s Hospital and assistant professor of pediatrics at Northwestern University, Chicago, said in a related news release. “We need to take that into account in efforts to reduce transmission as we continue to learn more about this virus.”.

The study included 145 patients with mild or moderate illness who were within 1 week of symptom onset. The researchers used reverse transcriptase–polymerase chain reaction (rt-PCR) on nasopharyngeal swabs collected at inpatient, outpatient, emergency department, or drive-through testing sites to measure SARS-CoV-2 levels. The investigators compared PCR amplification cycle threshold (CT) values for children younger than 5 years (n = 46), children aged 5-17 years (n = 51), and adults aged 18-65 years (n = 48); lower CT values indicate higher amounts of viral nucleic acid.

Median CT values for older children and adults were similar (about 11), whereas the median CT value for young children was significantly lower (6.5). The differences between young children and adults “approximate a 10-fold to 100-fold greater amount of SARS-CoV-2 in the upper respiratory tract of young children,” the researchers wrote.

“Behavioral habits of young children and close quarters in school and day care settings raise concern for SARS-CoV-2 amplification in this population as public health restrictions are eased,” they write.
 

Modeling the impact of school closures

In the JAMA study, Katherine A. Auger, MD, of Cincinnati Children’s Hospital Medical Center, and colleagues examined at the U.S. population level whether closing schools, as all 50 states did in March, was associated with relative decreases in COVID-19 incidence and mortality.

To isolate the effect of school closures, the researchers used an interrupted time series analysis and included other state-level nonpharmaceutical interventions and variables in their regression models.

“Per week, the incidence was estimated to have been 39% of what it would have been had schools remained open,” Dr. Auger and colleagues wrote. “Extrapolating the absolute differences of 423.9 cases and 12.6 deaths per 100,000 to 322.2 million residents nationally suggests that school closure may have been associated with approximately 1.37 million fewer cases of COVID-19 over a 26-day period and 40,600 fewer deaths over a 16-day period; however, these figures do not account for uncertainty in the model assumptions and the resulting estimates.”

Relative reductions in incidence and mortality were largest in states that closed schools when the incidence of COVID-19 was low, the authors found.
 

Decisions with high stakes

In an accompanying editorial, Julie M. Donohue, PhD, and Elizabeth Miller, MD, PhD, both affiliated with the University of Pittsburgh, emphasized that the results are estimates. “School closures were enacted in close proximity ... to other physical distancing measures, such as nonessential business closures and stay-at-home orders, making it difficult to disentangle the potential effect of each intervention.”

Although the findings “suggest a role for school closures in virus mitigation, school and health officials must balance this with academic, health, and economic consequences,” Dr. Donohue and Dr. Miller added. “Given the strong connection between education, income, and life expectancy, school closures could have long-term deleterious consequences for child health, likely reaching into adulthood.” Schools provide “meals and nutrition, health care including behavioral health supports, physical activity, social interaction, supports for students with special education needs and disabilities, and other vital resources for healthy development.”

In a viewpoint article also published in JAMA, authors involved in the creation of a National Academies of Sciences, Engineering, and Medicine reported on the reopening of schools recommend that districts “make every effort to prioritize reopening with an emphasis on providing in-person instruction for students in kindergarten through grade 5 as well as those students with special needs who might be best served by in-person instruction.

“To reopen safely, school districts are encouraged to ensure ventilation and air filtration, clean surfaces frequently, provide facilities for regular handwashing, and provide space for physical distancing,” write Kenne A. Dibner, PhD, of the NASEM in Washington, D.C., and coauthors.

Furthermore, districts “need to consider transparent communication of the reality that while measures can be implemented to lower the risk of transmitting COVID-19 when schools reopen, there is no way to eliminate that risk entirely. It is critical to share both the risks and benefits of different scenarios,” they wrote.

The JAMA modeling study received funding from the Agency for Healthcare Research and Quality and the National Institutes of Health. The NASEM report was funded by the Brady Education Foundation and the Spencer Foundation. The authors disclosed no relevant financial relationships.

A version of this story originally appeared on Medscape.com.

When officials closed U.S. schools in March to limit the spread of COVID-19, they may have prevented more than 1 million cases over a 26-day period, a new estimate published online July 29 in JAMA suggests.

But school closures also left blind spots in understanding how children and schools affect disease transmission.

“School closures early in pandemic responses thwarted larger-scale investigations of schools as a source of community transmission,” researchers noted in a separate study, published online July 30 in JAMA Pediatrics, that examined levels of viral RNA in children and adults with COVID-19.

“Our analyses suggest children younger than 5 years with mild to moderate COVID-19 have high amounts of SARS-CoV-2 viral RNA in their nasopharynx, compared with older children and adults,” reported Taylor Heald-Sargent, MD, PhD, and colleagues. “Thus, young children can potentially be important drivers of SARS-CoV-2 spread in the general population, as has been demonstrated with respiratory syncytial virus, where children with high viral loads are more likely to transmit.”

Although the study “was not designed to prove that younger children spread COVID-19 as much as adults,” it is a possibility, Dr. Heald-Sargent, a pediatric infectious diseases specialist at Ann and Robert H. Lurie Children’s Hospital and assistant professor of pediatrics at Northwestern University, Chicago, said in a related news release. “We need to take that into account in efforts to reduce transmission as we continue to learn more about this virus.”.

The study included 145 patients with mild or moderate illness who were within 1 week of symptom onset. The researchers used reverse transcriptase–polymerase chain reaction (rt-PCR) on nasopharyngeal swabs collected at inpatient, outpatient, emergency department, or drive-through testing sites to measure SARS-CoV-2 levels. The investigators compared PCR amplification cycle threshold (CT) values for children younger than 5 years (n = 46), children aged 5-17 years (n = 51), and adults aged 18-65 years (n = 48); lower CT values indicate higher amounts of viral nucleic acid.

Median CT values for older children and adults were similar (about 11), whereas the median CT value for young children was significantly lower (6.5). The differences between young children and adults “approximate a 10-fold to 100-fold greater amount of SARS-CoV-2 in the upper respiratory tract of young children,” the researchers wrote.

“Behavioral habits of young children and close quarters in school and day care settings raise concern for SARS-CoV-2 amplification in this population as public health restrictions are eased,” they write.
 

Modeling the impact of school closures

In the JAMA study, Katherine A. Auger, MD, of Cincinnati Children’s Hospital Medical Center, and colleagues examined at the U.S. population level whether closing schools, as all 50 states did in March, was associated with relative decreases in COVID-19 incidence and mortality.

To isolate the effect of school closures, the researchers used an interrupted time series analysis and included other state-level nonpharmaceutical interventions and variables in their regression models.

“Per week, the incidence was estimated to have been 39% of what it would have been had schools remained open,” Dr. Auger and colleagues wrote. “Extrapolating the absolute differences of 423.9 cases and 12.6 deaths per 100,000 to 322.2 million residents nationally suggests that school closure may have been associated with approximately 1.37 million fewer cases of COVID-19 over a 26-day period and 40,600 fewer deaths over a 16-day period; however, these figures do not account for uncertainty in the model assumptions and the resulting estimates.”

Relative reductions in incidence and mortality were largest in states that closed schools when the incidence of COVID-19 was low, the authors found.
 

Decisions with high stakes

In an accompanying editorial, Julie M. Donohue, PhD, and Elizabeth Miller, MD, PhD, both affiliated with the University of Pittsburgh, emphasized that the results are estimates. “School closures were enacted in close proximity ... to other physical distancing measures, such as nonessential business closures and stay-at-home orders, making it difficult to disentangle the potential effect of each intervention.”

Although the findings “suggest a role for school closures in virus mitigation, school and health officials must balance this with academic, health, and economic consequences,” Dr. Donohue and Dr. Miller added. “Given the strong connection between education, income, and life expectancy, school closures could have long-term deleterious consequences for child health, likely reaching into adulthood.” Schools provide “meals and nutrition, health care including behavioral health supports, physical activity, social interaction, supports for students with special education needs and disabilities, and other vital resources for healthy development.”

In a viewpoint article also published in JAMA, authors involved in the creation of a National Academies of Sciences, Engineering, and Medicine reported on the reopening of schools recommend that districts “make every effort to prioritize reopening with an emphasis on providing in-person instruction for students in kindergarten through grade 5 as well as those students with special needs who might be best served by in-person instruction.

“To reopen safely, school districts are encouraged to ensure ventilation and air filtration, clean surfaces frequently, provide facilities for regular handwashing, and provide space for physical distancing,” write Kenne A. Dibner, PhD, of the NASEM in Washington, D.C., and coauthors.

Furthermore, districts “need to consider transparent communication of the reality that while measures can be implemented to lower the risk of transmitting COVID-19 when schools reopen, there is no way to eliminate that risk entirely. It is critical to share both the risks and benefits of different scenarios,” they wrote.

The JAMA modeling study received funding from the Agency for Healthcare Research and Quality and the National Institutes of Health. The NASEM report was funded by the Brady Education Foundation and the Spencer Foundation. The authors disclosed no relevant financial relationships.

A version of this story originally appeared on Medscape.com.

When officials closed U.S. schools in March to limit the spread of COVID-19, they may have prevented more than 1 million cases over a 26-day period, a new estimate published online July 29 in JAMA suggests.

But school closures also left blind spots in understanding how children and schools affect disease transmission.

“School closures early in pandemic responses thwarted larger-scale investigations of schools as a source of community transmission,” researchers noted in a separate study, published online July 30 in JAMA Pediatrics, that examined levels of viral RNA in children and adults with COVID-19.

“Our analyses suggest children younger than 5 years with mild to moderate COVID-19 have high amounts of SARS-CoV-2 viral RNA in their nasopharynx, compared with older children and adults,” reported Taylor Heald-Sargent, MD, PhD, and colleagues. “Thus, young children can potentially be important drivers of SARS-CoV-2 spread in the general population, as has been demonstrated with respiratory syncytial virus, where children with high viral loads are more likely to transmit.”

Although the study “was not designed to prove that younger children spread COVID-19 as much as adults,” it is a possibility, Dr. Heald-Sargent, a pediatric infectious diseases specialist at Ann and Robert H. Lurie Children’s Hospital and assistant professor of pediatrics at Northwestern University, Chicago, said in a related news release. “We need to take that into account in efforts to reduce transmission as we continue to learn more about this virus.”.

The study included 145 patients with mild or moderate illness who were within 1 week of symptom onset. The researchers used reverse transcriptase–polymerase chain reaction (rt-PCR) on nasopharyngeal swabs collected at inpatient, outpatient, emergency department, or drive-through testing sites to measure SARS-CoV-2 levels. The investigators compared PCR amplification cycle threshold (CT) values for children younger than 5 years (n = 46), children aged 5-17 years (n = 51), and adults aged 18-65 years (n = 48); lower CT values indicate higher amounts of viral nucleic acid.

Median CT values for older children and adults were similar (about 11), whereas the median CT value for young children was significantly lower (6.5). The differences between young children and adults “approximate a 10-fold to 100-fold greater amount of SARS-CoV-2 in the upper respiratory tract of young children,” the researchers wrote.

“Behavioral habits of young children and close quarters in school and day care settings raise concern for SARS-CoV-2 amplification in this population as public health restrictions are eased,” they write.
 

Modeling the impact of school closures

In the JAMA study, Katherine A. Auger, MD, of Cincinnati Children’s Hospital Medical Center, and colleagues examined at the U.S. population level whether closing schools, as all 50 states did in March, was associated with relative decreases in COVID-19 incidence and mortality.

To isolate the effect of school closures, the researchers used an interrupted time series analysis and included other state-level nonpharmaceutical interventions and variables in their regression models.

“Per week, the incidence was estimated to have been 39% of what it would have been had schools remained open,” Dr. Auger and colleagues wrote. “Extrapolating the absolute differences of 423.9 cases and 12.6 deaths per 100,000 to 322.2 million residents nationally suggests that school closure may have been associated with approximately 1.37 million fewer cases of COVID-19 over a 26-day period and 40,600 fewer deaths over a 16-day period; however, these figures do not account for uncertainty in the model assumptions and the resulting estimates.”

Relative reductions in incidence and mortality were largest in states that closed schools when the incidence of COVID-19 was low, the authors found.
 

Decisions with high stakes

In an accompanying editorial, Julie M. Donohue, PhD, and Elizabeth Miller, MD, PhD, both affiliated with the University of Pittsburgh, emphasized that the results are estimates. “School closures were enacted in close proximity ... to other physical distancing measures, such as nonessential business closures and stay-at-home orders, making it difficult to disentangle the potential effect of each intervention.”

Although the findings “suggest a role for school closures in virus mitigation, school and health officials must balance this with academic, health, and economic consequences,” Dr. Donohue and Dr. Miller added. “Given the strong connection between education, income, and life expectancy, school closures could have long-term deleterious consequences for child health, likely reaching into adulthood.” Schools provide “meals and nutrition, health care including behavioral health supports, physical activity, social interaction, supports for students with special education needs and disabilities, and other vital resources for healthy development.”

In a viewpoint article also published in JAMA, authors involved in the creation of a National Academies of Sciences, Engineering, and Medicine reported on the reopening of schools recommend that districts “make every effort to prioritize reopening with an emphasis on providing in-person instruction for students in kindergarten through grade 5 as well as those students with special needs who might be best served by in-person instruction.

“To reopen safely, school districts are encouraged to ensure ventilation and air filtration, clean surfaces frequently, provide facilities for regular handwashing, and provide space for physical distancing,” write Kenne A. Dibner, PhD, of the NASEM in Washington, D.C., and coauthors.

Furthermore, districts “need to consider transparent communication of the reality that while measures can be implemented to lower the risk of transmitting COVID-19 when schools reopen, there is no way to eliminate that risk entirely. It is critical to share both the risks and benefits of different scenarios,” they wrote.

The JAMA modeling study received funding from the Agency for Healthcare Research and Quality and the National Institutes of Health. The NASEM report was funded by the Brady Education Foundation and the Spencer Foundation. The authors disclosed no relevant financial relationships.

A version of this story originally appeared on Medscape.com.

On behalf of SHM’s Practice Analysis Committee, I am excited to announce the scheduled September 2020 release of the 2020 State of Hospital Medicine Report (SoHM)!

For reasons all too familiar, this year’s SoHM survey process was unlike any in SHM’s history. We were still collecting survey responses from a few stragglers in early March when the entire world shut down almost overnight to flatten the curve of a deadly pandemic. Hospital medicine group (HMG) leaders were suddenly either up to their eyeballs trying to figure out how to safely care for huge influxes of COVID-19 patients that overwhelmed established systems of care or were trying to figure out how to staff in a low-volume environment with few COVID patients, a relative trickle of ED admissions, and virtually no surgical care. And everywhere, hospitals and their HMGs were quickly stressed in ways that would have been unimaginable just a couple of months earlier – financially, operationally, epidemiologically, and culturally.

SHM offices closed, with all staff working from home. And the talented people who would normally have been working diligently on the survey data were suddenly redirected to focus on COVID-related issues, including tracking government announcements that were changing daily and providing needed resources to SHM members. By the time they could raise their heads and begin thinking about survey data, we were months behind schedule.

I need to give a huge shout-out to our survey manager extraordinaire Josh Lapps, SHM’s Director of Policy and Practice Management, and his survey support team including Luke Heisinger and Kim Schonberger. Once they were able to turn their focus back to the SoHM, they worked like demons to catch up. And in addition to the work of preparing the SoHM for publication, they helped issue and analyze a follow-up survey to investigate how HMGs adjusted their staffing and operations in response to COVID! As I write this, we appear to be back on schedule for a September SoHM release date, with the COVID supplemental survey report to follow soon after. Thanks also to PAC committee members who, despite their own stresses, rose to the challenge of participating in calls and planning the supplemental survey.

Despite the pandemic, HMGs found survey participation valuable. When all was said and done, we had a respectable number of respondent groups: 502 this year vs. 569 in 2018. Although the number of respondent groups is down, the average group size has increased, so that an all-time high of 10,122 employed/contracted full-time equivalent (FTE) hospitalists (plus 484 locum tenens FTEs) are represented in the data set. The respondents continue to be very diverse, representing all practice models and every state – and even a couple of other countries. One notable change is a significant increase in pediatric HM group participation, thanks to a recruitment charge led by PAC member Sandra Gage, associate division chief of hospital medicine at Phoenix Children’s Hospital, and supported by the inclusion of several new pediatric HM-specific questions to better capture unique attributes of these hospital medicine practices.

We had more multisite respondents than ever, and the multisite respondents overwhelmingly used the new “retake” feature in the online version of the survey. I’m happy to report that we received consistent positive feedback about our new electronic survey platform, and thanks to its capabilities data analysis has been significantly automated, enhancing both efficiency and data reliability.

The survey content is more wide ranging than ever. In addition to the usual topics such as scope of services, staffing and scheduling, compensation models, evaluation and management code distribution, and HM group finances, the 2020 report will include the afore-referenced information about HM groups serving children, expanded information on nurse practitioner (NPs)/physician assistant (PA) roles, and data on diversity in HM physician leadership. The follow-up COVID survey will be published separately as a supplement, available only to purchasers of the SoHM report.

Multiple options for SoHM report purchase. All survey participants will receive access to the online version of the survey. Others may purchase the hard copy report, online access, or both. The report has a colorful, easy-to-read layout, and many of the tables have been streamlined to make them easier to read. I encourage you to sign up to preorder your copy of the SoHM Report today at www.hospitalmedicine.org/sohm; you’ll almost certainly discover a treasure trove of worthwhile information.

Use the report to assess how your practice compares to other practices, but always keep in mind that surveys don’t tell you what should be; they only tell you what currently is the case – or at least, what was during the survey period. New best practices not yet reflected in survey data are emerging all the time, and that is probably more true today in the new world affected by this pandemic than ever before. And while the ways others do things won’t always be right for your group’s unique situation and needs, it always helps to know how you compare with others. Whether you are partners or employees, you and your colleagues “own” the success of your hospital medicine practice and, armed with the best available data, are the best judges of what is right for you.
 

Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants in La Quinta, Calif. She serves on SHM’s Practice Analysis and Annual Conference Committees and helps to coordinate SHM’s biannual State of Hospital Medicine survey.

On behalf of SHM’s Practice Analysis Committee, I am excited to announce the scheduled September 2020 release of the 2020 State of Hospital Medicine Report (SoHM)!

For reasons all too familiar, this year’s SoHM survey process was unlike any in SHM’s history. We were still collecting survey responses from a few stragglers in early March when the entire world shut down almost overnight to flatten the curve of a deadly pandemic. Hospital medicine group (HMG) leaders were suddenly either up to their eyeballs trying to figure out how to safely care for huge influxes of COVID-19 patients that overwhelmed established systems of care or were trying to figure out how to staff in a low-volume environment with few COVID patients, a relative trickle of ED admissions, and virtually no surgical care. And everywhere, hospitals and their HMGs were quickly stressed in ways that would have been unimaginable just a couple of months earlier – financially, operationally, epidemiologically, and culturally.

SHM offices closed, with all staff working from home. And the talented people who would normally have been working diligently on the survey data were suddenly redirected to focus on COVID-related issues, including tracking government announcements that were changing daily and providing needed resources to SHM members. By the time they could raise their heads and begin thinking about survey data, we were months behind schedule.

I need to give a huge shout-out to our survey manager extraordinaire Josh Lapps, SHM’s Director of Policy and Practice Management, and his survey support team including Luke Heisinger and Kim Schonberger. Once they were able to turn their focus back to the SoHM, they worked like demons to catch up. And in addition to the work of preparing the SoHM for publication, they helped issue and analyze a follow-up survey to investigate how HMGs adjusted their staffing and operations in response to COVID! As I write this, we appear to be back on schedule for a September SoHM release date, with the COVID supplemental survey report to follow soon after. Thanks also to PAC committee members who, despite their own stresses, rose to the challenge of participating in calls and planning the supplemental survey.

Despite the pandemic, HMGs found survey participation valuable. When all was said and done, we had a respectable number of respondent groups: 502 this year vs. 569 in 2018. Although the number of respondent groups is down, the average group size has increased, so that an all-time high of 10,122 employed/contracted full-time equivalent (FTE) hospitalists (plus 484 locum tenens FTEs) are represented in the data set. The respondents continue to be very diverse, representing all practice models and every state – and even a couple of other countries. One notable change is a significant increase in pediatric HM group participation, thanks to a recruitment charge led by PAC member Sandra Gage, associate division chief of hospital medicine at Phoenix Children’s Hospital, and supported by the inclusion of several new pediatric HM-specific questions to better capture unique attributes of these hospital medicine practices.

We had more multisite respondents than ever, and the multisite respondents overwhelmingly used the new “retake” feature in the online version of the survey. I’m happy to report that we received consistent positive feedback about our new electronic survey platform, and thanks to its capabilities data analysis has been significantly automated, enhancing both efficiency and data reliability.

The survey content is more wide ranging than ever. In addition to the usual topics such as scope of services, staffing and scheduling, compensation models, evaluation and management code distribution, and HM group finances, the 2020 report will include the afore-referenced information about HM groups serving children, expanded information on nurse practitioner (NPs)/physician assistant (PA) roles, and data on diversity in HM physician leadership. The follow-up COVID survey will be published separately as a supplement, available only to purchasers of the SoHM report.

Multiple options for SoHM report purchase. All survey participants will receive access to the online version of the survey. Others may purchase the hard copy report, online access, or both. The report has a colorful, easy-to-read layout, and many of the tables have been streamlined to make them easier to read. I encourage you to sign up to preorder your copy of the SoHM Report today at www.hospitalmedicine.org/sohm; you’ll almost certainly discover a treasure trove of worthwhile information.

Use the report to assess how your practice compares to other practices, but always keep in mind that surveys don’t tell you what should be; they only tell you what currently is the case – or at least, what was during the survey period. New best practices not yet reflected in survey data are emerging all the time, and that is probably more true today in the new world affected by this pandemic than ever before. And while the ways others do things won’t always be right for your group’s unique situation and needs, it always helps to know how you compare with others. Whether you are partners or employees, you and your colleagues “own” the success of your hospital medicine practice and, armed with the best available data, are the best judges of what is right for you.
 

Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants in La Quinta, Calif. She serves on SHM’s Practice Analysis and Annual Conference Committees and helps to coordinate SHM’s biannual State of Hospital Medicine survey.

On behalf of SHM’s Practice Analysis Committee, I am excited to announce the scheduled September 2020 release of the 2020 State of Hospital Medicine Report (SoHM)!

For reasons all too familiar, this year’s SoHM survey process was unlike any in SHM’s history. We were still collecting survey responses from a few stragglers in early March when the entire world shut down almost overnight to flatten the curve of a deadly pandemic. Hospital medicine group (HMG) leaders were suddenly either up to their eyeballs trying to figure out how to safely care for huge influxes of COVID-19 patients that overwhelmed established systems of care or were trying to figure out how to staff in a low-volume environment with few COVID patients, a relative trickle of ED admissions, and virtually no surgical care. And everywhere, hospitals and their HMGs were quickly stressed in ways that would have been unimaginable just a couple of months earlier – financially, operationally, epidemiologically, and culturally.

SHM offices closed, with all staff working from home. And the talented people who would normally have been working diligently on the survey data were suddenly redirected to focus on COVID-related issues, including tracking government announcements that were changing daily and providing needed resources to SHM members. By the time they could raise their heads and begin thinking about survey data, we were months behind schedule.

I need to give a huge shout-out to our survey manager extraordinaire Josh Lapps, SHM’s Director of Policy and Practice Management, and his survey support team including Luke Heisinger and Kim Schonberger. Once they were able to turn their focus back to the SoHM, they worked like demons to catch up. And in addition to the work of preparing the SoHM for publication, they helped issue and analyze a follow-up survey to investigate how HMGs adjusted their staffing and operations in response to COVID! As I write this, we appear to be back on schedule for a September SoHM release date, with the COVID supplemental survey report to follow soon after. Thanks also to PAC committee members who, despite their own stresses, rose to the challenge of participating in calls and planning the supplemental survey.

Despite the pandemic, HMGs found survey participation valuable. When all was said and done, we had a respectable number of respondent groups: 502 this year vs. 569 in 2018. Although the number of respondent groups is down, the average group size has increased, so that an all-time high of 10,122 employed/contracted full-time equivalent (FTE) hospitalists (plus 484 locum tenens FTEs) are represented in the data set. The respondents continue to be very diverse, representing all practice models and every state – and even a couple of other countries. One notable change is a significant increase in pediatric HM group participation, thanks to a recruitment charge led by PAC member Sandra Gage, associate division chief of hospital medicine at Phoenix Children’s Hospital, and supported by the inclusion of several new pediatric HM-specific questions to better capture unique attributes of these hospital medicine practices.

We had more multisite respondents than ever, and the multisite respondents overwhelmingly used the new “retake” feature in the online version of the survey. I’m happy to report that we received consistent positive feedback about our new electronic survey platform, and thanks to its capabilities data analysis has been significantly automated, enhancing both efficiency and data reliability.

The survey content is more wide ranging than ever. In addition to the usual topics such as scope of services, staffing and scheduling, compensation models, evaluation and management code distribution, and HM group finances, the 2020 report will include the afore-referenced information about HM groups serving children, expanded information on nurse practitioner (NPs)/physician assistant (PA) roles, and data on diversity in HM physician leadership. The follow-up COVID survey will be published separately as a supplement, available only to purchasers of the SoHM report.

Multiple options for SoHM report purchase. All survey participants will receive access to the online version of the survey. Others may purchase the hard copy report, online access, or both. The report has a colorful, easy-to-read layout, and many of the tables have been streamlined to make them easier to read. I encourage you to sign up to preorder your copy of the SoHM Report today at www.hospitalmedicine.org/sohm; you’ll almost certainly discover a treasure trove of worthwhile information.

Use the report to assess how your practice compares to other practices, but always keep in mind that surveys don’t tell you what should be; they only tell you what currently is the case – or at least, what was during the survey period. New best practices not yet reflected in survey data are emerging all the time, and that is probably more true today in the new world affected by this pandemic than ever before. And while the ways others do things won’t always be right for your group’s unique situation and needs, it always helps to know how you compare with others. Whether you are partners or employees, you and your colleagues “own” the success of your hospital medicine practice and, armed with the best available data, are the best judges of what is right for you.
 

Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants in La Quinta, Calif. She serves on SHM’s Practice Analysis and Annual Conference Committees and helps to coordinate SHM’s biannual State of Hospital Medicine survey.

Less than half of internal medicine residency program directors report formal curricula on the topic of health disparities, according to findings of a survey of medical directors and residents across the United States.

Despite recommendations from the Institute of Medicine going back to 2002 calling for increased education on the topic for health care providers, data from a 2012 survey showed that only 17% of internal medicine programs had a health disparities curriculum, wrote Denise M. Dupras, MD, of the Mayo Medical School, Rochester, Minn., and colleagues.

To describe internal medicine residency training programs’ curricula and educational experiences on health disparities and to determine residents’ perceptions of training, the researchers designed a cross-sectional survey study including 227 program directors and 22,723 internal medicine residents. The survey was conducted from August to November 2015.

Overall, 91 program directors (40%) reported a curriculum in health disparities, but only 16 of them described the quality of their education as very good or excellent. In 56% of the programs, outcomes of the curriculum were not measured.

A majority (90%) of the programs included racial/ethnic diversity and socioeconomic status in their curricula, 58% included information about limited English proficiency, and 53% included information about gender identity and sexual orientation.

Reported barriers to curriculum development in 132 programs that did not have a health disparities curriculum included lack of time in the current curriculum, insufficient faculty skill to teach the topic, lack of institutional support, and lack of faculty interest, the researchers noted.

A total of 13,251 residents (70%) reported receiving some training in caring for patients at risk for health disparities over 3 years of training, and 10,494 (80%) of these rated the quality as very good or excellent. “Residents who cared for a larger proportion of underserved patients perceived that they received health disparities training at a higher rate,” the researchers wrote. However, increased care of at-risk populations does not necessarily translate into increased knowledge and skills. “Our finding that residents’ rating of the quality of their training was not associated with the presence of a curriculum in health disparities in their program also raises a concern that perceptions may overestimate the acquisition of needed skills,” they added.

The major limitation of the study was “that residents were not asked directly if they were exposed to a curriculum in health disparities but rather if they received training in the care of patients who would be at risk, which raises the concern that we cannot distinguish between their recognition of a formal and informal curriculum,” the researchers noted. In addition, the survey could not confirm that program directors were aware of all training. “Furthermore, because the survey items were embedded in larger program director survey, we were limited in the ability to ask them to define more specifically the components of their health disparities curricula,” they wrote.

However, the results were strengthened by the large and comprehensive study population, and highlight not only the need for standardized health disparities curricula, but also the need for research to determine the most effective domains for such curricula in graduate medical education, they emphasized.

“There are opportunities to explore partnerships among residencies, institutional clinical practices, and communities for productive collaborations around disparities-related quality improvement projects to address gaps in health care that are specific to the populations they serve,” they concluded.

The surveys were conducted in 2015 and the comparative work in 2018, prior to the COVID-19 pandemic and the subsequent increased concerns about disparities in health care, Dr. Dupras said in an interview.

“We conducted the survey because we recognized that health disparities were still prevalent in our society despite calls to improve the education of our learners to address them. We wanted to determine what our programs were providing for educational curriculum and what our learners were experiencing,” she said.

“We did not know what the surveys would show, so I cannot say that we were surprised by the findings,” said Dr. Dupras. “One of the challenges in interpreting our results is inherent in studies that rely on surveys. We cannot know how those filling out the surveys interpret the questions.” The study results yield several messages.

“First, residency training programs have opportunities to do a better job in developing educational opportunities related to health disparities; second, residents learn in the context of care and we must optimize education around these experiences; third, every patient is different. It is time to move towards cultural humility, since the risk for disparities is not associated with one patient characteristic, but composed of multiple factors,” she said.

“Given that 5 years has passed since our original survey, it would be important to repeat the survey and consider expanding it to include other training programs that provide frontline care, such as family medicine and pediatrics,” Dr. Dupras noted.

Dr. Dupras and colleagues had no financial conflicts to disclose.

SOURCE: Dupras DM et al. JAMA Netw Open. 2020 Aug 10. doi: 10.1001/jamanetworkopen.2020.12757.

Less than half of internal medicine residency program directors report formal curricula on the topic of health disparities, according to findings of a survey of medical directors and residents across the United States.

Despite recommendations from the Institute of Medicine going back to 2002 calling for increased education on the topic for health care providers, data from a 2012 survey showed that only 17% of internal medicine programs had a health disparities curriculum, wrote Denise M. Dupras, MD, of the Mayo Medical School, Rochester, Minn., and colleagues.

To describe internal medicine residency training programs’ curricula and educational experiences on health disparities and to determine residents’ perceptions of training, the researchers designed a cross-sectional survey study including 227 program directors and 22,723 internal medicine residents. The survey was conducted from August to November 2015.

Overall, 91 program directors (40%) reported a curriculum in health disparities, but only 16 of them described the quality of their education as very good or excellent. In 56% of the programs, outcomes of the curriculum were not measured.

A majority (90%) of the programs included racial/ethnic diversity and socioeconomic status in their curricula, 58% included information about limited English proficiency, and 53% included information about gender identity and sexual orientation.

Reported barriers to curriculum development in 132 programs that did not have a health disparities curriculum included lack of time in the current curriculum, insufficient faculty skill to teach the topic, lack of institutional support, and lack of faculty interest, the researchers noted.

A total of 13,251 residents (70%) reported receiving some training in caring for patients at risk for health disparities over 3 years of training, and 10,494 (80%) of these rated the quality as very good or excellent. “Residents who cared for a larger proportion of underserved patients perceived that they received health disparities training at a higher rate,” the researchers wrote. However, increased care of at-risk populations does not necessarily translate into increased knowledge and skills. “Our finding that residents’ rating of the quality of their training was not associated with the presence of a curriculum in health disparities in their program also raises a concern that perceptions may overestimate the acquisition of needed skills,” they added.

The major limitation of the study was “that residents were not asked directly if they were exposed to a curriculum in health disparities but rather if they received training in the care of patients who would be at risk, which raises the concern that we cannot distinguish between their recognition of a formal and informal curriculum,” the researchers noted. In addition, the survey could not confirm that program directors were aware of all training. “Furthermore, because the survey items were embedded in larger program director survey, we were limited in the ability to ask them to define more specifically the components of their health disparities curricula,” they wrote.

However, the results were strengthened by the large and comprehensive study population, and highlight not only the need for standardized health disparities curricula, but also the need for research to determine the most effective domains for such curricula in graduate medical education, they emphasized.

“There are opportunities to explore partnerships among residencies, institutional clinical practices, and communities for productive collaborations around disparities-related quality improvement projects to address gaps in health care that are specific to the populations they serve,” they concluded.

The surveys were conducted in 2015 and the comparative work in 2018, prior to the COVID-19 pandemic and the subsequent increased concerns about disparities in health care, Dr. Dupras said in an interview.

“We conducted the survey because we recognized that health disparities were still prevalent in our society despite calls to improve the education of our learners to address them. We wanted to determine what our programs were providing for educational curriculum and what our learners were experiencing,” she said.

“We did not know what the surveys would show, so I cannot say that we were surprised by the findings,” said Dr. Dupras. “One of the challenges in interpreting our results is inherent in studies that rely on surveys. We cannot know how those filling out the surveys interpret the questions.” The study results yield several messages.

“First, residency training programs have opportunities to do a better job in developing educational opportunities related to health disparities; second, residents learn in the context of care and we must optimize education around these experiences; third, every patient is different. It is time to move towards cultural humility, since the risk for disparities is not associated with one patient characteristic, but composed of multiple factors,” she said.

“Given that 5 years has passed since our original survey, it would be important to repeat the survey and consider expanding it to include other training programs that provide frontline care, such as family medicine and pediatrics,” Dr. Dupras noted.

Dr. Dupras and colleagues had no financial conflicts to disclose.

SOURCE: Dupras DM et al. JAMA Netw Open. 2020 Aug 10. doi: 10.1001/jamanetworkopen.2020.12757.

Less than half of internal medicine residency program directors report formal curricula on the topic of health disparities, according to findings of a survey of medical directors and residents across the United States.

Despite recommendations from the Institute of Medicine going back to 2002 calling for increased education on the topic for health care providers, data from a 2012 survey showed that only 17% of internal medicine programs had a health disparities curriculum, wrote Denise M. Dupras, MD, of the Mayo Medical School, Rochester, Minn., and colleagues.

To describe internal medicine residency training programs’ curricula and educational experiences on health disparities and to determine residents’ perceptions of training, the researchers designed a cross-sectional survey study including 227 program directors and 22,723 internal medicine residents. The survey was conducted from August to November 2015.

Overall, 91 program directors (40%) reported a curriculum in health disparities, but only 16 of them described the quality of their education as very good or excellent. In 56% of the programs, outcomes of the curriculum were not measured.

A majority (90%) of the programs included racial/ethnic diversity and socioeconomic status in their curricula, 58% included information about limited English proficiency, and 53% included information about gender identity and sexual orientation.

Reported barriers to curriculum development in 132 programs that did not have a health disparities curriculum included lack of time in the current curriculum, insufficient faculty skill to teach the topic, lack of institutional support, and lack of faculty interest, the researchers noted.

A total of 13,251 residents (70%) reported receiving some training in caring for patients at risk for health disparities over 3 years of training, and 10,494 (80%) of these rated the quality as very good or excellent. “Residents who cared for a larger proportion of underserved patients perceived that they received health disparities training at a higher rate,” the researchers wrote. However, increased care of at-risk populations does not necessarily translate into increased knowledge and skills. “Our finding that residents’ rating of the quality of their training was not associated with the presence of a curriculum in health disparities in their program also raises a concern that perceptions may overestimate the acquisition of needed skills,” they added.

The major limitation of the study was “that residents were not asked directly if they were exposed to a curriculum in health disparities but rather if they received training in the care of patients who would be at risk, which raises the concern that we cannot distinguish between their recognition of a formal and informal curriculum,” the researchers noted. In addition, the survey could not confirm that program directors were aware of all training. “Furthermore, because the survey items were embedded in larger program director survey, we were limited in the ability to ask them to define more specifically the components of their health disparities curricula,” they wrote.

However, the results were strengthened by the large and comprehensive study population, and highlight not only the need for standardized health disparities curricula, but also the need for research to determine the most effective domains for such curricula in graduate medical education, they emphasized.

“There are opportunities to explore partnerships among residencies, institutional clinical practices, and communities for productive collaborations around disparities-related quality improvement projects to address gaps in health care that are specific to the populations they serve,” they concluded.

The surveys were conducted in 2015 and the comparative work in 2018, prior to the COVID-19 pandemic and the subsequent increased concerns about disparities in health care, Dr. Dupras said in an interview.

“We conducted the survey because we recognized that health disparities were still prevalent in our society despite calls to improve the education of our learners to address them. We wanted to determine what our programs were providing for educational curriculum and what our learners were experiencing,” she said.

“We did not know what the surveys would show, so I cannot say that we were surprised by the findings,” said Dr. Dupras. “One of the challenges in interpreting our results is inherent in studies that rely on surveys. We cannot know how those filling out the surveys interpret the questions.” The study results yield several messages.

“First, residency training programs have opportunities to do a better job in developing educational opportunities related to health disparities; second, residents learn in the context of care and we must optimize education around these experiences; third, every patient is different. It is time to move towards cultural humility, since the risk for disparities is not associated with one patient characteristic, but composed of multiple factors,” she said.

“Given that 5 years has passed since our original survey, it would be important to repeat the survey and consider expanding it to include other training programs that provide frontline care, such as family medicine and pediatrics,” Dr. Dupras noted.

Dr. Dupras and colleagues had no financial conflicts to disclose.

SOURCE: Dupras DM et al. JAMA Netw Open. 2020 Aug 10. doi: 10.1001/jamanetworkopen.2020.12757.

New guidance from the U.K. National Diabetes COVID-19 Response Group addresses glucose management in patients with COVID-19 who are receiving dexamethasone therapy.

Although there are already guidelines that address inpatient management of steroid-induced hyperglycemia, the authors of the new document wrote that this new expert opinion paper was needed “given the ‘triple insult’ of dexamethasone-induced–impaired glucose metabolism, COVID-19–induced insulin resistance, and COVID-19–impaired insulin production.”

RECOVERY trial spurs response

The document, which is the latest in a series from the Association of British Clinical Diabetologists, was published online Aug. 2 in Diabetic Medicine. The group is chaired by Gerry Rayman, MD, consultant physician at the diabetes centre and diabetes research unit, East Suffolk (England) and North East NHS Foundation Trust.

The guidance was developed in response to the recent “breakthrough” Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial, which showed that dexamethasone reduced deaths in patients with COVID-19 on ventilators or receiving oxygen therapy. The advice is not intended for critical care units but can be adapted for that use.

The dose used in RECOVERY – 6 mg daily for 10 days – is 400%-500% greater than the therapeutic glucocorticoid replacement dose. High glucocorticoid doses can exacerbate hyperglycemia in people with established diabetes, unmask undiagnosed diabetes, precipitate hyperglycemia or new-onset diabetes, and can also cause hyperglycemic hyperosmolar state (HHS), the authors explained.

They recommended a target glucose of 6.0-10.0 mmol/L (108-180 mg/dL), although they say up to 12 mmol/L (216 mg/dL) is “acceptable.” They then gave advice on frequency of monitoring for people with and without known diabetes, exclusion of diabetic ketoacidosis and HHS, correction of initial hyperglycemia and maintenance of glycemic control using subcutaneous insulin, and prevention of hypoglycemia at the end of dexamethasone therapy (day 10) with insulin down-titration, discharge, and follow-up.

The detailed insulin guidance covers dose escalation for both insulin-treated and insulin-naive patients. A table suggests increasing correction doses of rapid-acting insulin based on prior total daily dose or weight.

Use of once- or twice-daily NPH insulin is recommended for patients whose glucose has risen above 12 mmol/L, in some cases with the addition of a long-acting analog. A second chart gives dose adjustments for those insulins. Additional guidance addresses patients on insulin pumps.

Guidance useful for U.S. physicians

Francisco Pasquel, MD, assistant professor of medicine in the division of endocrinology at Emory University, Atlanta, said in an interview that he believes the guidance is “acceptable” for worldwide use, and that “it’s coherent and consistent with what we typically do.”

However, Dr. Pasquel, who founded COVID-in-Diabetes, an online repository of published guidance and shared experience – to which this new document has now been added – did take issue with one piece of advice. The guidance says that patients already taking premixed insulin formulations can continue using them while increasing the dose by 20%-40%. Given the risk of hypoglycemia associated with those formulations, Dr. Pasquel said he would switch those patients to NPH during the time that they’re on dexamethasone.

He also noted that the rapid-acting insulin dose range of 2-10 units provided in the first table, for correction of initial hyperglycemia, are more conservative than those used at his hospital, where correction doses of up to 14-16 units are sometimes necessary.

But Dr. Pasquel praised the group’s overall efforts since the pandemic began, noting that “they’re very organized and constantly updating their recommendations. They have a unified system in the [National Health Service], so it’s easier to standardize. They have a unique [electronic health record] which is far superior to what we do from a public health perspective.”

Dr. Rayman reported no relevant financial relationships. Dr. Pasquel reported receiving research funding from Dexcom, Merck, and the National Institutes of Health, and consulting for AstraZeneca, Eli Lilly, Merck, and Boehringer Ingelheim.

A version of this article originally appeared on Medscape.com.

New guidance from the U.K. National Diabetes COVID-19 Response Group addresses glucose management in patients with COVID-19 who are receiving dexamethasone therapy.

Although there are already guidelines that address inpatient management of steroid-induced hyperglycemia, the authors of the new document wrote that this new expert opinion paper was needed “given the ‘triple insult’ of dexamethasone-induced–impaired glucose metabolism, COVID-19–induced insulin resistance, and COVID-19–impaired insulin production.”

RECOVERY trial spurs response

The document, which is the latest in a series from the Association of British Clinical Diabetologists, was published online Aug. 2 in Diabetic Medicine. The group is chaired by Gerry Rayman, MD, consultant physician at the diabetes centre and diabetes research unit, East Suffolk (England) and North East NHS Foundation Trust.

The guidance was developed in response to the recent “breakthrough” Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial, which showed that dexamethasone reduced deaths in patients with COVID-19 on ventilators or receiving oxygen therapy. The advice is not intended for critical care units but can be adapted for that use.

The dose used in RECOVERY – 6 mg daily for 10 days – is 400%-500% greater than the therapeutic glucocorticoid replacement dose. High glucocorticoid doses can exacerbate hyperglycemia in people with established diabetes, unmask undiagnosed diabetes, precipitate hyperglycemia or new-onset diabetes, and can also cause hyperglycemic hyperosmolar state (HHS), the authors explained.

They recommended a target glucose of 6.0-10.0 mmol/L (108-180 mg/dL), although they say up to 12 mmol/L (216 mg/dL) is “acceptable.” They then gave advice on frequency of monitoring for people with and without known diabetes, exclusion of diabetic ketoacidosis and HHS, correction of initial hyperglycemia and maintenance of glycemic control using subcutaneous insulin, and prevention of hypoglycemia at the end of dexamethasone therapy (day 10) with insulin down-titration, discharge, and follow-up.

The detailed insulin guidance covers dose escalation for both insulin-treated and insulin-naive patients. A table suggests increasing correction doses of rapid-acting insulin based on prior total daily dose or weight.

Use of once- or twice-daily NPH insulin is recommended for patients whose glucose has risen above 12 mmol/L, in some cases with the addition of a long-acting analog. A second chart gives dose adjustments for those insulins. Additional guidance addresses patients on insulin pumps.

Guidance useful for U.S. physicians

Francisco Pasquel, MD, assistant professor of medicine in the division of endocrinology at Emory University, Atlanta, said in an interview that he believes the guidance is “acceptable” for worldwide use, and that “it’s coherent and consistent with what we typically do.”

However, Dr. Pasquel, who founded COVID-in-Diabetes, an online repository of published guidance and shared experience – to which this new document has now been added – did take issue with one piece of advice. The guidance says that patients already taking premixed insulin formulations can continue using them while increasing the dose by 20%-40%. Given the risk of hypoglycemia associated with those formulations, Dr. Pasquel said he would switch those patients to NPH during the time that they’re on dexamethasone.

He also noted that the rapid-acting insulin dose range of 2-10 units provided in the first table, for correction of initial hyperglycemia, are more conservative than those used at his hospital, where correction doses of up to 14-16 units are sometimes necessary.

But Dr. Pasquel praised the group’s overall efforts since the pandemic began, noting that “they’re very organized and constantly updating their recommendations. They have a unified system in the [National Health Service], so it’s easier to standardize. They have a unique [electronic health record] which is far superior to what we do from a public health perspective.”

Dr. Rayman reported no relevant financial relationships. Dr. Pasquel reported receiving research funding from Dexcom, Merck, and the National Institutes of Health, and consulting for AstraZeneca, Eli Lilly, Merck, and Boehringer Ingelheim.

A version of this article originally appeared on Medscape.com.

New guidance from the U.K. National Diabetes COVID-19 Response Group addresses glucose management in patients with COVID-19 who are receiving dexamethasone therapy.

Although there are already guidelines that address inpatient management of steroid-induced hyperglycemia, the authors of the new document wrote that this new expert opinion paper was needed “given the ‘triple insult’ of dexamethasone-induced–impaired glucose metabolism, COVID-19–induced insulin resistance, and COVID-19–impaired insulin production.”

RECOVERY trial spurs response

The document, which is the latest in a series from the Association of British Clinical Diabetologists, was published online Aug. 2 in Diabetic Medicine. The group is chaired by Gerry Rayman, MD, consultant physician at the diabetes centre and diabetes research unit, East Suffolk (England) and North East NHS Foundation Trust.

The guidance was developed in response to the recent “breakthrough” Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial, which showed that dexamethasone reduced deaths in patients with COVID-19 on ventilators or receiving oxygen therapy. The advice is not intended for critical care units but can be adapted for that use.

The dose used in RECOVERY – 6 mg daily for 10 days – is 400%-500% greater than the therapeutic glucocorticoid replacement dose. High glucocorticoid doses can exacerbate hyperglycemia in people with established diabetes, unmask undiagnosed diabetes, precipitate hyperglycemia or new-onset diabetes, and can also cause hyperglycemic hyperosmolar state (HHS), the authors explained.

They recommended a target glucose of 6.0-10.0 mmol/L (108-180 mg/dL), although they say up to 12 mmol/L (216 mg/dL) is “acceptable.” They then gave advice on frequency of monitoring for people with and without known diabetes, exclusion of diabetic ketoacidosis and HHS, correction of initial hyperglycemia and maintenance of glycemic control using subcutaneous insulin, and prevention of hypoglycemia at the end of dexamethasone therapy (day 10) with insulin down-titration, discharge, and follow-up.

The detailed insulin guidance covers dose escalation for both insulin-treated and insulin-naive patients. A table suggests increasing correction doses of rapid-acting insulin based on prior total daily dose or weight.

Use of once- or twice-daily NPH insulin is recommended for patients whose glucose has risen above 12 mmol/L, in some cases with the addition of a long-acting analog. A second chart gives dose adjustments for those insulins. Additional guidance addresses patients on insulin pumps.

Guidance useful for U.S. physicians

Francisco Pasquel, MD, assistant professor of medicine in the division of endocrinology at Emory University, Atlanta, said in an interview that he believes the guidance is “acceptable” for worldwide use, and that “it’s coherent and consistent with what we typically do.”

However, Dr. Pasquel, who founded COVID-in-Diabetes, an online repository of published guidance and shared experience – to which this new document has now been added – did take issue with one piece of advice. The guidance says that patients already taking premixed insulin formulations can continue using them while increasing the dose by 20%-40%. Given the risk of hypoglycemia associated with those formulations, Dr. Pasquel said he would switch those patients to NPH during the time that they’re on dexamethasone.

He also noted that the rapid-acting insulin dose range of 2-10 units provided in the first table, for correction of initial hyperglycemia, are more conservative than those used at his hospital, where correction doses of up to 14-16 units are sometimes necessary.

But Dr. Pasquel praised the group’s overall efforts since the pandemic began, noting that “they’re very organized and constantly updating their recommendations. They have a unified system in the [National Health Service], so it’s easier to standardize. They have a unique [electronic health record] which is far superior to what we do from a public health perspective.”

Dr. Rayman reported no relevant financial relationships. Dr. Pasquel reported receiving research funding from Dexcom, Merck, and the National Institutes of Health, and consulting for AstraZeneca, Eli Lilly, Merck, and Boehringer Ingelheim.

A version of this article originally appeared on Medscape.com.

A study of patients with pulmonary hypertension suggests a reconsideration of the accepted benchmark for pulmonary vascular hypertension as a predictor of heart failure may be warranted.

An elevated pulmonary vascular resistance of 3.0 Wood units or greater has been used as a prognostic marker for death and heart failure in pulmonary hypertension subgroups. But a large, multiyear study of a veterans population suggests that shifting that threshold to 2.2 Wood units in patients with right-heart catheterization may be justified.

Bradley A. Maron, MD, of the Veterans Affairs Boston Healthcare System and Brigham and Women’s Hospital and Harvard Medical School, Boston, and colleagues evaluated 40,082 veterans in the VA Clinical Assessment, Reporting and Tracking (CART) program who had right-heart catheterization (RHC) in the VA system from Oct. 1, 2007, to Sept. 30, 2016.

“To our knowledge, these data provide the first evidence-based information on the continuum of clinical risk related to PVR in patients with elevated pulmonary artery pressure,” the researchers wrote. Their report was published online in Lancet Respiratory Medicine (2020 Jul 27. doi: 10.1016/S2213-2600(20)30317-9).

The retrospective cohort study found that all-cause mortality hazard ratio (HR), when adjusted for clinical variables, and mean pulmonary artery pressure (mPAP) increased progressively beginning at around 2.0 Wood units (WU). Clinically significant mortality HR emerged at 2.2 WU, with an adjusted risk 9% greater than a PVR of 2.1 Wood units (P < .0034), which the study considered the upper limit of normal PVR in health adults of a similar age range (61.5 to 73.5 years) as the study cohort. The researchers noted that a PVR of 3.0 WU has been the standard for forecasting outcomes in pulmonary hypertension (PH) (Eur Heart J. 2010;31:2915-57).

“Overall, these results suggest that reconsidering the hemodynamic parameters that define pulmonary hypertension in patients with cardiopulmonary disease is warranted, and they identify a need for early detection strategies to capture this large and vulnerable population,” the researchers wrote.

A subsequent analysis focused on patients with an mPAP of >19 mm HG (n = 32,725) and found that all-cause death when adjusted over a wide range of clinical variables that included PVR of 2.2 WU increased to a 25% HR. “However,” the researchers added, “a median cardiac output of < 4.0 L/min, which has been shown to be independently associated with adverse outcome, was present only when PVR was more than 4.0 Wood units.”

For a PVR of 2.2-3.0 WU, the median cardiac output was 4.87 L/min; for > 3.0 WU, it was 4.13 L/min. Among the patients with PVR > 2.2 WU (n = 15,780), 13.6% (n = 2,147) had an mPAP of 19-24 mm Hg.

In all patients with mPAP > 19 mm HG, pulmonary artery wedge pressure (PAWP) became a determining risk factor, with 15 mm HG the demarcation between low and high PAWP. At PVR of 2.2 WU, low-PAWP patients had a 52% greater adjusted risk of death and high-PAWP a 23% greater risk. At 4.0 WU, those adjusted risks rose dramatically – to 272% and 58%, for the low- and high-PAWP subgroups, respectively (P < .0001).

“Stratification of patients by PAWP had a major effect on outcome estimates in our study, illustrating the limitations of using the same PVR level to define clinical risk between precapillary and postcapillary pulmonary hypertension,” the researchers wrote.

They called for further study into how these findings impact people with PH but lower levels of cardiopulmonary disease than the cohort. “Overall, these findings support reconsidering the combination of hemodynamic variables used to identify patients with pulmonary hypertension,” the researchers stated.

The analyses of the VA CART database makes this “an interesting study,” said G. Hossein Almassi, MD, FCCP, of the Medical College of Wisconsin and Zablocki VA Medical Center in Milwaukee. “Within its limitation as a retrospective cohort study, the findings of a lower PVR and a lower mean PAP of > 19 mm being associated with increased risk of all-cause mortality and HF hospitalization are significant.”

He added: “Time will tell whether this will be an impetus for the clinicians to consider earlier therapeutic interventions in addition to lifestyle modification such as smoking cessation in this group of patients.”

Dr. Maron disclosed a financial relationship with Actelion.

SOURCE: Maron BA et al. Lancet Respir Med. 2020 Jul 27. doi: 10.1016/S2213-2600(20)30317-9.

A study of patients with pulmonary hypertension suggests a reconsideration of the accepted benchmark for pulmonary vascular hypertension as a predictor of heart failure may be warranted.

An elevated pulmonary vascular resistance of 3.0 Wood units or greater has been used as a prognostic marker for death and heart failure in pulmonary hypertension subgroups. But a large, multiyear study of a veterans population suggests that shifting that threshold to 2.2 Wood units in patients with right-heart catheterization may be justified.

Bradley A. Maron, MD, of the Veterans Affairs Boston Healthcare System and Brigham and Women’s Hospital and Harvard Medical School, Boston, and colleagues evaluated 40,082 veterans in the VA Clinical Assessment, Reporting and Tracking (CART) program who had right-heart catheterization (RHC) in the VA system from Oct. 1, 2007, to Sept. 30, 2016.

“To our knowledge, these data provide the first evidence-based information on the continuum of clinical risk related to PVR in patients with elevated pulmonary artery pressure,” the researchers wrote. Their report was published online in Lancet Respiratory Medicine (2020 Jul 27. doi: 10.1016/S2213-2600(20)30317-9).

The retrospective cohort study found that all-cause mortality hazard ratio (HR), when adjusted for clinical variables, and mean pulmonary artery pressure (mPAP) increased progressively beginning at around 2.0 Wood units (WU). Clinically significant mortality HR emerged at 2.2 WU, with an adjusted risk 9% greater than a PVR of 2.1 Wood units (P < .0034), which the study considered the upper limit of normal PVR in health adults of a similar age range (61.5 to 73.5 years) as the study cohort. The researchers noted that a PVR of 3.0 WU has been the standard for forecasting outcomes in pulmonary hypertension (PH) (Eur Heart J. 2010;31:2915-57).

“Overall, these results suggest that reconsidering the hemodynamic parameters that define pulmonary hypertension in patients with cardiopulmonary disease is warranted, and they identify a need for early detection strategies to capture this large and vulnerable population,” the researchers wrote.

A subsequent analysis focused on patients with an mPAP of >19 mm HG (n = 32,725) and found that all-cause death when adjusted over a wide range of clinical variables that included PVR of 2.2 WU increased to a 25% HR. “However,” the researchers added, “a median cardiac output of < 4.0 L/min, which has been shown to be independently associated with adverse outcome, was present only when PVR was more than 4.0 Wood units.”

For a PVR of 2.2-3.0 WU, the median cardiac output was 4.87 L/min; for > 3.0 WU, it was 4.13 L/min. Among the patients with PVR > 2.2 WU (n = 15,780), 13.6% (n = 2,147) had an mPAP of 19-24 mm Hg.

In all patients with mPAP > 19 mm HG, pulmonary artery wedge pressure (PAWP) became a determining risk factor, with 15 mm HG the demarcation between low and high PAWP. At PVR of 2.2 WU, low-PAWP patients had a 52% greater adjusted risk of death and high-PAWP a 23% greater risk. At 4.0 WU, those adjusted risks rose dramatically – to 272% and 58%, for the low- and high-PAWP subgroups, respectively (P < .0001).

“Stratification of patients by PAWP had a major effect on outcome estimates in our study, illustrating the limitations of using the same PVR level to define clinical risk between precapillary and postcapillary pulmonary hypertension,” the researchers wrote.

They called for further study into how these findings impact people with PH but lower levels of cardiopulmonary disease than the cohort. “Overall, these findings support reconsidering the combination of hemodynamic variables used to identify patients with pulmonary hypertension,” the researchers stated.

The analyses of the VA CART database makes this “an interesting study,” said G. Hossein Almassi, MD, FCCP, of the Medical College of Wisconsin and Zablocki VA Medical Center in Milwaukee. “Within its limitation as a retrospective cohort study, the findings of a lower PVR and a lower mean PAP of > 19 mm being associated with increased risk of all-cause mortality and HF hospitalization are significant.”

He added: “Time will tell whether this will be an impetus for the clinicians to consider earlier therapeutic interventions in addition to lifestyle modification such as smoking cessation in this group of patients.”

Dr. Maron disclosed a financial relationship with Actelion.

SOURCE: Maron BA et al. Lancet Respir Med. 2020 Jul 27. doi: 10.1016/S2213-2600(20)30317-9.

A study of patients with pulmonary hypertension suggests a reconsideration of the accepted benchmark for pulmonary vascular hypertension as a predictor of heart failure may be warranted.

An elevated pulmonary vascular resistance of 3.0 Wood units or greater has been used as a prognostic marker for death and heart failure in pulmonary hypertension subgroups. But a large, multiyear study of a veterans population suggests that shifting that threshold to 2.2 Wood units in patients with right-heart catheterization may be justified.

Bradley A. Maron, MD, of the Veterans Affairs Boston Healthcare System and Brigham and Women’s Hospital and Harvard Medical School, Boston, and colleagues evaluated 40,082 veterans in the VA Clinical Assessment, Reporting and Tracking (CART) program who had right-heart catheterization (RHC) in the VA system from Oct. 1, 2007, to Sept. 30, 2016.

“To our knowledge, these data provide the first evidence-based information on the continuum of clinical risk related to PVR in patients with elevated pulmonary artery pressure,” the researchers wrote. Their report was published online in Lancet Respiratory Medicine (2020 Jul 27. doi: 10.1016/S2213-2600(20)30317-9).

The retrospective cohort study found that all-cause mortality hazard ratio (HR), when adjusted for clinical variables, and mean pulmonary artery pressure (mPAP) increased progressively beginning at around 2.0 Wood units (WU). Clinically significant mortality HR emerged at 2.2 WU, with an adjusted risk 9% greater than a PVR of 2.1 Wood units (P < .0034), which the study considered the upper limit of normal PVR in health adults of a similar age range (61.5 to 73.5 years) as the study cohort. The researchers noted that a PVR of 3.0 WU has been the standard for forecasting outcomes in pulmonary hypertension (PH) (Eur Heart J. 2010;31:2915-57).

“Overall, these results suggest that reconsidering the hemodynamic parameters that define pulmonary hypertension in patients with cardiopulmonary disease is warranted, and they identify a need for early detection strategies to capture this large and vulnerable population,” the researchers wrote.

A subsequent analysis focused on patients with an mPAP of >19 mm HG (n = 32,725) and found that all-cause death when adjusted over a wide range of clinical variables that included PVR of 2.2 WU increased to a 25% HR. “However,” the researchers added, “a median cardiac output of < 4.0 L/min, which has been shown to be independently associated with adverse outcome, was present only when PVR was more than 4.0 Wood units.”

For a PVR of 2.2-3.0 WU, the median cardiac output was 4.87 L/min; for > 3.0 WU, it was 4.13 L/min. Among the patients with PVR > 2.2 WU (n = 15,780), 13.6% (n = 2,147) had an mPAP of 19-24 mm Hg.

In all patients with mPAP > 19 mm HG, pulmonary artery wedge pressure (PAWP) became a determining risk factor, with 15 mm HG the demarcation between low and high PAWP. At PVR of 2.2 WU, low-PAWP patients had a 52% greater adjusted risk of death and high-PAWP a 23% greater risk. At 4.0 WU, those adjusted risks rose dramatically – to 272% and 58%, for the low- and high-PAWP subgroups, respectively (P < .0001).

“Stratification of patients by PAWP had a major effect on outcome estimates in our study, illustrating the limitations of using the same PVR level to define clinical risk between precapillary and postcapillary pulmonary hypertension,” the researchers wrote.

They called for further study into how these findings impact people with PH but lower levels of cardiopulmonary disease than the cohort. “Overall, these findings support reconsidering the combination of hemodynamic variables used to identify patients with pulmonary hypertension,” the researchers stated.

The analyses of the VA CART database makes this “an interesting study,” said G. Hossein Almassi, MD, FCCP, of the Medical College of Wisconsin and Zablocki VA Medical Center in Milwaukee. “Within its limitation as a retrospective cohort study, the findings of a lower PVR and a lower mean PAP of > 19 mm being associated with increased risk of all-cause mortality and HF hospitalization are significant.”

He added: “Time will tell whether this will be an impetus for the clinicians to consider earlier therapeutic interventions in addition to lifestyle modification such as smoking cessation in this group of patients.”

Dr. Maron disclosed a financial relationship with Actelion.

SOURCE: Maron BA et al. Lancet Respir Med. 2020 Jul 27. doi: 10.1016/S2213-2600(20)30317-9.

The memories I have from the few nights spent in the adult pop-up cardiac intensive care unit are pouring in as I sit down to tell this story. I am a pediatric hospitalist at Columbia University NewYork-Presbyterian Morgan Stanley Children’s Hospital. I usually take care of sick, hospitalized children. However, in these extraordinary times, I have joined an army of colleagues taking care of adult patients with COVID-19.

Almost all these patients had tracheostomies connected to ventilators, as well as acute-on-chronic cardiac issues. They were often delirious and unable to speak, and always alone. I was happy to help our adult colleagues, but I was also afraid. I was scared to make a mistake that could be detrimental to my patient, even though I knew well that ICU residents, fellows, and attendings were just a phone call away.

I felt like Alice in Wonderland, initially too small compared with her environment, and the next minute hunched, giant, and still clearly displaced. Except I was not dreaming or watching a movie. There was no white rabbit to chase. The situation was serious and emotionally challenging. I imagined that each patient was the dearest member of my family: my mother, my father, my aunt or uncle. I took pleasure in sharing smiles while asking the patients how they were feeling, and I touched their hands, even though much of my face was covered and there were gloves on my hands.

The year 2020 has been surreal. People have had to find their own way of pushing through the unknown and unexpected. For a start, I would never in a million years have imagined using phrases like pop-up ICU.¹ I was signing an admission note for a 90-year-old lady with acute-on-chronic congestive heart failure and acute respiratory hypoxemic failure and there, at the bottom of the note, was my name, followed by an odd remark: “pediatric hospital medicine.” That is what happened in New York City in 2020: Many unexpected events took place.

This article represents a virtual conversation with three other pediatric hospitalists who, under different sets of circumstances, did the same thing: took care of adult patients. I hope that the answers to the questions I asked make you pause, reflect, and learn from the experiences described.
 

Would you describe the usual environment where you practice pediatric hospital medicine?

Julie Dunbar, MD: I am a full-time pediatric hospitalist at the Children’s Hospital at Montefiore, a tertiary care academic children’s hospital in the Bronx. A typical day on service involves staffing up to 14 patients, up to 21 years old, on a teaching service with residents and physician assistants. We normally staff the hospital in two shifts – day and evening – until 11:00 at night. We are situated at the heart of a medically underserved area, and our hospital system cares for about one-third of the total population of the Bronx.



L. Nell Hodo, MD: I work at Kravis Children’s Hospital at the Mount Sinai Hospital, in Manhattan at the juncture of the Upper East Side and Harlem. Our usual hospital medicine environment is the general ward/floor in a nested children’s hospital within an adult hospital. We have about 32 non-ICU beds, and the patients are managed by a combination of hospitalists, general pediatricians, and specialist attendings. All patients are on resident teams. We have a comanagement model in which the primary attending for surgical patients is always a pediatric attending (hospitalist or specialist).



Avital M. Fischer, MD: NewYork-Presbyterian Morgan Stanley Children’s Hospital is a quaternary care center – where children from the area receive subspecialty care – as well as, functionally, a community hospital for the Washington Heights area. Therefore, we always have an interesting mix of general pediatric inpatient medicine including patients with complex medical conditions, rare diseases, postoperative conditions, and undiagnosed illnesses on our wards. We are a children’s hospital, connected to a larger adult hospital system. Pediatric hospitalists cover two pediatric wards, team-staffed by residents, and a progressive care unit, staffed by nurse practitioners. There is usually evening coverage until 11 p.m.

How did this change when New York became the U.S. epicenter of the SARS-CoV-2 pandemic? Was the transition to taking care of adult patients gradual or sudden? Were you deployed to a different hospital or part of the hospital? How prepared did you feel?

Dr. Dunbar: We experienced the COVID-19 pandemic like much of the rest of New York City – it started as a slow and uncertain process, and then it hit us all at once. In initial conversations, like everyone else, we did not know exactly what was coming. We started with small changes like working from home on nonclinical days and canceling family-centered rounds to conserve personal protective equipment (PPE). In mid-March, we were still expecting that redeployment to adult floors was a highly unlikely scenario. We made work-from-home schedules and planned projects we would work on while social distancing. We planned journal clubs about emerging evidence on COVID-19. However, things happened fast, and many of these plans were scrapped.

On Saturday, March 28, we closed the main floor of the children’s hospital because so few pediatric patients were being admitted. Two days later, we admitted our first cohort of adult COVID-19 patients, all more than 30 years old. They were transferred en masse from an outside hospital emergency department that desperately needed our beds. They arrived all at once, and they all required respiratory support. At the last hospitalist division meeting before the adults arrived, we had time for only one priority set of information, and so we chose end-of-life care. We reviewed scripts for advance care planning and logistics of death certificates. As fast as things changed for us, they changed even faster for the patients. Most were relatively healthy people who rather suddenly found themselves isolated, on oxygen, dictating their final wishes to pediatricians in full protective gear. Many, many patients got better, and of course, several spent their last moments with us. One physician assistant, who works closely with the hospitalists, spent the last 5 hours of an elderly patient’s life holding her hand and helping her FaceTime with family.

For the most part, the patients came to us. We worked with our own colleagues and our own nurses, on our own territory. A few of my colleagues were briefly redeployed to a series of conference rooms that were used for several weeks as overflow space for more stable COVID-19 patients. Staffing by the pediatrics teams was so robust, with willing volunteers from every corner of the children’s hospital, that we were not needed for long.

During the early days, there was no clinical pathway to follow to care for COVID-19 patients – it didn’t exist for this novel and variable disease. We created a platform to share documents and resources in real time as they became available to us. We used group texts and emails to learn from our experiences and encourage one another. Importantly, no one was afraid to ask for help, and we relied on our adult colleagues when patients started to decompensate. Adult critical care came to our aid for all rapid responses for patients older than 30. Pediatric critical care, in their infinite flexibility, was responsible for anyone younger.
 

Dr. Hodo: We had a variety of changes. The first thing was the deployment of many of our attendings (hospital medicine, ICU, outpatient, and subspecialists) and residents to the adult side to work on medical COVID-19 units or in the many ICUs (some new “pop-up” units in former medical units, postanesthesia care units, and so on).² On the adult floor we had “COVID teams,” which had an attending and two frontline providers; one of these three people was an internal medicine faculty member or resident. Residents from other specialties (emergency medicine, family medicine) were pulled off pediatric assignments in pediatric wards, PICUs, and EDs, so pediatric residents not originally assigned to inpatient rotations were sent to cover these core pediatric areas. The remaining pediatric faculty backfilled the pediatric services – so the remaining ICU docs did more shifts to cover ICU; the undeployed specialists took more inpatient service or clinic time, and so on. Outpatient pediatrics covered the inpatient pediatric service for the 3 weeks when most of the hospitalists were deployed.

We had one pediatric unit, which was a unit with equipment that made it capable of having ICU patients or floor patients, that was designated a COVID-19 unit. Most COVID-19 patients were there. Some were also in negative-pressure rooms on other floors or in the unit directly above the COVID-19 unit. Some adult patients came to the unit in the pediatric hospital but not as many as initially expected, and most were young adults in their 20s. So rather than adult patients coming to pediatrics, our experience was more that pediatricians went to the adult side.

The transition to adult care for physicians was variable in its suddenness. Most people had at least 48 hours’ notice, whereas some had as much as a week. Most of our department members deployed within the hospital complex of which we are a part, though a few went to other sites in the health system. Some were deployed into administrative or support roles in the system, rather than patient-facing roles. I felt, I would say, reasonably prepared. I trained in family medicine, though I have been exclusively in pediatrics for the past 7 years. I felt rusty, for sure, but perhaps not quite as out of my element as others. In preparation, I read a lot about COVID, reviewed some adult medicine topics provided by the medicine department, used the resources on the Pediatric Overflow Planning Contingency Response Network (POPCoRN), including an Advanced Cardiac Life Support review, and was able to shadow on a COVID-19 unit before I actually started – that was incredibly helpful. I also had the opportunity to speak about that shadowing experience in a department meeting, which I hope was helpful for others.
 

Dr. Fischer: Our whole focus for a relatively short time shifted to how to take care of adults within the children’s hospital. Although we had some time to prepare – the ICU was the first unit to take adults, so we knew they would come to the floor – it still felt quick. We took adult patients onto the general pediatrics floor from both the emergency department and the ICU. We took adults mostly with COVID-19, but we did have some young adults admitted for other reasons too. Those of us who were on service during this time collaborated closely, sharing what we learned and even joining one another on rounds to provide support. We basically would “teach it forward” as we learned. We also had adult providers available by phone for questions, and our pediatric subspecialists were readily available for consults and would reach out to their adult counterparts for support. Some of the hospitalists were reaching out to POPCoRN, and some were attending an ACLS crash course prior to getting on service.

What was hardest about this experience for you?

Dr. Dunbar: For me, one of the hardest aspects of dealing with COVID-19 was the unknown. In every aspect of professional life and clinical care, there were unanswered questions. What’s the best way to care for these patients? What prognoses can we give their loved ones? How can I help when it seems like there’s so little I can offer? Will we run out of PPE? As doctors, what behaviors most endanger our friends and family when we go home after work? When will things start to get better?

Dr. Hodo: For me, the week or two before being notified of the deployment was the worst and hardest time. The uncertainty about if I would be called or no, and to do what? And where? I was trying to read everything there was on management, what little was known about treatment, and so on. Once I received notification of a start date, that allowed me to focus on very clear endpoints and knowledge items (for example, reviewing ACLS algorithms) and to do things I knew would help me settle and be more effective (like shadowing).

Dr. Fischer: It was a lot of new. Not only were we taking care of a population that we hadn’t cared for since medical school (adults), but we were facing a disease process that was also new to everyone. We were learning on our feet, while at the same time providing guidance to our house staff.

What have you learned about yourself that you did not know before?

Dr. Dunbar: I was surprised to learn how much I liked caring for adult patients. The fear I felt immediately before they arrived dissipated fairly quickly after they arrived. The opportunity to address their chronic conditions while supporting them in an acute illness took me back to many of the fundamentals of medicine that I hadn’t thought much about since medical school. I liked that they could speak up to tell us how they were feeling, both physically and emotionally, so that we could address their needs and allow them to participate in their own care. Some of my favorite patients kept detailed histories of their own C-reactive protein values and oxygen levels to show they were active participants in their own recovery.

I was worried that these adult patients would be offended or scared to learn that they were being cared for by pediatricians, but at no point did anyone ask me why they were not assigned to an adult hospitalist. They saw us only as doctors and nurses, and they were grateful for our care. One 65-year-old U.S. Army veteran told me that his nurse had told him to take a shower and make his bed. “She treated me just like a 5-year-old kid. And I loved it!” he said.
 

Dr. Hodo: I don’t know that I was totally unaware of these things, but I will say that I had partially forgotten them: I really like adult medicine, and I love geriatrics. I like high-energy and high-stress situations … at least occasionally! I feel very comfortable discussing end-of-life decisions and death. I cope with personal stress by helping and supporting others – patients, team members, colleagues, neighbors. I risk not taking enough time for myself and have to remind myself to do so.

Dr. Fischer: I actually loved taking care of adults. It felt like there was a different kind of patient-doctor relationship to be had, and it was interesting to get to know people who had jobs and families of their own – essentially a different type of story than you typically hear taking care of children.

Were there any silver linings in this situation? How did you grow personally through this experience? What do we need to do better going forward as a profession and a community?

Dr. Dunbar: The part that I hope will stay with me is the memory of how we came together as clinicians to fight a common invisible enemy. The teamwork was unprecedented. Our day-to-day goals were simple and straightforward: do what needed to be done to help as many New Yorkers as possible. Our team made themselves available for last-minute meetings and shift changes without complaint. We practiced a type of medicine that prioritized patient comfort, flexibility, and compassionate care. We ordered methadone and insulin and antihypertensives – brand new experiences for us, but we figured it out. We worked through novel clinical problems together because there was no textbook to read.

Our colleagues from other specialties and different levels of experience stepped up to join us on overnight shifts, and we welcomed them. With the help of an ad hoc palliative care team, we improved how we listened to patients’ own self-directed needs. We reached across the aisle to our internal medicine and adult hospitalist colleagues to refresh our memories on chronic conditions, and they always answered the phone. I hope we always remember who we were during this crisis, because we were ourselves at our most generous.
 

Dr. Hodo: This was an unexpected but great opportunity to meet physicians, nurses, and staff in different departments and sections of the hospital from my own. I am hopeful that this experience will help us in the future with multidisciplinary work and breaking down silos that isolate specialties and units in the hospital.

I feel (and this is probably weird) invigorated by this experience. It feels good to have been able to help when I was needed. Even though there are a lot of things in adult hospital medicine I do not know, I know I did my best, asked for help when I needed it, and asked for feedback regularly from the medicine residents and nurses I worked with. I know I supported my team and my colleagues to the best of my ability through stressful and sometimes upsetting and emotionally draining times.

As a profession, we can continue to remember the value of the multidisciplinary team and the value of listening to, and making space for, different voices to be heard. We can reconsider the traditional, rigid hierarchy in medicine and medical education that can stifle creative thought and innovative ideas. We can remember that the people “at the top” of the pyramid can always learn something from those “at the bottom.” We can see the ways that department and discipline and specialty can help us but also sometimes hinder, and seek involvement in programs and discussions that unite and pool resources and skills. And, most of all, we can try, every day we are at work, to put the patients’ and families’ needs first – and when we leave work, to turn that around, and put ourselves and our loved ones in that prime position.

As a community, we also can work on thinking communally – that, after all, is the entire point of the wearing of masks in public and social distancing. It is as much about you as about me! We can try to hold on to some of this perspective of the greater good and appreciation for the work others do that makes our lives better and easier. It is not only health care workers who deserve a round of applause every day; it is every person who did something today that benefited someone else, be that giving extra space in a line, wearing a mask in a store, delivering food to an elder, teaching a class over Zoom, or simply minimizing time outside the house. It is every person who thought about the community at or near the same level of priority that they thought about themselves.

Dr. Fischer: It was a very challenging situation, but because our adult patients in the children’s hospital were relatively young with fewer comorbidities, we got to see people get well. I took care of one man with renal failure who we thought would be on dialysis for the rest of his life. By the end of my first week on service, he had begun to regain kidney function. It was amazing. I think most frontline providers caring for adults in this pandemic have had to face significant morbidity and mortality. I felt lucky that we were able to care for patients who generally got better.

I recently read the article published in the Journal of Pediatrics laying out how the Children’s Hospital at Montefiore adapted an entire pediatric floor to caring for adults.³ This example of recognition of need, quick preparation, and collaboration both within the children’s hospital and with the adult hospital was admirable. I also feel that at the beginning of this pandemic, there was a glimmer that the failure of our health care system to cover everyone and the repercussions of this failure would be drawn into sharp relief. I hope that this understanding of the importance of universal coverage persists beyond the pandemic.

Dr. Giordano is assistant professor of pediatrics at Columbia University and a pediatric hospitalist at NewYork-Presbyterian Morgan Stanley Children’s Hospital with an interest in surgical comanagement. She serves on the Society of Hospital Medicine’s Pediatric Special Interest Group Executive Committee and is the chair of the Education Subcommittee. She is also an advisory board member for the New York/Westchester SHM Chapter.
 

References

1. Kumaraiah D et al. Innovative ICU physician care models: Covid-19 pandemic at NewYork-Presbyterian. NEJM Catal. 2020 Apr 28. doi: 10.1056/CAT.20.0158.

2. Kim MK et al. A primer for clinician deployment to the medicine floors from an epicenter of Covid-19. NEJM Catal. 2020 May 4. doi: 10.1056/CAT.20.0180.

3. Philips K, et al. Rapid Implementation of an Adult COVID-19 Unit in a Children’s Hospital. J Pediatr. 2020. doi: 10.1016/j.jpeds.2020.04.060.

The memories I have from the few nights spent in the adult pop-up cardiac intensive care unit are pouring in as I sit down to tell this story. I am a pediatric hospitalist at Columbia University NewYork-Presbyterian Morgan Stanley Children’s Hospital. I usually take care of sick, hospitalized children. However, in these extraordinary times, I have joined an army of colleagues taking care of adult patients with COVID-19.

Almost all these patients had tracheostomies connected to ventilators, as well as acute-on-chronic cardiac issues. They were often delirious and unable to speak, and always alone. I was happy to help our adult colleagues, but I was also afraid. I was scared to make a mistake that could be detrimental to my patient, even though I knew well that ICU residents, fellows, and attendings were just a phone call away.

I felt like Alice in Wonderland, initially too small compared with her environment, and the next minute hunched, giant, and still clearly displaced. Except I was not dreaming or watching a movie. There was no white rabbit to chase. The situation was serious and emotionally challenging. I imagined that each patient was the dearest member of my family: my mother, my father, my aunt or uncle. I took pleasure in sharing smiles while asking the patients how they were feeling, and I touched their hands, even though much of my face was covered and there were gloves on my hands.

The year 2020 has been surreal. People have had to find their own way of pushing through the unknown and unexpected. For a start, I would never in a million years have imagined using phrases like pop-up ICU.¹ I was signing an admission note for a 90-year-old lady with acute-on-chronic congestive heart failure and acute respiratory hypoxemic failure and there, at the bottom of the note, was my name, followed by an odd remark: “pediatric hospital medicine.” That is what happened in New York City in 2020: Many unexpected events took place.

This article represents a virtual conversation with three other pediatric hospitalists who, under different sets of circumstances, did the same thing: took care of adult patients. I hope that the answers to the questions I asked make you pause, reflect, and learn from the experiences described.
 

Would you describe the usual environment where you practice pediatric hospital medicine?

Julie Dunbar, MD: I am a full-time pediatric hospitalist at the Children’s Hospital at Montefiore, a tertiary care academic children’s hospital in the Bronx. A typical day on service involves staffing up to 14 patients, up to 21 years old, on a teaching service with residents and physician assistants. We normally staff the hospital in two shifts – day and evening – until 11:00 at night. We are situated at the heart of a medically underserved area, and our hospital system cares for about one-third of the total population of the Bronx.



L. Nell Hodo, MD: I work at Kravis Children’s Hospital at the Mount Sinai Hospital, in Manhattan at the juncture of the Upper East Side and Harlem. Our usual hospital medicine environment is the general ward/floor in a nested children’s hospital within an adult hospital. We have about 32 non-ICU beds, and the patients are managed by a combination of hospitalists, general pediatricians, and specialist attendings. All patients are on resident teams. We have a comanagement model in which the primary attending for surgical patients is always a pediatric attending (hospitalist or specialist).



Avital M. Fischer, MD: NewYork-Presbyterian Morgan Stanley Children’s Hospital is a quaternary care center – where children from the area receive subspecialty care – as well as, functionally, a community hospital for the Washington Heights area. Therefore, we always have an interesting mix of general pediatric inpatient medicine including patients with complex medical conditions, rare diseases, postoperative conditions, and undiagnosed illnesses on our wards. We are a children’s hospital, connected to a larger adult hospital system. Pediatric hospitalists cover two pediatric wards, team-staffed by residents, and a progressive care unit, staffed by nurse practitioners. There is usually evening coverage until 11 p.m.

How did this change when New York became the U.S. epicenter of the SARS-CoV-2 pandemic? Was the transition to taking care of adult patients gradual or sudden? Were you deployed to a different hospital or part of the hospital? How prepared did you feel?

Dr. Dunbar: We experienced the COVID-19 pandemic like much of the rest of New York City – it started as a slow and uncertain process, and then it hit us all at once. In initial conversations, like everyone else, we did not know exactly what was coming. We started with small changes like working from home on nonclinical days and canceling family-centered rounds to conserve personal protective equipment (PPE). In mid-March, we were still expecting that redeployment to adult floors was a highly unlikely scenario. We made work-from-home schedules and planned projects we would work on while social distancing. We planned journal clubs about emerging evidence on COVID-19. However, things happened fast, and many of these plans were scrapped.

On Saturday, March 28, we closed the main floor of the children’s hospital because so few pediatric patients were being admitted. Two days later, we admitted our first cohort of adult COVID-19 patients, all more than 30 years old. They were transferred en masse from an outside hospital emergency department that desperately needed our beds. They arrived all at once, and they all required respiratory support. At the last hospitalist division meeting before the adults arrived, we had time for only one priority set of information, and so we chose end-of-life care. We reviewed scripts for advance care planning and logistics of death certificates. As fast as things changed for us, they changed even faster for the patients. Most were relatively healthy people who rather suddenly found themselves isolated, on oxygen, dictating their final wishes to pediatricians in full protective gear. Many, many patients got better, and of course, several spent their last moments with us. One physician assistant, who works closely with the hospitalists, spent the last 5 hours of an elderly patient’s life holding her hand and helping her FaceTime with family.

For the most part, the patients came to us. We worked with our own colleagues and our own nurses, on our own territory. A few of my colleagues were briefly redeployed to a series of conference rooms that were used for several weeks as overflow space for more stable COVID-19 patients. Staffing by the pediatrics teams was so robust, with willing volunteers from every corner of the children’s hospital, that we were not needed for long.

During the early days, there was no clinical pathway to follow to care for COVID-19 patients – it didn’t exist for this novel and variable disease. We created a platform to share documents and resources in real time as they became available to us. We used group texts and emails to learn from our experiences and encourage one another. Importantly, no one was afraid to ask for help, and we relied on our adult colleagues when patients started to decompensate. Adult critical care came to our aid for all rapid responses for patients older than 30. Pediatric critical care, in their infinite flexibility, was responsible for anyone younger.
 

Dr. Hodo: We had a variety of changes. The first thing was the deployment of many of our attendings (hospital medicine, ICU, outpatient, and subspecialists) and residents to the adult side to work on medical COVID-19 units or in the many ICUs (some new “pop-up” units in former medical units, postanesthesia care units, and so on).² On the adult floor we had “COVID teams,” which had an attending and two frontline providers; one of these three people was an internal medicine faculty member or resident. Residents from other specialties (emergency medicine, family medicine) were pulled off pediatric assignments in pediatric wards, PICUs, and EDs, so pediatric residents not originally assigned to inpatient rotations were sent to cover these core pediatric areas. The remaining pediatric faculty backfilled the pediatric services – so the remaining ICU docs did more shifts to cover ICU; the undeployed specialists took more inpatient service or clinic time, and so on. Outpatient pediatrics covered the inpatient pediatric service for the 3 weeks when most of the hospitalists were deployed.

We had one pediatric unit, which was a unit with equipment that made it capable of having ICU patients or floor patients, that was designated a COVID-19 unit. Most COVID-19 patients were there. Some were also in negative-pressure rooms on other floors or in the unit directly above the COVID-19 unit. Some adult patients came to the unit in the pediatric hospital but not as many as initially expected, and most were young adults in their 20s. So rather than adult patients coming to pediatrics, our experience was more that pediatricians went to the adult side.

The transition to adult care for physicians was variable in its suddenness. Most people had at least 48 hours’ notice, whereas some had as much as a week. Most of our department members deployed within the hospital complex of which we are a part, though a few went to other sites in the health system. Some were deployed into administrative or support roles in the system, rather than patient-facing roles. I felt, I would say, reasonably prepared. I trained in family medicine, though I have been exclusively in pediatrics for the past 7 years. I felt rusty, for sure, but perhaps not quite as out of my element as others. In preparation, I read a lot about COVID, reviewed some adult medicine topics provided by the medicine department, used the resources on the Pediatric Overflow Planning Contingency Response Network (POPCoRN), including an Advanced Cardiac Life Support review, and was able to shadow on a COVID-19 unit before I actually started – that was incredibly helpful. I also had the opportunity to speak about that shadowing experience in a department meeting, which I hope was helpful for others.
 

Dr. Fischer: Our whole focus for a relatively short time shifted to how to take care of adults within the children’s hospital. Although we had some time to prepare – the ICU was the first unit to take adults, so we knew they would come to the floor – it still felt quick. We took adult patients onto the general pediatrics floor from both the emergency department and the ICU. We took adults mostly with COVID-19, but we did have some young adults admitted for other reasons too. Those of us who were on service during this time collaborated closely, sharing what we learned and even joining one another on rounds to provide support. We basically would “teach it forward” as we learned. We also had adult providers available by phone for questions, and our pediatric subspecialists were readily available for consults and would reach out to their adult counterparts for support. Some of the hospitalists were reaching out to POPCoRN, and some were attending an ACLS crash course prior to getting on service.

What was hardest about this experience for you?

Dr. Dunbar: For me, one of the hardest aspects of dealing with COVID-19 was the unknown. In every aspect of professional life and clinical care, there were unanswered questions. What’s the best way to care for these patients? What prognoses can we give their loved ones? How can I help when it seems like there’s so little I can offer? Will we run out of PPE? As doctors, what behaviors most endanger our friends and family when we go home after work? When will things start to get better?

Dr. Hodo: For me, the week or two before being notified of the deployment was the worst and hardest time. The uncertainty about if I would be called or no, and to do what? And where? I was trying to read everything there was on management, what little was known about treatment, and so on. Once I received notification of a start date, that allowed me to focus on very clear endpoints and knowledge items (for example, reviewing ACLS algorithms) and to do things I knew would help me settle and be more effective (like shadowing).

Dr. Fischer: It was a lot of new. Not only were we taking care of a population that we hadn’t cared for since medical school (adults), but we were facing a disease process that was also new to everyone. We were learning on our feet, while at the same time providing guidance to our house staff.

What have you learned about yourself that you did not know before?

Dr. Dunbar: I was surprised to learn how much I liked caring for adult patients. The fear I felt immediately before they arrived dissipated fairly quickly after they arrived. The opportunity to address their chronic conditions while supporting them in an acute illness took me back to many of the fundamentals of medicine that I hadn’t thought much about since medical school. I liked that they could speak up to tell us how they were feeling, both physically and emotionally, so that we could address their needs and allow them to participate in their own care. Some of my favorite patients kept detailed histories of their own C-reactive protein values and oxygen levels to show they were active participants in their own recovery.

I was worried that these adult patients would be offended or scared to learn that they were being cared for by pediatricians, but at no point did anyone ask me why they were not assigned to an adult hospitalist. They saw us only as doctors and nurses, and they were grateful for our care. One 65-year-old U.S. Army veteran told me that his nurse had told him to take a shower and make his bed. “She treated me just like a 5-year-old kid. And I loved it!” he said.
 

Dr. Hodo: I don’t know that I was totally unaware of these things, but I will say that I had partially forgotten them: I really like adult medicine, and I love geriatrics. I like high-energy and high-stress situations … at least occasionally! I feel very comfortable discussing end-of-life decisions and death. I cope with personal stress by helping and supporting others – patients, team members, colleagues, neighbors. I risk not taking enough time for myself and have to remind myself to do so.

Dr. Fischer: I actually loved taking care of adults. It felt like there was a different kind of patient-doctor relationship to be had, and it was interesting to get to know people who had jobs and families of their own – essentially a different type of story than you typically hear taking care of children.

Were there any silver linings in this situation? How did you grow personally through this experience? What do we need to do better going forward as a profession and a community?

Dr. Dunbar: The part that I hope will stay with me is the memory of how we came together as clinicians to fight a common invisible enemy. The teamwork was unprecedented. Our day-to-day goals were simple and straightforward: do what needed to be done to help as many New Yorkers as possible. Our team made themselves available for last-minute meetings and shift changes without complaint. We practiced a type of medicine that prioritized patient comfort, flexibility, and compassionate care. We ordered methadone and insulin and antihypertensives – brand new experiences for us, but we figured it out. We worked through novel clinical problems together because there was no textbook to read.

Our colleagues from other specialties and different levels of experience stepped up to join us on overnight shifts, and we welcomed them. With the help of an ad hoc palliative care team, we improved how we listened to patients’ own self-directed needs. We reached across the aisle to our internal medicine and adult hospitalist colleagues to refresh our memories on chronic conditions, and they always answered the phone. I hope we always remember who we were during this crisis, because we were ourselves at our most generous.
 

Dr. Hodo: This was an unexpected but great opportunity to meet physicians, nurses, and staff in different departments and sections of the hospital from my own. I am hopeful that this experience will help us in the future with multidisciplinary work and breaking down silos that isolate specialties and units in the hospital.

I feel (and this is probably weird) invigorated by this experience. It feels good to have been able to help when I was needed. Even though there are a lot of things in adult hospital medicine I do not know, I know I did my best, asked for help when I needed it, and asked for feedback regularly from the medicine residents and nurses I worked with. I know I supported my team and my colleagues to the best of my ability through stressful and sometimes upsetting and emotionally draining times.

As a profession, we can continue to remember the value of the multidisciplinary team and the value of listening to, and making space for, different voices to be heard. We can reconsider the traditional, rigid hierarchy in medicine and medical education that can stifle creative thought and innovative ideas. We can remember that the people “at the top” of the pyramid can always learn something from those “at the bottom.” We can see the ways that department and discipline and specialty can help us but also sometimes hinder, and seek involvement in programs and discussions that unite and pool resources and skills. And, most of all, we can try, every day we are at work, to put the patients’ and families’ needs first – and when we leave work, to turn that around, and put ourselves and our loved ones in that prime position.

As a community, we also can work on thinking communally – that, after all, is the entire point of the wearing of masks in public and social distancing. It is as much about you as about me! We can try to hold on to some of this perspective of the greater good and appreciation for the work others do that makes our lives better and easier. It is not only health care workers who deserve a round of applause every day; it is every person who did something today that benefited someone else, be that giving extra space in a line, wearing a mask in a store, delivering food to an elder, teaching a class over Zoom, or simply minimizing time outside the house. It is every person who thought about the community at or near the same level of priority that they thought about themselves.

Dr. Fischer: It was a very challenging situation, but because our adult patients in the children’s hospital were relatively young with fewer comorbidities, we got to see people get well. I took care of one man with renal failure who we thought would be on dialysis for the rest of his life. By the end of my first week on service, he had begun to regain kidney function. It was amazing. I think most frontline providers caring for adults in this pandemic have had to face significant morbidity and mortality. I felt lucky that we were able to care for patients who generally got better.

I recently read the article published in the Journal of Pediatrics laying out how the Children’s Hospital at Montefiore adapted an entire pediatric floor to caring for adults.³ This example of recognition of need, quick preparation, and collaboration both within the children’s hospital and with the adult hospital was admirable. I also feel that at the beginning of this pandemic, there was a glimmer that the failure of our health care system to cover everyone and the repercussions of this failure would be drawn into sharp relief. I hope that this understanding of the importance of universal coverage persists beyond the pandemic.

Dr. Giordano is assistant professor of pediatrics at Columbia University and a pediatric hospitalist at NewYork-Presbyterian Morgan Stanley Children’s Hospital with an interest in surgical comanagement. She serves on the Society of Hospital Medicine’s Pediatric Special Interest Group Executive Committee and is the chair of the Education Subcommittee. She is also an advisory board member for the New York/Westchester SHM Chapter.
 

References

1. Kumaraiah D et al. Innovative ICU physician care models: Covid-19 pandemic at NewYork-Presbyterian. NEJM Catal. 2020 Apr 28. doi: 10.1056/CAT.20.0158.

2. Kim MK et al. A primer for clinician deployment to the medicine floors from an epicenter of Covid-19. NEJM Catal. 2020 May 4. doi: 10.1056/CAT.20.0180.

3. Philips K, et al. Rapid Implementation of an Adult COVID-19 Unit in a Children’s Hospital. J Pediatr. 2020. doi: 10.1016/j.jpeds.2020.04.060.

The memories I have from the few nights spent in the adult pop-up cardiac intensive care unit are pouring in as I sit down to tell this story. I am a pediatric hospitalist at Columbia University NewYork-Presbyterian Morgan Stanley Children’s Hospital. I usually take care of sick, hospitalized children. However, in these extraordinary times, I have joined an army of colleagues taking care of adult patients with COVID-19.

Almost all these patients had tracheostomies connected to ventilators, as well as acute-on-chronic cardiac issues. They were often delirious and unable to speak, and always alone. I was happy to help our adult colleagues, but I was also afraid. I was scared to make a mistake that could be detrimental to my patient, even though I knew well that ICU residents, fellows, and attendings were just a phone call away.

I felt like Alice in Wonderland, initially too small compared with her environment, and the next minute hunched, giant, and still clearly displaced. Except I was not dreaming or watching a movie. There was no white rabbit to chase. The situation was serious and emotionally challenging. I imagined that each patient was the dearest member of my family: my mother, my father, my aunt or uncle. I took pleasure in sharing smiles while asking the patients how they were feeling, and I touched their hands, even though much of my face was covered and there were gloves on my hands.

The year 2020 has been surreal. People have had to find their own way of pushing through the unknown and unexpected. For a start, I would never in a million years have imagined using phrases like pop-up ICU.¹ I was signing an admission note for a 90-year-old lady with acute-on-chronic congestive heart failure and acute respiratory hypoxemic failure and there, at the bottom of the note, was my name, followed by an odd remark: “pediatric hospital medicine.” That is what happened in New York City in 2020: Many unexpected events took place.

This article represents a virtual conversation with three other pediatric hospitalists who, under different sets of circumstances, did the same thing: took care of adult patients. I hope that the answers to the questions I asked make you pause, reflect, and learn from the experiences described.
 

Would you describe the usual environment where you practice pediatric hospital medicine?

Julie Dunbar, MD: I am a full-time pediatric hospitalist at the Children’s Hospital at Montefiore, a tertiary care academic children’s hospital in the Bronx. A typical day on service involves staffing up to 14 patients, up to 21 years old, on a teaching service with residents and physician assistants. We normally staff the hospital in two shifts – day and evening – until 11:00 at night. We are situated at the heart of a medically underserved area, and our hospital system cares for about one-third of the total population of the Bronx.



L. Nell Hodo, MD: I work at Kravis Children’s Hospital at the Mount Sinai Hospital, in Manhattan at the juncture of the Upper East Side and Harlem. Our usual hospital medicine environment is the general ward/floor in a nested children’s hospital within an adult hospital. We have about 32 non-ICU beds, and the patients are managed by a combination of hospitalists, general pediatricians, and specialist attendings. All patients are on resident teams. We have a comanagement model in which the primary attending for surgical patients is always a pediatric attending (hospitalist or specialist).



Avital M. Fischer, MD: NewYork-Presbyterian Morgan Stanley Children’s Hospital is a quaternary care center – where children from the area receive subspecialty care – as well as, functionally, a community hospital for the Washington Heights area. Therefore, we always have an interesting mix of general pediatric inpatient medicine including patients with complex medical conditions, rare diseases, postoperative conditions, and undiagnosed illnesses on our wards. We are a children’s hospital, connected to a larger adult hospital system. Pediatric hospitalists cover two pediatric wards, team-staffed by residents, and a progressive care unit, staffed by nurse practitioners. There is usually evening coverage until 11 p.m.

How did this change when New York became the U.S. epicenter of the SARS-CoV-2 pandemic? Was the transition to taking care of adult patients gradual or sudden? Were you deployed to a different hospital or part of the hospital? How prepared did you feel?

Dr. Dunbar: We experienced the COVID-19 pandemic like much of the rest of New York City – it started as a slow and uncertain process, and then it hit us all at once. In initial conversations, like everyone else, we did not know exactly what was coming. We started with small changes like working from home on nonclinical days and canceling family-centered rounds to conserve personal protective equipment (PPE). In mid-March, we were still expecting that redeployment to adult floors was a highly unlikely scenario. We made work-from-home schedules and planned projects we would work on while social distancing. We planned journal clubs about emerging evidence on COVID-19. However, things happened fast, and many of these plans were scrapped.

On Saturday, March 28, we closed the main floor of the children’s hospital because so few pediatric patients were being admitted. Two days later, we admitted our first cohort of adult COVID-19 patients, all more than 30 years old. They were transferred en masse from an outside hospital emergency department that desperately needed our beds. They arrived all at once, and they all required respiratory support. At the last hospitalist division meeting before the adults arrived, we had time for only one priority set of information, and so we chose end-of-life care. We reviewed scripts for advance care planning and logistics of death certificates. As fast as things changed for us, they changed even faster for the patients. Most were relatively healthy people who rather suddenly found themselves isolated, on oxygen, dictating their final wishes to pediatricians in full protective gear. Many, many patients got better, and of course, several spent their last moments with us. One physician assistant, who works closely with the hospitalists, spent the last 5 hours of an elderly patient’s life holding her hand and helping her FaceTime with family.

For the most part, the patients came to us. We worked with our own colleagues and our own nurses, on our own territory. A few of my colleagues were briefly redeployed to a series of conference rooms that were used for several weeks as overflow space for more stable COVID-19 patients. Staffing by the pediatrics teams was so robust, with willing volunteers from every corner of the children’s hospital, that we were not needed for long.

During the early days, there was no clinical pathway to follow to care for COVID-19 patients – it didn’t exist for this novel and variable disease. We created a platform to share documents and resources in real time as they became available to us. We used group texts and emails to learn from our experiences and encourage one another. Importantly, no one was afraid to ask for help, and we relied on our adult colleagues when patients started to decompensate. Adult critical care came to our aid for all rapid responses for patients older than 30. Pediatric critical care, in their infinite flexibility, was responsible for anyone younger.
 

Dr. Hodo: We had a variety of changes. The first thing was the deployment of many of our attendings (hospital medicine, ICU, outpatient, and subspecialists) and residents to the adult side to work on medical COVID-19 units or in the many ICUs (some new “pop-up” units in former medical units, postanesthesia care units, and so on).² On the adult floor we had “COVID teams,” which had an attending and two frontline providers; one of these three people was an internal medicine faculty member or resident. Residents from other specialties (emergency medicine, family medicine) were pulled off pediatric assignments in pediatric wards, PICUs, and EDs, so pediatric residents not originally assigned to inpatient rotations were sent to cover these core pediatric areas. The remaining pediatric faculty backfilled the pediatric services – so the remaining ICU docs did more shifts to cover ICU; the undeployed specialists took more inpatient service or clinic time, and so on. Outpatient pediatrics covered the inpatient pediatric service for the 3 weeks when most of the hospitalists were deployed.

We had one pediatric unit, which was a unit with equipment that made it capable of having ICU patients or floor patients, that was designated a COVID-19 unit. Most COVID-19 patients were there. Some were also in negative-pressure rooms on other floors or in the unit directly above the COVID-19 unit. Some adult patients came to the unit in the pediatric hospital but not as many as initially expected, and most were young adults in their 20s. So rather than adult patients coming to pediatrics, our experience was more that pediatricians went to the adult side.

The transition to adult care for physicians was variable in its suddenness. Most people had at least 48 hours’ notice, whereas some had as much as a week. Most of our department members deployed within the hospital complex of which we are a part, though a few went to other sites in the health system. Some were deployed into administrative or support roles in the system, rather than patient-facing roles. I felt, I would say, reasonably prepared. I trained in family medicine, though I have been exclusively in pediatrics for the past 7 years. I felt rusty, for sure, but perhaps not quite as out of my element as others. In preparation, I read a lot about COVID, reviewed some adult medicine topics provided by the medicine department, used the resources on the Pediatric Overflow Planning Contingency Response Network (POPCoRN), including an Advanced Cardiac Life Support review, and was able to shadow on a COVID-19 unit before I actually started – that was incredibly helpful. I also had the opportunity to speak about that shadowing experience in a department meeting, which I hope was helpful for others.
 

Dr. Fischer: Our whole focus for a relatively short time shifted to how to take care of adults within the children’s hospital. Although we had some time to prepare – the ICU was the first unit to take adults, so we knew they would come to the floor – it still felt quick. We took adult patients onto the general pediatrics floor from both the emergency department and the ICU. We took adults mostly with COVID-19, but we did have some young adults admitted for other reasons too. Those of us who were on service during this time collaborated closely, sharing what we learned and even joining one another on rounds to provide support. We basically would “teach it forward” as we learned. We also had adult providers available by phone for questions, and our pediatric subspecialists were readily available for consults and would reach out to their adult counterparts for support. Some of the hospitalists were reaching out to POPCoRN, and some were attending an ACLS crash course prior to getting on service.

What was hardest about this experience for you?

Dr. Dunbar: For me, one of the hardest aspects of dealing with COVID-19 was the unknown. In every aspect of professional life and clinical care, there were unanswered questions. What’s the best way to care for these patients? What prognoses can we give their loved ones? How can I help when it seems like there’s so little I can offer? Will we run out of PPE? As doctors, what behaviors most endanger our friends and family when we go home after work? When will things start to get better?

Dr. Hodo: For me, the week or two before being notified of the deployment was the worst and hardest time. The uncertainty about if I would be called or no, and to do what? And where? I was trying to read everything there was on management, what little was known about treatment, and so on. Once I received notification of a start date, that allowed me to focus on very clear endpoints and knowledge items (for example, reviewing ACLS algorithms) and to do things I knew would help me settle and be more effective (like shadowing).

Dr. Fischer: It was a lot of new. Not only were we taking care of a population that we hadn’t cared for since medical school (adults), but we were facing a disease process that was also new to everyone. We were learning on our feet, while at the same time providing guidance to our house staff.

What have you learned about yourself that you did not know before?

Dr. Dunbar: I was surprised to learn how much I liked caring for adult patients. The fear I felt immediately before they arrived dissipated fairly quickly after they arrived. The opportunity to address their chronic conditions while supporting them in an acute illness took me back to many of the fundamentals of medicine that I hadn’t thought much about since medical school. I liked that they could speak up to tell us how they were feeling, both physically and emotionally, so that we could address their needs and allow them to participate in their own care. Some of my favorite patients kept detailed histories of their own C-reactive protein values and oxygen levels to show they were active participants in their own recovery.

I was worried that these adult patients would be offended or scared to learn that they were being cared for by pediatricians, but at no point did anyone ask me why they were not assigned to an adult hospitalist. They saw us only as doctors and nurses, and they were grateful for our care. One 65-year-old U.S. Army veteran told me that his nurse had told him to take a shower and make his bed. “She treated me just like a 5-year-old kid. And I loved it!” he said.
 

Dr. Hodo: I don’t know that I was totally unaware of these things, but I will say that I had partially forgotten them: I really like adult medicine, and I love geriatrics. I like high-energy and high-stress situations … at least occasionally! I feel very comfortable discussing end-of-life decisions and death. I cope with personal stress by helping and supporting others – patients, team members, colleagues, neighbors. I risk not taking enough time for myself and have to remind myself to do so.

Dr. Fischer: I actually loved taking care of adults. It felt like there was a different kind of patient-doctor relationship to be had, and it was interesting to get to know people who had jobs and families of their own – essentially a different type of story than you typically hear taking care of children.

Were there any silver linings in this situation? How did you grow personally through this experience? What do we need to do better going forward as a profession and a community?

Dr. Dunbar: The part that I hope will stay with me is the memory of how we came together as clinicians to fight a common invisible enemy. The teamwork was unprecedented. Our day-to-day goals were simple and straightforward: do what needed to be done to help as many New Yorkers as possible. Our team made themselves available for last-minute meetings and shift changes without complaint. We practiced a type of medicine that prioritized patient comfort, flexibility, and compassionate care. We ordered methadone and insulin and antihypertensives – brand new experiences for us, but we figured it out. We worked through novel clinical problems together because there was no textbook to read.

Our colleagues from other specialties and different levels of experience stepped up to join us on overnight shifts, and we welcomed them. With the help of an ad hoc palliative care team, we improved how we listened to patients’ own self-directed needs. We reached across the aisle to our internal medicine and adult hospitalist colleagues to refresh our memories on chronic conditions, and they always answered the phone. I hope we always remember who we were during this crisis, because we were ourselves at our most generous.
 

Dr. Hodo: This was an unexpected but great opportunity to meet physicians, nurses, and staff in different departments and sections of the hospital from my own. I am hopeful that this experience will help us in the future with multidisciplinary work and breaking down silos that isolate specialties and units in the hospital.

I feel (and this is probably weird) invigorated by this experience. It feels good to have been able to help when I was needed. Even though there are a lot of things in adult hospital medicine I do not know, I know I did my best, asked for help when I needed it, and asked for feedback regularly from the medicine residents and nurses I worked with. I know I supported my team and my colleagues to the best of my ability through stressful and sometimes upsetting and emotionally draining times.

As a profession, we can continue to remember the value of the multidisciplinary team and the value of listening to, and making space for, different voices to be heard. We can reconsider the traditional, rigid hierarchy in medicine and medical education that can stifle creative thought and innovative ideas. We can remember that the people “at the top” of the pyramid can always learn something from those “at the bottom.” We can see the ways that department and discipline and specialty can help us but also sometimes hinder, and seek involvement in programs and discussions that unite and pool resources and skills. And, most of all, we can try, every day we are at work, to put the patients’ and families’ needs first – and when we leave work, to turn that around, and put ourselves and our loved ones in that prime position.

As a community, we also can work on thinking communally – that, after all, is the entire point of the wearing of masks in public and social distancing. It is as much about you as about me! We can try to hold on to some of this perspective of the greater good and appreciation for the work others do that makes our lives better and easier. It is not only health care workers who deserve a round of applause every day; it is every person who did something today that benefited someone else, be that giving extra space in a line, wearing a mask in a store, delivering food to an elder, teaching a class over Zoom, or simply minimizing time outside the house. It is every person who thought about the community at or near the same level of priority that they thought about themselves.

Dr. Fischer: It was a very challenging situation, but because our adult patients in the children’s hospital were relatively young with fewer comorbidities, we got to see people get well. I took care of one man with renal failure who we thought would be on dialysis for the rest of his life. By the end of my first week on service, he had begun to regain kidney function. It was amazing. I think most frontline providers caring for adults in this pandemic have had to face significant morbidity and mortality. I felt lucky that we were able to care for patients who generally got better.

I recently read the article published in the Journal of Pediatrics laying out how the Children’s Hospital at Montefiore adapted an entire pediatric floor to caring for adults.³ This example of recognition of need, quick preparation, and collaboration both within the children’s hospital and with the adult hospital was admirable. I also feel that at the beginning of this pandemic, there was a glimmer that the failure of our health care system to cover everyone and the repercussions of this failure would be drawn into sharp relief. I hope that this understanding of the importance of universal coverage persists beyond the pandemic.

Dr. Giordano is assistant professor of pediatrics at Columbia University and a pediatric hospitalist at NewYork-Presbyterian Morgan Stanley Children’s Hospital with an interest in surgical comanagement. She serves on the Society of Hospital Medicine’s Pediatric Special Interest Group Executive Committee and is the chair of the Education Subcommittee. She is also an advisory board member for the New York/Westchester SHM Chapter.
 

References

1. Kumaraiah D et al. Innovative ICU physician care models: Covid-19 pandemic at NewYork-Presbyterian. NEJM Catal. 2020 Apr 28. doi: 10.1056/CAT.20.0158.

2. Kim MK et al. A primer for clinician deployment to the medicine floors from an epicenter of Covid-19. NEJM Catal. 2020 May 4. doi: 10.1056/CAT.20.0180.

3. Philips K, et al. Rapid Implementation of an Adult COVID-19 Unit in a Children’s Hospital. J Pediatr. 2020. doi: 10.1016/j.jpeds.2020.04.060.

Most children who tested positive for SARS-CoV-2 had no respiratory illness, according to data from a retrospective study of 22 patients at a single center.

Fuse/thinkstockphotos.com

To date, children account for less than 5% of COVID-19 cases in the United States, but details of the clinical presentations in children are limited, wrote Rabia Agha, MD, and colleagues of Maimonides Children’s Hospital, Brooklyn, N.Y.

In a study published in Hospital Pediatrics, the researchers reviewed data from 22 children aged 0-18 years who tested positive for SARS-CoV-2 by polymerase chain reaction (PCR) and were admitted to a single hospital over a 4-week period from March 18, 2020, to April 15, 2020.

Overall, 9 patients (41%) presented with a respiratory illness, and 7 (32%) required respiratory support. Of four patients requiring mechanical ventilation, two had underlying pulmonary disease. The other two patients who required intubation were one with cerebral palsy and status epilepticus and one who presented in a state of cardiac arrest.

The study population ranged from 11 days to 18 years of age, but 45% were infants younger than 1 year. None of the children had a travel history that might increase their risk for SARS-CoV-2 infection; 27% had confirmed exposure to the virus.

Most of the children (82%) were hospitalized within 3 days of the onset of symptoms, and no deaths occurred during the study period. The most common symptom was fever without a source in five (23%) otherwise healthy infants aged 11-35 days. All five of these children underwent a sepsis evaluation, received empiric antibiotics, and were discharged home with negative bacterial cultures within 48-72 hours. Another 10 children had fever in combination with other symptoms.

Other presenting symptoms were respiratory (9), fatigue (6), seizures (2), and headache (1).

Most children with respiratory illness were treated with supportive therapy and antibiotics, but three of those on mechanical ventilation also were treated with remdesivir; all three were ultimately extubated.

Neurological abnormalities occurred in two patients: an 11-year-old otherwise healthy boy who presented with fever, headache, confusion, and seizure but ultimately improved without short-term sequelae; and a 12-year-old girl with cerebral palsy who developed new onset seizures and required mechanical ventilation, but ultimately improved to baseline.

Positive PCR results were identified in seven patients (32%) during the second half of the study period who were initially hospitalized for non-COVID related symptoms; four with bacterial infections, two with illnesses of unknown etiology, and one with cardiac arrest. Another two children were completely asymptomatic at the time of admission but then tested positive by PCR; one child had been admitted for routine chemotherapy and the other for social reasons, Dr. Agha and associates said.

The study findings contrast with early data from China in which respiratory illness of varying severity was the major presentation in children with COVID-19, but support a more recent meta-analysis of 551 cases, the researchers noted. The findings also highlight the value of universal testing for children.

“Our initial testing strategy was according to the federal and local guidelines that recommended PCR testing for the symptoms of fever, cough and shortness of breath, or travel to certain countries or close contact with a confirmed case,” Dr. Agha and colleagues said.

“With the implementation of our universal screening strategy of all admitted pediatric patients, we identified 9 (41%) patients with COVID-19 that would have been missed, as they did not meet the then-recommended criteria for testing,” they wrote.

The results suggest the need for broader guidelines to test pediatric patients because children presenting with other illnesses may be positive for SARS-CoV-2 as well, the researchers said.

“Testing of all hospitalized patients will not only identify cases early in the course of their admission process, but will also help prevent inadvertent exposure of other patients and health care workers, assist in cohorting infected patients, and aid in conservation of personal protective equipment,” Dr. Agha and associates concluded.

The current study is important as clinicians continue to learn about how infection with SARS-CoV-2 presents in different populations, Diana Lee, MD, of the Icahn School of Medicine at Mount Sinai, New York, said in an interview.

“Understanding how it can present in the pediatric population is important in identifying children who may have the infection and developing strategies for testing,” she said.

“I was not surprised by the finding that most children did not present with the classic symptoms of COVID-19 in adults based on other published studies and my personal clinical experience taking care of hospitalized children in New York City,” said Dr. Lee. “Studies from the U.S. and other countries have reported that fewer children experience fever, cough, and shortness of breath [compared with] adults, and that most children have a milder clinical course, though there is a small percentage of children who can have severe or critical illness,” she said.

“A multisystem inflammatory syndrome in children associated with COVID-19 has also emerged and appears to be a postinfectious process with a presentation that often differs from classic COVID-19 infection in adults,” she added.

The take-home message for clinicians is the reminder that SARS-CoV-2 infection often presents differently in children than in adults, said Dr. Lee.

“Children who present to the hospital with non-classic COVID-19 symptoms or with other diagnoses may be positive for SARS-CoV-2 on testing. Broadly testing hospitalized children for SARS-CoV-2 and instituting appropriate isolation precautions may help to protect other individuals from being exposed to the virus,” she said.  

“Further research is needed to understand which individuals are contagious and how to accurately distinguish those who are infectious versus those who are not,” said Dr. Lee. “There have been individuals who persistently test positive for SARS-CoV-2 RNA (the genetic material of the virus), but were not found to have virus in their bodies that can replicate and thereby infect others,” she emphasized. “Further study is needed regarding the likelihood of household exposures in children with SARS-CoV-2 infection given that this study was done early in the epidemic in New York City when testing and contact tracing was less established,” she said.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Lee had no financial conflicts to disclose.

SOURCE: Agha R et al. Hosp Pediatr. 2020 July. doi: 10.1542/hpeds.2020-000257.

Most children who tested positive for SARS-CoV-2 had no respiratory illness, according to data from a retrospective study of 22 patients at a single center.

Fuse/thinkstockphotos.com

To date, children account for less than 5% of COVID-19 cases in the United States, but details of the clinical presentations in children are limited, wrote Rabia Agha, MD, and colleagues of Maimonides Children’s Hospital, Brooklyn, N.Y.

In a study published in Hospital Pediatrics, the researchers reviewed data from 22 children aged 0-18 years who tested positive for SARS-CoV-2 by polymerase chain reaction (PCR) and were admitted to a single hospital over a 4-week period from March 18, 2020, to April 15, 2020.

Overall, 9 patients (41%) presented with a respiratory illness, and 7 (32%) required respiratory support. Of four patients requiring mechanical ventilation, two had underlying pulmonary disease. The other two patients who required intubation were one with cerebral palsy and status epilepticus and one who presented in a state of cardiac arrest.

The study population ranged from 11 days to 18 years of age, but 45% were infants younger than 1 year. None of the children had a travel history that might increase their risk for SARS-CoV-2 infection; 27% had confirmed exposure to the virus.

Most of the children (82%) were hospitalized within 3 days of the onset of symptoms, and no deaths occurred during the study period. The most common symptom was fever without a source in five (23%) otherwise healthy infants aged 11-35 days. All five of these children underwent a sepsis evaluation, received empiric antibiotics, and were discharged home with negative bacterial cultures within 48-72 hours. Another 10 children had fever in combination with other symptoms.

Other presenting symptoms were respiratory (9), fatigue (6), seizures (2), and headache (1).

Most children with respiratory illness were treated with supportive therapy and antibiotics, but three of those on mechanical ventilation also were treated with remdesivir; all three were ultimately extubated.

Neurological abnormalities occurred in two patients: an 11-year-old otherwise healthy boy who presented with fever, headache, confusion, and seizure but ultimately improved without short-term sequelae; and a 12-year-old girl with cerebral palsy who developed new onset seizures and required mechanical ventilation, but ultimately improved to baseline.

Positive PCR results were identified in seven patients (32%) during the second half of the study period who were initially hospitalized for non-COVID related symptoms; four with bacterial infections, two with illnesses of unknown etiology, and one with cardiac arrest. Another two children were completely asymptomatic at the time of admission but then tested positive by PCR; one child had been admitted for routine chemotherapy and the other for social reasons, Dr. Agha and associates said.

The study findings contrast with early data from China in which respiratory illness of varying severity was the major presentation in children with COVID-19, but support a more recent meta-analysis of 551 cases, the researchers noted. The findings also highlight the value of universal testing for children.

“Our initial testing strategy was according to the federal and local guidelines that recommended PCR testing for the symptoms of fever, cough and shortness of breath, or travel to certain countries or close contact with a confirmed case,” Dr. Agha and colleagues said.

“With the implementation of our universal screening strategy of all admitted pediatric patients, we identified 9 (41%) patients with COVID-19 that would have been missed, as they did not meet the then-recommended criteria for testing,” they wrote.

The results suggest the need for broader guidelines to test pediatric patients because children presenting with other illnesses may be positive for SARS-CoV-2 as well, the researchers said.

“Testing of all hospitalized patients will not only identify cases early in the course of their admission process, but will also help prevent inadvertent exposure of other patients and health care workers, assist in cohorting infected patients, and aid in conservation of personal protective equipment,” Dr. Agha and associates concluded.

The current study is important as clinicians continue to learn about how infection with SARS-CoV-2 presents in different populations, Diana Lee, MD, of the Icahn School of Medicine at Mount Sinai, New York, said in an interview.

“Understanding how it can present in the pediatric population is important in identifying children who may have the infection and developing strategies for testing,” she said.

“I was not surprised by the finding that most children did not present with the classic symptoms of COVID-19 in adults based on other published studies and my personal clinical experience taking care of hospitalized children in New York City,” said Dr. Lee. “Studies from the U.S. and other countries have reported that fewer children experience fever, cough, and shortness of breath [compared with] adults, and that most children have a milder clinical course, though there is a small percentage of children who can have severe or critical illness,” she said.

“A multisystem inflammatory syndrome in children associated with COVID-19 has also emerged and appears to be a postinfectious process with a presentation that often differs from classic COVID-19 infection in adults,” she added.

The take-home message for clinicians is the reminder that SARS-CoV-2 infection often presents differently in children than in adults, said Dr. Lee.

“Children who present to the hospital with non-classic COVID-19 symptoms or with other diagnoses may be positive for SARS-CoV-2 on testing. Broadly testing hospitalized children for SARS-CoV-2 and instituting appropriate isolation precautions may help to protect other individuals from being exposed to the virus,” she said.  

“Further research is needed to understand which individuals are contagious and how to accurately distinguish those who are infectious versus those who are not,” said Dr. Lee. “There have been individuals who persistently test positive for SARS-CoV-2 RNA (the genetic material of the virus), but were not found to have virus in their bodies that can replicate and thereby infect others,” she emphasized. “Further study is needed regarding the likelihood of household exposures in children with SARS-CoV-2 infection given that this study was done early in the epidemic in New York City when testing and contact tracing was less established,” she said.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Lee had no financial conflicts to disclose.

SOURCE: Agha R et al. Hosp Pediatr. 2020 July. doi: 10.1542/hpeds.2020-000257.

Most children who tested positive for SARS-CoV-2 had no respiratory illness, according to data from a retrospective study of 22 patients at a single center.

Fuse/thinkstockphotos.com

To date, children account for less than 5% of COVID-19 cases in the United States, but details of the clinical presentations in children are limited, wrote Rabia Agha, MD, and colleagues of Maimonides Children’s Hospital, Brooklyn, N.Y.

In a study published in Hospital Pediatrics, the researchers reviewed data from 22 children aged 0-18 years who tested positive for SARS-CoV-2 by polymerase chain reaction (PCR) and were admitted to a single hospital over a 4-week period from March 18, 2020, to April 15, 2020.

Overall, 9 patients (41%) presented with a respiratory illness, and 7 (32%) required respiratory support. Of four patients requiring mechanical ventilation, two had underlying pulmonary disease. The other two patients who required intubation were one with cerebral palsy and status epilepticus and one who presented in a state of cardiac arrest.

The study population ranged from 11 days to 18 years of age, but 45% were infants younger than 1 year. None of the children had a travel history that might increase their risk for SARS-CoV-2 infection; 27% had confirmed exposure to the virus.

Most of the children (82%) were hospitalized within 3 days of the onset of symptoms, and no deaths occurred during the study period. The most common symptom was fever without a source in five (23%) otherwise healthy infants aged 11-35 days. All five of these children underwent a sepsis evaluation, received empiric antibiotics, and were discharged home with negative bacterial cultures within 48-72 hours. Another 10 children had fever in combination with other symptoms.

Other presenting symptoms were respiratory (9), fatigue (6), seizures (2), and headache (1).

Most children with respiratory illness were treated with supportive therapy and antibiotics, but three of those on mechanical ventilation also were treated with remdesivir; all three were ultimately extubated.

Neurological abnormalities occurred in two patients: an 11-year-old otherwise healthy boy who presented with fever, headache, confusion, and seizure but ultimately improved without short-term sequelae; and a 12-year-old girl with cerebral palsy who developed new onset seizures and required mechanical ventilation, but ultimately improved to baseline.

Positive PCR results were identified in seven patients (32%) during the second half of the study period who were initially hospitalized for non-COVID related symptoms; four with bacterial infections, two with illnesses of unknown etiology, and one with cardiac arrest. Another two children were completely asymptomatic at the time of admission but then tested positive by PCR; one child had been admitted for routine chemotherapy and the other for social reasons, Dr. Agha and associates said.

The study findings contrast with early data from China in which respiratory illness of varying severity was the major presentation in children with COVID-19, but support a more recent meta-analysis of 551 cases, the researchers noted. The findings also highlight the value of universal testing for children.

“Our initial testing strategy was according to the federal and local guidelines that recommended PCR testing for the symptoms of fever, cough and shortness of breath, or travel to certain countries or close contact with a confirmed case,” Dr. Agha and colleagues said.

“With the implementation of our universal screening strategy of all admitted pediatric patients, we identified 9 (41%) patients with COVID-19 that would have been missed, as they did not meet the then-recommended criteria for testing,” they wrote.

The results suggest the need for broader guidelines to test pediatric patients because children presenting with other illnesses may be positive for SARS-CoV-2 as well, the researchers said.

“Testing of all hospitalized patients will not only identify cases early in the course of their admission process, but will also help prevent inadvertent exposure of other patients and health care workers, assist in cohorting infected patients, and aid in conservation of personal protective equipment,” Dr. Agha and associates concluded.

The current study is important as clinicians continue to learn about how infection with SARS-CoV-2 presents in different populations, Diana Lee, MD, of the Icahn School of Medicine at Mount Sinai, New York, said in an interview.

“Understanding how it can present in the pediatric population is important in identifying children who may have the infection and developing strategies for testing,” she said.

“I was not surprised by the finding that most children did not present with the classic symptoms of COVID-19 in adults based on other published studies and my personal clinical experience taking care of hospitalized children in New York City,” said Dr. Lee. “Studies from the U.S. and other countries have reported that fewer children experience fever, cough, and shortness of breath [compared with] adults, and that most children have a milder clinical course, though there is a small percentage of children who can have severe or critical illness,” she said.

“A multisystem inflammatory syndrome in children associated with COVID-19 has also emerged and appears to be a postinfectious process with a presentation that often differs from classic COVID-19 infection in adults,” she added.

The take-home message for clinicians is the reminder that SARS-CoV-2 infection often presents differently in children than in adults, said Dr. Lee.

“Children who present to the hospital with non-classic COVID-19 symptoms or with other diagnoses may be positive for SARS-CoV-2 on testing. Broadly testing hospitalized children for SARS-CoV-2 and instituting appropriate isolation precautions may help to protect other individuals from being exposed to the virus,” she said.  

“Further research is needed to understand which individuals are contagious and how to accurately distinguish those who are infectious versus those who are not,” said Dr. Lee. “There have been individuals who persistently test positive for SARS-CoV-2 RNA (the genetic material of the virus), but were not found to have virus in their bodies that can replicate and thereby infect others,” she emphasized. “Further study is needed regarding the likelihood of household exposures in children with SARS-CoV-2 infection given that this study was done early in the epidemic in New York City when testing and contact tracing was less established,” she said.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Lee had no financial conflicts to disclose.

SOURCE: Agha R et al. Hosp Pediatr. 2020 July. doi: 10.1542/hpeds.2020-000257.

Background: Since the advent of early goal-directed therapy (EGDT), studies have challenged the notion that high-volume IV fluid resuscitation improves clinical outcomes in sepsis and septic shock. The optimal IV fluid resuscitation strategy for severe sepsis and septic shock remains unclear.

Limitations to RIFTS include its small sample size, single-system design, and inadequate power to detect noninferiority or superiority. While larger, multicenter trials are required for further investigation, hospitalists should note a trend toward conservative IV fluid administration in severe sepsis and septic shock.

Bottom line: Restrictive IV fluid resuscitation for severe sepsis and septic shock may result in mortality rates similar to those of usual care, but larger, multicenter studies are needed to confirm noninferiority.

Citation: Corl KA et al. The restrictive IV fluid trial in severe sepsis and septic shock (RIFTS): A randomized pilot study. Crit Care Med. 2019;47(7):951-9.

Dr. McIntyre is a hospitalist at Ochsner Health System, New Orleans.

Background: Since the advent of early goal-directed therapy (EGDT), studies have challenged the notion that high-volume IV fluid resuscitation improves clinical outcomes in sepsis and septic shock. The optimal IV fluid resuscitation strategy for severe sepsis and septic shock remains unclear.

Limitations to RIFTS include its small sample size, single-system design, and inadequate power to detect noninferiority or superiority. While larger, multicenter trials are required for further investigation, hospitalists should note a trend toward conservative IV fluid administration in severe sepsis and septic shock.

Bottom line: Restrictive IV fluid resuscitation for severe sepsis and septic shock may result in mortality rates similar to those of usual care, but larger, multicenter studies are needed to confirm noninferiority.

Citation: Corl KA et al. The restrictive IV fluid trial in severe sepsis and septic shock (RIFTS): A randomized pilot study. Crit Care Med. 2019;47(7):951-9.

Dr. McIntyre is a hospitalist at Ochsner Health System, New Orleans.

Background: Since the advent of early goal-directed therapy (EGDT), studies have challenged the notion that high-volume IV fluid resuscitation improves clinical outcomes in sepsis and septic shock. The optimal IV fluid resuscitation strategy for severe sepsis and septic shock remains unclear.

Limitations to RIFTS include its small sample size, single-system design, and inadequate power to detect noninferiority or superiority. While larger, multicenter trials are required for further investigation, hospitalists should note a trend toward conservative IV fluid administration in severe sepsis and septic shock.

Bottom line: Restrictive IV fluid resuscitation for severe sepsis and septic shock may result in mortality rates similar to those of usual care, but larger, multicenter studies are needed to confirm noninferiority.

Citation: Corl KA et al. The restrictive IV fluid trial in severe sepsis and septic shock (RIFTS): A randomized pilot study. Crit Care Med. 2019;47(7):951-9.

Dr. McIntyre is a hospitalist at Ochsner Health System, New Orleans.

The COVID-19 pandemic continues to disrupt all aspects of hospital care, and has altered nearly all fundamental practices, including discharge protocols. A session presented at the Society of Hospitalist Medicine’s 2020 Virtual Annual Conference will focus on discharge issues in the COVID-19 era.

“Discharge planning is an integral part of a hospitalist’s clinical care. On a daily basis, we think carefully about how to help our patients safely transition back into life outside of the hospital,” said Maralyssa Bann, MD, of the University of Washington, Seattle, a copresenter at the session.

“Patients need up-to-date information about how to keep themselves and those around them safe,” she said. “They need resources and supports to help them recover from illness.”

These supports include access to appropriate follow-up with primary care doctors or other specialists and being discharged to the right location, such as home or a skilled nursing facility, Dr. Bann noted.

In response to COVID-19, “within an exceptionally short time frame, hospitals have had to rapidly adapt their discharge planning protocols and have had to continue to adapt as new information comes out,” Dr. Bann said.

“In many ways, the COVID-19 pandemic has highlighted the importance of discharge planning for patient care and has added a new element of public health in that we have to take all possible precautions to ensure that patients are not spreading the virus after they leave the hospital,” said Ryan Greysen, MD, of the University of Pennsylvania, Philadelphia, and Dr. Bann’s copresenter.

Dan Burke Photography

Many elements go into creating a good discharge plan, but there are often many unknowns, Dr. Greysen said. “I think there is an opportunity to improve the process by improving follow-up as well.”

“For example, one program at our hospital focused on vulnerable older adults includes an in-home visit by a visiting nurse on the day of discharge to verify the patient has everything they need when they arrive home,” However, now with more telemedicine and social distancing, there should be creative approaches to tying up loose ends and monitoring for things that can go wrong in order to give additional guidance, he said.

“In a previous study of 12 U.S. academic medical centers, my colleagues and I interviewed over 1,000 patients who were discharged and then readmitted to ask them what they thought went wrong,” said Dr. Greysen. “Overwhelmingly, patients indicated that they understood their discharge instructions and the plan of care at the time they left the hospital, but then when there were breakdowns or unanticipated challenges in the plan, they were uncertain what to do.”

In the HM20 Virtual session, Dr. Greysen and Dr. Bann will present additional data from the same network that Dr. Greysen used in his study, the Hospital Medicine Reengineering Network or HOMERuN, but expanded to include 22 sites.

The specific areas will include clinical and nonclinical criteria for patients to be discharged home, how criteria differed for discharge destinations other than home, discharge logistics, discharge instructions for patients and caregivers, and postdischarge follow-up.

“Developing a discharge protocol during a pandemic is a major challenge. There are new barriers and challenges to finding the right discharge location, as information about illness course and outcome is incomplete or evolving,” Dr. Bann said. “The safety of patients and their loved ones, health care workers and staff, as well as the public at large is always top of mind. Decisions have to be made in a timely way and communicated clearly. This is a huge task in addition to all of the other competing work in the midst of a pandemic, which is why learning from each other and collectively creating our shared best practices is tremendously helpful. If I can take example approaches from other hospitals and update them for use at my site, this saves a lot of time and effort.”

“There is great urgency to understand when it is safe to discharge these patients from the hospital,” Dr. Greysen said. “Many COVID patients can have worsening of their symptoms after a period of initial improvement so sending them home too soon is a major concern. On the other hand, we can’t keep COVID patients in the hospital until they have fully recovered; we would increase their risk of iatrogenic events and we could risk using up capacity of the health care system to care for other patients, both COVID and non-COVID.”

Unfortunately, no evidence base yet exists to guide the creation of discharge guidelines for COVID patients, said Dr. Greysen. “Therefore, we conducted a survey of HOMERuN sites to synthesize practices across sites and provide some guidance for hospitals based on themes or concordance between these sites.

“One area of clear concordance among sites in our study was around the use of [Centers for Disease Control and Prevention] guidelines to address patient isolation procedures as well as strategies to mitigate transmission, such as providing patients with protective gear like masks or requiring the driver who picks up the patient wear a mask for transportation,” Dr. Greysen said. “We also found that many sites used certain clinical criteria – for example, temperature, oxygen saturation or supplementation, and improvement of presenting symptoms – but there was wide variation in the details for these criteria.”

In addition, “some sites required that a patient be afebrile for a certain period of time before discharge whereas others only required that patients be afebrile at the time of discharge. There was also relatively strong consensus around assessing the level of social support and ability to perform activities of daily living prior to discharge,” since social support and ability to function are often interrelated and can be difficult to assess without visiting the home, he said.

“Further development the evidence around which discharge criteria are associated with adverse outcomes such as readmission or death is urgently needed. At this moment, we really don’t know which clinical criteria such as oxygen supplementation or nonclinical criteria are associated with better outcomes in COVID patients,” Dr. Greysen said, but he and his team plan to study this using EMR data in HOMERuN.

Dr. Bann said that clinical criteria for discharge will likely provoke lively discussions during the interactive part of the virtual session. “Also, I have heard a lot of discussion and interest in learning about how different sites are handling postdischarge monitoring and follow-up, such as how we ensure that patients are recovering well after discharge, and whether there are new or different needs for this patient population,” she added.

“Attendees should come away from this session with an understanding of how hospitals across the country have augmented their discharge planning responses during the COVID-19 pandemic,” Dr. Bann said. “This session is all about learning from each other and creating shared best practices,” she said.

“I hope that those who attend our session are able to see some areas of consensus in our study that could be applied to their discharge criteria,” Dr. Greysen added.

Dr. Bann and Dr. Greysen had no relevant financial conflicts to disclose.



Discharge Planning for COVID-19: Collected Practices from Across the U.S.

The COVID-19 pandemic continues to disrupt all aspects of hospital care, and has altered nearly all fundamental practices, including discharge protocols. A session presented at the Society of Hospitalist Medicine’s 2020 Virtual Annual Conference will focus on discharge issues in the COVID-19 era.

“Discharge planning is an integral part of a hospitalist’s clinical care. On a daily basis, we think carefully about how to help our patients safely transition back into life outside of the hospital,” said Maralyssa Bann, MD, of the University of Washington, Seattle, a copresenter at the session.

“Patients need up-to-date information about how to keep themselves and those around them safe,” she said. “They need resources and supports to help them recover from illness.”

These supports include access to appropriate follow-up with primary care doctors or other specialists and being discharged to the right location, such as home or a skilled nursing facility, Dr. Bann noted.

In response to COVID-19, “within an exceptionally short time frame, hospitals have had to rapidly adapt their discharge planning protocols and have had to continue to adapt as new information comes out,” Dr. Bann said.

“In many ways, the COVID-19 pandemic has highlighted the importance of discharge planning for patient care and has added a new element of public health in that we have to take all possible precautions to ensure that patients are not spreading the virus after they leave the hospital,” said Ryan Greysen, MD, of the University of Pennsylvania, Philadelphia, and Dr. Bann’s copresenter.

Dan Burke Photography

Many elements go into creating a good discharge plan, but there are often many unknowns, Dr. Greysen said. “I think there is an opportunity to improve the process by improving follow-up as well.”

“For example, one program at our hospital focused on vulnerable older adults includes an in-home visit by a visiting nurse on the day of discharge to verify the patient has everything they need when they arrive home,” However, now with more telemedicine and social distancing, there should be creative approaches to tying up loose ends and monitoring for things that can go wrong in order to give additional guidance, he said.

“In a previous study of 12 U.S. academic medical centers, my colleagues and I interviewed over 1,000 patients who were discharged and then readmitted to ask them what they thought went wrong,” said Dr. Greysen. “Overwhelmingly, patients indicated that they understood their discharge instructions and the plan of care at the time they left the hospital, but then when there were breakdowns or unanticipated challenges in the plan, they were uncertain what to do.”

In the HM20 Virtual session, Dr. Greysen and Dr. Bann will present additional data from the same network that Dr. Greysen used in his study, the Hospital Medicine Reengineering Network or HOMERuN, but expanded to include 22 sites.

The specific areas will include clinical and nonclinical criteria for patients to be discharged home, how criteria differed for discharge destinations other than home, discharge logistics, discharge instructions for patients and caregivers, and postdischarge follow-up.

“Developing a discharge protocol during a pandemic is a major challenge. There are new barriers and challenges to finding the right discharge location, as information about illness course and outcome is incomplete or evolving,” Dr. Bann said. “The safety of patients and their loved ones, health care workers and staff, as well as the public at large is always top of mind. Decisions have to be made in a timely way and communicated clearly. This is a huge task in addition to all of the other competing work in the midst of a pandemic, which is why learning from each other and collectively creating our shared best practices is tremendously helpful. If I can take example approaches from other hospitals and update them for use at my site, this saves a lot of time and effort.”

“There is great urgency to understand when it is safe to discharge these patients from the hospital,” Dr. Greysen said. “Many COVID patients can have worsening of their symptoms after a period of initial improvement so sending them home too soon is a major concern. On the other hand, we can’t keep COVID patients in the hospital until they have fully recovered; we would increase their risk of iatrogenic events and we could risk using up capacity of the health care system to care for other patients, both COVID and non-COVID.”

Unfortunately, no evidence base yet exists to guide the creation of discharge guidelines for COVID patients, said Dr. Greysen. “Therefore, we conducted a survey of HOMERuN sites to synthesize practices across sites and provide some guidance for hospitals based on themes or concordance between these sites.

“One area of clear concordance among sites in our study was around the use of [Centers for Disease Control and Prevention] guidelines to address patient isolation procedures as well as strategies to mitigate transmission, such as providing patients with protective gear like masks or requiring the driver who picks up the patient wear a mask for transportation,” Dr. Greysen said. “We also found that many sites used certain clinical criteria – for example, temperature, oxygen saturation or supplementation, and improvement of presenting symptoms – but there was wide variation in the details for these criteria.”

In addition, “some sites required that a patient be afebrile for a certain period of time before discharge whereas others only required that patients be afebrile at the time of discharge. There was also relatively strong consensus around assessing the level of social support and ability to perform activities of daily living prior to discharge,” since social support and ability to function are often interrelated and can be difficult to assess without visiting the home, he said.

“Further development the evidence around which discharge criteria are associated with adverse outcomes such as readmission or death is urgently needed. At this moment, we really don’t know which clinical criteria such as oxygen supplementation or nonclinical criteria are associated with better outcomes in COVID patients,” Dr. Greysen said, but he and his team plan to study this using EMR data in HOMERuN.

Dr. Bann said that clinical criteria for discharge will likely provoke lively discussions during the interactive part of the virtual session. “Also, I have heard a lot of discussion and interest in learning about how different sites are handling postdischarge monitoring and follow-up, such as how we ensure that patients are recovering well after discharge, and whether there are new or different needs for this patient population,” she added.

“Attendees should come away from this session with an understanding of how hospitals across the country have augmented their discharge planning responses during the COVID-19 pandemic,” Dr. Bann said. “This session is all about learning from each other and creating shared best practices,” she said.

“I hope that those who attend our session are able to see some areas of consensus in our study that could be applied to their discharge criteria,” Dr. Greysen added.

Dr. Bann and Dr. Greysen had no relevant financial conflicts to disclose.



Discharge Planning for COVID-19: Collected Practices from Across the U.S.

The COVID-19 pandemic continues to disrupt all aspects of hospital care, and has altered nearly all fundamental practices, including discharge protocols. A session presented at the Society of Hospitalist Medicine’s 2020 Virtual Annual Conference will focus on discharge issues in the COVID-19 era.

“Discharge planning is an integral part of a hospitalist’s clinical care. On a daily basis, we think carefully about how to help our patients safely transition back into life outside of the hospital,” said Maralyssa Bann, MD, of the University of Washington, Seattle, a copresenter at the session.

“Patients need up-to-date information about how to keep themselves and those around them safe,” she said. “They need resources and supports to help them recover from illness.”

These supports include access to appropriate follow-up with primary care doctors or other specialists and being discharged to the right location, such as home or a skilled nursing facility, Dr. Bann noted.

In response to COVID-19, “within an exceptionally short time frame, hospitals have had to rapidly adapt their discharge planning protocols and have had to continue to adapt as new information comes out,” Dr. Bann said.

“In many ways, the COVID-19 pandemic has highlighted the importance of discharge planning for patient care and has added a new element of public health in that we have to take all possible precautions to ensure that patients are not spreading the virus after they leave the hospital,” said Ryan Greysen, MD, of the University of Pennsylvania, Philadelphia, and Dr. Bann’s copresenter.

Dan Burke Photography

Many elements go into creating a good discharge plan, but there are often many unknowns, Dr. Greysen said. “I think there is an opportunity to improve the process by improving follow-up as well.”

“For example, one program at our hospital focused on vulnerable older adults includes an in-home visit by a visiting nurse on the day of discharge to verify the patient has everything they need when they arrive home,” However, now with more telemedicine and social distancing, there should be creative approaches to tying up loose ends and monitoring for things that can go wrong in order to give additional guidance, he said.

“In a previous study of 12 U.S. academic medical centers, my colleagues and I interviewed over 1,000 patients who were discharged and then readmitted to ask them what they thought went wrong,” said Dr. Greysen. “Overwhelmingly, patients indicated that they understood their discharge instructions and the plan of care at the time they left the hospital, but then when there were breakdowns or unanticipated challenges in the plan, they were uncertain what to do.”

In the HM20 Virtual session, Dr. Greysen and Dr. Bann will present additional data from the same network that Dr. Greysen used in his study, the Hospital Medicine Reengineering Network or HOMERuN, but expanded to include 22 sites.

The specific areas will include clinical and nonclinical criteria for patients to be discharged home, how criteria differed for discharge destinations other than home, discharge logistics, discharge instructions for patients and caregivers, and postdischarge follow-up.

“Developing a discharge protocol during a pandemic is a major challenge. There are new barriers and challenges to finding the right discharge location, as information about illness course and outcome is incomplete or evolving,” Dr. Bann said. “The safety of patients and their loved ones, health care workers and staff, as well as the public at large is always top of mind. Decisions have to be made in a timely way and communicated clearly. This is a huge task in addition to all of the other competing work in the midst of a pandemic, which is why learning from each other and collectively creating our shared best practices is tremendously helpful. If I can take example approaches from other hospitals and update them for use at my site, this saves a lot of time and effort.”

“There is great urgency to understand when it is safe to discharge these patients from the hospital,” Dr. Greysen said. “Many COVID patients can have worsening of their symptoms after a period of initial improvement so sending them home too soon is a major concern. On the other hand, we can’t keep COVID patients in the hospital until they have fully recovered; we would increase their risk of iatrogenic events and we could risk using up capacity of the health care system to care for other patients, both COVID and non-COVID.”

Unfortunately, no evidence base yet exists to guide the creation of discharge guidelines for COVID patients, said Dr. Greysen. “Therefore, we conducted a survey of HOMERuN sites to synthesize practices across sites and provide some guidance for hospitals based on themes or concordance between these sites.

“One area of clear concordance among sites in our study was around the use of [Centers for Disease Control and Prevention] guidelines to address patient isolation procedures as well as strategies to mitigate transmission, such as providing patients with protective gear like masks or requiring the driver who picks up the patient wear a mask for transportation,” Dr. Greysen said. “We also found that many sites used certain clinical criteria – for example, temperature, oxygen saturation or supplementation, and improvement of presenting symptoms – but there was wide variation in the details for these criteria.”

In addition, “some sites required that a patient be afebrile for a certain period of time before discharge whereas others only required that patients be afebrile at the time of discharge. There was also relatively strong consensus around assessing the level of social support and ability to perform activities of daily living prior to discharge,” since social support and ability to function are often interrelated and can be difficult to assess without visiting the home, he said.

“Further development the evidence around which discharge criteria are associated with adverse outcomes such as readmission or death is urgently needed. At this moment, we really don’t know which clinical criteria such as oxygen supplementation or nonclinical criteria are associated with better outcomes in COVID patients,” Dr. Greysen said, but he and his team plan to study this using EMR data in HOMERuN.

Dr. Bann said that clinical criteria for discharge will likely provoke lively discussions during the interactive part of the virtual session. “Also, I have heard a lot of discussion and interest in learning about how different sites are handling postdischarge monitoring and follow-up, such as how we ensure that patients are recovering well after discharge, and whether there are new or different needs for this patient population,” she added.

“Attendees should come away from this session with an understanding of how hospitals across the country have augmented their discharge planning responses during the COVID-19 pandemic,” Dr. Bann said. “This session is all about learning from each other and creating shared best practices,” she said.

“I hope that those who attend our session are able to see some areas of consensus in our study that could be applied to their discharge criteria,” Dr. Greysen added.

Dr. Bann and Dr. Greysen had no relevant financial conflicts to disclose.



Discharge Planning for COVID-19: Collected Practices from Across the U.S.