Andrew Auerbach, MD, MPH

The coronavirus disease of 2019 (COVID-19) pandemic has resulted in a surge in hospitalizations of patients with a novel, serious, and highly contagious infectious disease for which there is yet no proven treatment. Currently, much of the focus has been on intensive care unit (ICU) and ventilator capacity for the sickest of these patients who develop respiratory failure. However, most hospitalized patients are being cared for in general medical units.¹ Some evidence exists to describe adaptations to capacity needs outside of medical wards,^2-4 but few studies have specifically addressed the ward setting. Therefore, there is a pressing need for evidence to describe how to expand capacity and deliver medical ward–based care.

To better understand how inpatient care in the United States is adapting to the COVID-19 pandemic, we surveyed 72 sites participating in the Hospital Medicine Reengineering Network (HOMERuN), a national consortium of hospital medicine groups.⁵ We report results of this survey, carried out between April 3 and April 5, 2020.

Sites and Subjects

HOMERuN is a collaborative network of hospitalists from across the United States whose primary goal is to catalyze research and share best practices across hospital medicine groups. Using surveys of Hospital Medicine leaders, targeted medical record review, and other methods, HOMERuN’s funded research interests to date have included care transitions, workforce issues, patient and family engagement, and diagnostic errors. Sites participating in HOMERuN sites are relatively large urban academic medical centers (Appendix).

Survey Development and Deployment

We designed a focused survey that aimed to provide a snapshot of evolving operational and clinical aspects of COVID-19 care (Appendix). Domains included COVID-19 testing turnaround times, personal protective equipment (PPE) stewardship,⁶ features of respiratory isolation units (RIUs; ie, dedicated units for patients with known or suspected COVID-19), and observed effects on clinical care. We tested the instrument to ensure feasibility and clarity internally, performed brief cognitive testing with several hospital medicine leaders in HOMERuN, then disseminated the survey by email on April 3, with two follow-up emails on 2 subsequent days. Our study was deemed non–human subjects research by the University of California, San Francisco, Committee on Human Research. Descriptive statistics were used to characterize survey responses.

Of 72 hospitals surveyed, 51 (71%) responded. Mean hospital bed count was 940, three were safety-net hospitals, and one was a community-based teaching center; responding and nonresponding hospitals did not differ significantly in terms of bed count (Appendix).

Health System Adaptations, Testing, and PPE Status

Nearly all responding hospitals (46 of 51; 90%) had RIUs for patients with known or suspected COVID-19 (Table 1). Nearly all hospitals took steps to keep potentially sick healthcare providers from infecting others (eg, staying home if sick or exposed). Among respondents, 32% had rapid response teams, 24% had respiratory therapy teams, and 29% had case management teams that were dedicated to COVID-19 care. Thirty-two (63%) had developed models, such as ethics or palliative care consult services, to assist with difficult resource-allocation decisions (eg, how to prioritize ventilator use if demand exceeded supply). Twenty-three (45%) had developed post-acute care monitoring programs dedicated to COVID-19 patients.

auerbach03660722e_t1.jpg

At the time of our survey, only 2 sites (4%) reported COVID-19 test time turnaround under 1 hour, and 15 (30%) reported turnaround in less than 6 hours. Of the 29 sites able to provide estimates of PPE stockpile, 14 (48%) reported a supply of 2 weeks or less. The most common approaches to PPE stewardship focused on reuse of masks and face shields if not obviously soiled, centralizing PPE distribution, and disinfecting or sterilizing masks. Ten sites (20%) were utilizing 3-D printed masks, while 10% used homemade face shields or masks.

Characteristics of COVID-19 RIUs

Forty-six hospitals (90% of all respondents) in our cohort had developed RIUs at the time of survey administration. The earliest RIU implementation date was February 10, 2020, and the most recent was launched on the day of our survey. Admission to RIUs was primarily based on clinical factors associated with known or suspected COVID-19 infection (Table 2). The number of non–critical care RIU beds among locations at that time ranged from 10 or less to more than 50. The mean number of hospitalist attendings caring for patients in the RIUs was 10.2, with a mean 4.1 advanced practice providers, 5.5 residents, and 0 medical students. The number of planned patients per attending was typically 5 to 15. Nurses and physicians typically rounded separately. Medical distancing (eg, reducing patient room entry) was accomplished most commonly by grouped timing of medication administration (76% of sites), video links to room outside of rounding times (54% of sites), the use of video or telemedicine during rounds (17%), and clustering of activities such as medication administration or phlebotomy. The most common criteria prompting discharge from the RIU were a negative COVID-19 test (59%) and hospital discharge (57%), though comments from many respondents suggested that discharge criteria were changing rapidly.

auerbach03660722e_t2.jpg

Effects of Isolation Measures on In-Room Encounters and Diagnostic Processes

More than 90% of sites reported decreases in in-room encounter frequency across all provider types whether as a result of policies in place or not. Reductions were reported among hospitalists, advanced practice providers, residents, consultants, and therapists (Table 3). Reduced room entry most often resulted from an established or developing policy, but many noted reduced room entry without formal policies in place. Nearly all sites reported moving specialty consultations to phone or video evaluations. Diagnostic error was commonly reported, with missed non–COVID-19 medical diagnoses among COVID-19 infected patients being reported by 22 sites (46%) and missed COVID-19 diagnoses in patients admitted for other reasons by 22 sites (45%).

auerbach03660722e_t3.jpg

In this study of medical wards at academic medical centers, we found that, in response to the COVID-19 pandemic, hospitals made several changes in a short period of time to adapt to the crisis. These included implementation and rapid expansion of dedicated RIUs, greatly expanded use of inpatient telehealth for patient assessments and consultation, implementation of other approaches to minimize room entry (such as grouping in-room activities), and deployment of ethics consultation services to help manage issues around potential scarcity of life-saving measures such as ventilators. We also found that availability of PPE and timely testing was limited. Finally, a large proportion of sites reported potential diagnostic problems in the assessment of both patients suspected and those not suspected of having COVID-19.

RIUs are emerging as a primary modality for caring for non-ICU COVID-19 patients, though they never involved medical students; we hope the role of students in particular will increase as new models of training emerge in response to the pandemic.⁷ In contrast, telemedicine evolved rapidly to hold a substantial role in RIUs, with both ward and specialty teams using video visit technology to communicate with patients. COVID-19 has been viewed as a perfect use case for outpatient telemedicine,⁸ and a growing number of studies are examining its outpatient use^9,10; however, to date, somewhat less attention has been paid to inpatient deployment. Although our data suggest telemedicine has found a prominent place in RIUs, it remains to be seen whether it is associated with differences in patient or provider outcomes. For example, deficiencies in the physical examination, limited face-to-face contact, and lack of physical presence could all affect the patient–provider relationship, patient engagement, and the accuracy of the diagnostic process.

Our data suggest the possibility of missing non–COVID-19 diagnoses in patients suspected of COVID-19 and missing COVID-19 in those admitted for nonrespiratory reasons. The latter may be addressed as routine COVID-19 screening of admitted patients becomes commonplace. For the former, however, it is possible that physicians are “anchoring” their thinking on COVID-19 to the exclusion of other diagnoses, that physicians are not fully aware of complications unique to COVID-19 infection (such as thromboembolism), and/or that the above-mentioned limitations of telemedicine have decreased diagnostic performance.

Although PPE stockpile data were not easily available for some sites, a distressingly large number reported stockpiles of 2 weeks or less, with reuse being the most common approach to extending PPE supply. We also found it concerning that 43% of hospital leaders did not know their stockpile data; we believe this is an important question that hospital leaders need to be asking. Most sites in our study reported test turnaround times of longer than 6 hours; lack of rapid COVID-19 testing further stresses PPE stockpile and may slow patients’ transition out of the RIU or discharge to home.

Our study has several limitations, including the evolving nature of the pandemic and rapid adaptations of care systems in the pandemic’s surge phase. However, we attempted to frame our questions in ways that provided a focused snapshot of care. Furthermore, respondents may not have had exhaustive knowledge of their institution’s COVID-19 response strategies, but most were the directors of their hospitalist services, and we encouraged the respondents to confer with others to gather high-fidelity data. Finally, as a survey of large academic medical centers, our results may not apply to nonacademic centers.

Approaches to caring for non-ICU patients during the COVID-19 pandemic are rapidly evolving. Expansion of RIUs and developing the workforce to support them has been a primary focus, with rapid innovation in use of technology emerging as a critical adaptation while PPE limitations persist and needs for “medical distancing” continue to grow. Although rates of missed COVID-19 diagnoses will likely be reduced with testing and systems improvements, physicians and systems will also need to consider how to utilize emerging technology in ways that can improve clinical care and provider safety while aiding diagnostic thinking. This survey illustrates the rapid adaptations made by our hospitals in response to the pandemic; ongoing adaptation will likely be needed to optimally care for hospitalized patients with COVID-19 while the pandemic continues to evolve.

Thanks to members of the HOMERuN COVID-19 Collaborative Group: Baylor Scott & White Medical Center – Temple, Texas - Tresa McNeal MD; Beth Israel Deaconess Medical Center - Shani Herzig MD MPH, Joseph Li MD, Julius Yang MD PhD; Brigham and Women’s Hospital - Christopher Roy MD, Jeffrey Schnipper MD MPH; Cedars-Sinai Medical Center - Ed Seferian MD, ; ChristianaCare - Surekha Bhamidipati MD; Cleveland Clinic - Matthew Pappas MD MPH; Dartmouth-Hitchcock Medical Center - Jonathan Lurie MD MS; Dell Medical School at The University of Texas at Austin - Chris Moriates MD, Luci Leykum MD MBA MSc; Denver Health and Hospitals Authority - Diana Mancini MD; Emory University Hospital - Dan Hunt MD; Johns Hopkins Hospital - Daniel J Brotman MD, Zishan K Siddiqui MD, Shaker Eid MD MBA; Maine Medical Center - Daniel A Meyer MD, Robert Trowbridge MD; Massachusetts General Hospital - Melissa Mattison MD; Mayo Clinic Rochester – Caroline Burton MD, Sagar Dugani MD PhD; Medical College of Wisconsin - Sanjay Bhandari MD; Miriam Hospital - Kwame Dapaah-Afriyie MD MBA; Mount Sinai Hospital - Andrew Dunn MD; NorthShore - David Lovinger MD; Northwestern Memorial Hospital - Kevin O’Leary MD MS; Ohio State University Wexner Medical Center - Eric Schumacher DO; Oregon Health & Science University - Angela Alday MD; Penn Medicine - Ryan Greysen MD MHS MA; Rutgers- Robert Wood Johnson University Hospital - Michael Steinberg MD MPH; Stanford University School of Medicine - Neera Ahuja MD; Tulane Hospital and University Medical Center - Geraldine Ménard MD; UC San Diego Health - Ian Jenkins MD; UC Los Angeles Health - Michael Lazarus MD, Magdalena E. Ptaszny, MD; UC San Francisco Health - Bradley A Sharpe, MD, Margaret Fang MD MPH; UK HealthCare - Mark Williams MD MHM, John Romond MD; University of Chicago – David Meltzer MD PhD, Gregory Ruhnke MD; University of Colorado - Marisha Burden MD; University of Florida - Nila Radhakrishnan MD; University of Iowa Hospitals and Clinics - Kevin Glenn MD MS; University of Miami - Efren Manjarrez MD; University of Michigan - Vineet Chopra MD MSc, Valerie Vaughn MD MSc; University of Missouri-Columbia Hospital - Hasan Naqvi MD; University of Nebraska Medical Center - Chad Vokoun MD; University of North Carolina at Chapel Hill - David Hemsey MD; University of Pittsburgh Medical Center - Gena Marie Walker MD; University of Vermont Medical Center - Steven Grant MD; University of Washington Medical Center - Christopher Kim MD MBA, Andrew White MD; University of Washington-Harborview Medical Center - Maralyssa Bann MD; University of Wisconsin Hospital and Clinics - David Sterken MD, Farah Kaiksow MD MPP, Ann Sheehy MD MS, Jordan Kenik MD MPH; UW Northwest Campus - Ben Wolpaw MD; Vanderbilt University Medical Center - Sunil Kripalani MD MSc, Eduard E Vasilevskis MD, Kathleene T Wooldridge MD MPH; Wake Forest Baptist Health - Erik Summers MD; Washington University St. Louis - Michael Lin MD; Weill Cornell - Justin Choi MD; Yale New Haven Hospital - William Cushing MA, Chris Sankey MD; Zuckerberg San Francisco General Hospital - Sumant Ranji MD.

The coronavirus disease of 2019 (COVID-19) pandemic has resulted in a surge in hospitalizations of patients with a novel, serious, and highly contagious infectious disease for which there is yet no proven treatment. Currently, much of the focus has been on intensive care unit (ICU) and ventilator capacity for the sickest of these patients who develop respiratory failure. However, most hospitalized patients are being cared for in general medical units.¹ Some evidence exists to describe adaptations to capacity needs outside of medical wards,^2-4 but few studies have specifically addressed the ward setting. Therefore, there is a pressing need for evidence to describe how to expand capacity and deliver medical ward–based care.

To better understand how inpatient care in the United States is adapting to the COVID-19 pandemic, we surveyed 72 sites participating in the Hospital Medicine Reengineering Network (HOMERuN), a national consortium of hospital medicine groups.⁵ We report results of this survey, carried out between April 3 and April 5, 2020.

Sites and Subjects

HOMERuN is a collaborative network of hospitalists from across the United States whose primary goal is to catalyze research and share best practices across hospital medicine groups. Using surveys of Hospital Medicine leaders, targeted medical record review, and other methods, HOMERuN’s funded research interests to date have included care transitions, workforce issues, patient and family engagement, and diagnostic errors. Sites participating in HOMERuN sites are relatively large urban academic medical centers (Appendix).

Survey Development and Deployment

We designed a focused survey that aimed to provide a snapshot of evolving operational and clinical aspects of COVID-19 care (Appendix). Domains included COVID-19 testing turnaround times, personal protective equipment (PPE) stewardship,⁶ features of respiratory isolation units (RIUs; ie, dedicated units for patients with known or suspected COVID-19), and observed effects on clinical care. We tested the instrument to ensure feasibility and clarity internally, performed brief cognitive testing with several hospital medicine leaders in HOMERuN, then disseminated the survey by email on April 3, with two follow-up emails on 2 subsequent days. Our study was deemed non–human subjects research by the University of California, San Francisco, Committee on Human Research. Descriptive statistics were used to characterize survey responses.

Of 72 hospitals surveyed, 51 (71%) responded. Mean hospital bed count was 940, three were safety-net hospitals, and one was a community-based teaching center; responding and nonresponding hospitals did not differ significantly in terms of bed count (Appendix).

Health System Adaptations, Testing, and PPE Status

Nearly all responding hospitals (46 of 51; 90%) had RIUs for patients with known or suspected COVID-19 (Table 1). Nearly all hospitals took steps to keep potentially sick healthcare providers from infecting others (eg, staying home if sick or exposed). Among respondents, 32% had rapid response teams, 24% had respiratory therapy teams, and 29% had case management teams that were dedicated to COVID-19 care. Thirty-two (63%) had developed models, such as ethics or palliative care consult services, to assist with difficult resource-allocation decisions (eg, how to prioritize ventilator use if demand exceeded supply). Twenty-three (45%) had developed post-acute care monitoring programs dedicated to COVID-19 patients.

auerbach03660722e_t1.jpg

At the time of our survey, only 2 sites (4%) reported COVID-19 test time turnaround under 1 hour, and 15 (30%) reported turnaround in less than 6 hours. Of the 29 sites able to provide estimates of PPE stockpile, 14 (48%) reported a supply of 2 weeks or less. The most common approaches to PPE stewardship focused on reuse of masks and face shields if not obviously soiled, centralizing PPE distribution, and disinfecting or sterilizing masks. Ten sites (20%) were utilizing 3-D printed masks, while 10% used homemade face shields or masks.

Characteristics of COVID-19 RIUs

Forty-six hospitals (90% of all respondents) in our cohort had developed RIUs at the time of survey administration. The earliest RIU implementation date was February 10, 2020, and the most recent was launched on the day of our survey. Admission to RIUs was primarily based on clinical factors associated with known or suspected COVID-19 infection (Table 2). The number of non–critical care RIU beds among locations at that time ranged from 10 or less to more than 50. The mean number of hospitalist attendings caring for patients in the RIUs was 10.2, with a mean 4.1 advanced practice providers, 5.5 residents, and 0 medical students. The number of planned patients per attending was typically 5 to 15. Nurses and physicians typically rounded separately. Medical distancing (eg, reducing patient room entry) was accomplished most commonly by grouped timing of medication administration (76% of sites), video links to room outside of rounding times (54% of sites), the use of video or telemedicine during rounds (17%), and clustering of activities such as medication administration or phlebotomy. The most common criteria prompting discharge from the RIU were a negative COVID-19 test (59%) and hospital discharge (57%), though comments from many respondents suggested that discharge criteria were changing rapidly.

auerbach03660722e_t2.jpg

Effects of Isolation Measures on In-Room Encounters and Diagnostic Processes

More than 90% of sites reported decreases in in-room encounter frequency across all provider types whether as a result of policies in place or not. Reductions were reported among hospitalists, advanced practice providers, residents, consultants, and therapists (Table 3). Reduced room entry most often resulted from an established or developing policy, but many noted reduced room entry without formal policies in place. Nearly all sites reported moving specialty consultations to phone or video evaluations. Diagnostic error was commonly reported, with missed non–COVID-19 medical diagnoses among COVID-19 infected patients being reported by 22 sites (46%) and missed COVID-19 diagnoses in patients admitted for other reasons by 22 sites (45%).

auerbach03660722e_t3.jpg

In this study of medical wards at academic medical centers, we found that, in response to the COVID-19 pandemic, hospitals made several changes in a short period of time to adapt to the crisis. These included implementation and rapid expansion of dedicated RIUs, greatly expanded use of inpatient telehealth for patient assessments and consultation, implementation of other approaches to minimize room entry (such as grouping in-room activities), and deployment of ethics consultation services to help manage issues around potential scarcity of life-saving measures such as ventilators. We also found that availability of PPE and timely testing was limited. Finally, a large proportion of sites reported potential diagnostic problems in the assessment of both patients suspected and those not suspected of having COVID-19.

RIUs are emerging as a primary modality for caring for non-ICU COVID-19 patients, though they never involved medical students; we hope the role of students in particular will increase as new models of training emerge in response to the pandemic.⁷ In contrast, telemedicine evolved rapidly to hold a substantial role in RIUs, with both ward and specialty teams using video visit technology to communicate with patients. COVID-19 has been viewed as a perfect use case for outpatient telemedicine,⁸ and a growing number of studies are examining its outpatient use^9,10; however, to date, somewhat less attention has been paid to inpatient deployment. Although our data suggest telemedicine has found a prominent place in RIUs, it remains to be seen whether it is associated with differences in patient or provider outcomes. For example, deficiencies in the physical examination, limited face-to-face contact, and lack of physical presence could all affect the patient–provider relationship, patient engagement, and the accuracy of the diagnostic process.

Our data suggest the possibility of missing non–COVID-19 diagnoses in patients suspected of COVID-19 and missing COVID-19 in those admitted for nonrespiratory reasons. The latter may be addressed as routine COVID-19 screening of admitted patients becomes commonplace. For the former, however, it is possible that physicians are “anchoring” their thinking on COVID-19 to the exclusion of other diagnoses, that physicians are not fully aware of complications unique to COVID-19 infection (such as thromboembolism), and/or that the above-mentioned limitations of telemedicine have decreased diagnostic performance.

Although PPE stockpile data were not easily available for some sites, a distressingly large number reported stockpiles of 2 weeks or less, with reuse being the most common approach to extending PPE supply. We also found it concerning that 43% of hospital leaders did not know their stockpile data; we believe this is an important question that hospital leaders need to be asking. Most sites in our study reported test turnaround times of longer than 6 hours; lack of rapid COVID-19 testing further stresses PPE stockpile and may slow patients’ transition out of the RIU or discharge to home.

Our study has several limitations, including the evolving nature of the pandemic and rapid adaptations of care systems in the pandemic’s surge phase. However, we attempted to frame our questions in ways that provided a focused snapshot of care. Furthermore, respondents may not have had exhaustive knowledge of their institution’s COVID-19 response strategies, but most were the directors of their hospitalist services, and we encouraged the respondents to confer with others to gather high-fidelity data. Finally, as a survey of large academic medical centers, our results may not apply to nonacademic centers.

Approaches to caring for non-ICU patients during the COVID-19 pandemic are rapidly evolving. Expansion of RIUs and developing the workforce to support them has been a primary focus, with rapid innovation in use of technology emerging as a critical adaptation while PPE limitations persist and needs for “medical distancing” continue to grow. Although rates of missed COVID-19 diagnoses will likely be reduced with testing and systems improvements, physicians and systems will also need to consider how to utilize emerging technology in ways that can improve clinical care and provider safety while aiding diagnostic thinking. This survey illustrates the rapid adaptations made by our hospitals in response to the pandemic; ongoing adaptation will likely be needed to optimally care for hospitalized patients with COVID-19 while the pandemic continues to evolve.

Thanks to members of the HOMERuN COVID-19 Collaborative Group: Baylor Scott & White Medical Center – Temple, Texas - Tresa McNeal MD; Beth Israel Deaconess Medical Center - Shani Herzig MD MPH, Joseph Li MD, Julius Yang MD PhD; Brigham and Women’s Hospital - Christopher Roy MD, Jeffrey Schnipper MD MPH; Cedars-Sinai Medical Center - Ed Seferian MD, ; ChristianaCare - Surekha Bhamidipati MD; Cleveland Clinic - Matthew Pappas MD MPH; Dartmouth-Hitchcock Medical Center - Jonathan Lurie MD MS; Dell Medical School at The University of Texas at Austin - Chris Moriates MD, Luci Leykum MD MBA MSc; Denver Health and Hospitals Authority - Diana Mancini MD; Emory University Hospital - Dan Hunt MD; Johns Hopkins Hospital - Daniel J Brotman MD, Zishan K Siddiqui MD, Shaker Eid MD MBA; Maine Medical Center - Daniel A Meyer MD, Robert Trowbridge MD; Massachusetts General Hospital - Melissa Mattison MD; Mayo Clinic Rochester – Caroline Burton MD, Sagar Dugani MD PhD; Medical College of Wisconsin - Sanjay Bhandari MD; Miriam Hospital - Kwame Dapaah-Afriyie MD MBA; Mount Sinai Hospital - Andrew Dunn MD; NorthShore - David Lovinger MD; Northwestern Memorial Hospital - Kevin O’Leary MD MS; Ohio State University Wexner Medical Center - Eric Schumacher DO; Oregon Health & Science University - Angela Alday MD; Penn Medicine - Ryan Greysen MD MHS MA; Rutgers- Robert Wood Johnson University Hospital - Michael Steinberg MD MPH; Stanford University School of Medicine - Neera Ahuja MD; Tulane Hospital and University Medical Center - Geraldine Ménard MD; UC San Diego Health - Ian Jenkins MD; UC Los Angeles Health - Michael Lazarus MD, Magdalena E. Ptaszny, MD; UC San Francisco Health - Bradley A Sharpe, MD, Margaret Fang MD MPH; UK HealthCare - Mark Williams MD MHM, John Romond MD; University of Chicago – David Meltzer MD PhD, Gregory Ruhnke MD; University of Colorado - Marisha Burden MD; University of Florida - Nila Radhakrishnan MD; University of Iowa Hospitals and Clinics - Kevin Glenn MD MS; University of Miami - Efren Manjarrez MD; University of Michigan - Vineet Chopra MD MSc, Valerie Vaughn MD MSc; University of Missouri-Columbia Hospital - Hasan Naqvi MD; University of Nebraska Medical Center - Chad Vokoun MD; University of North Carolina at Chapel Hill - David Hemsey MD; University of Pittsburgh Medical Center - Gena Marie Walker MD; University of Vermont Medical Center - Steven Grant MD; University of Washington Medical Center - Christopher Kim MD MBA, Andrew White MD; University of Washington-Harborview Medical Center - Maralyssa Bann MD; University of Wisconsin Hospital and Clinics - David Sterken MD, Farah Kaiksow MD MPP, Ann Sheehy MD MS, Jordan Kenik MD MPH; UW Northwest Campus - Ben Wolpaw MD; Vanderbilt University Medical Center - Sunil Kripalani MD MSc, Eduard E Vasilevskis MD, Kathleene T Wooldridge MD MPH; Wake Forest Baptist Health - Erik Summers MD; Washington University St. Louis - Michael Lin MD; Weill Cornell - Justin Choi MD; Yale New Haven Hospital - William Cushing MA, Chris Sankey MD; Zuckerberg San Francisco General Hospital - Sumant Ranji MD.

The coronavirus disease of 2019 (COVID-19) pandemic has resulted in a surge in hospitalizations of patients with a novel, serious, and highly contagious infectious disease for which there is yet no proven treatment. Currently, much of the focus has been on intensive care unit (ICU) and ventilator capacity for the sickest of these patients who develop respiratory failure. However, most hospitalized patients are being cared for in general medical units.¹ Some evidence exists to describe adaptations to capacity needs outside of medical wards,^2-4 but few studies have specifically addressed the ward setting. Therefore, there is a pressing need for evidence to describe how to expand capacity and deliver medical ward–based care.

To better understand how inpatient care in the United States is adapting to the COVID-19 pandemic, we surveyed 72 sites participating in the Hospital Medicine Reengineering Network (HOMERuN), a national consortium of hospital medicine groups.⁵ We report results of this survey, carried out between April 3 and April 5, 2020.

Sites and Subjects

HOMERuN is a collaborative network of hospitalists from across the United States whose primary goal is to catalyze research and share best practices across hospital medicine groups. Using surveys of Hospital Medicine leaders, targeted medical record review, and other methods, HOMERuN’s funded research interests to date have included care transitions, workforce issues, patient and family engagement, and diagnostic errors. Sites participating in HOMERuN sites are relatively large urban academic medical centers (Appendix).

Survey Development and Deployment

We designed a focused survey that aimed to provide a snapshot of evolving operational and clinical aspects of COVID-19 care (Appendix). Domains included COVID-19 testing turnaround times, personal protective equipment (PPE) stewardship,⁶ features of respiratory isolation units (RIUs; ie, dedicated units for patients with known or suspected COVID-19), and observed effects on clinical care. We tested the instrument to ensure feasibility and clarity internally, performed brief cognitive testing with several hospital medicine leaders in HOMERuN, then disseminated the survey by email on April 3, with two follow-up emails on 2 subsequent days. Our study was deemed non–human subjects research by the University of California, San Francisco, Committee on Human Research. Descriptive statistics were used to characterize survey responses.

Of 72 hospitals surveyed, 51 (71%) responded. Mean hospital bed count was 940, three were safety-net hospitals, and one was a community-based teaching center; responding and nonresponding hospitals did not differ significantly in terms of bed count (Appendix).

Health System Adaptations, Testing, and PPE Status

Nearly all responding hospitals (46 of 51; 90%) had RIUs for patients with known or suspected COVID-19 (Table 1). Nearly all hospitals took steps to keep potentially sick healthcare providers from infecting others (eg, staying home if sick or exposed). Among respondents, 32% had rapid response teams, 24% had respiratory therapy teams, and 29% had case management teams that were dedicated to COVID-19 care. Thirty-two (63%) had developed models, such as ethics or palliative care consult services, to assist with difficult resource-allocation decisions (eg, how to prioritize ventilator use if demand exceeded supply). Twenty-three (45%) had developed post-acute care monitoring programs dedicated to COVID-19 patients.

auerbach03660722e_t1.jpg

At the time of our survey, only 2 sites (4%) reported COVID-19 test time turnaround under 1 hour, and 15 (30%) reported turnaround in less than 6 hours. Of the 29 sites able to provide estimates of PPE stockpile, 14 (48%) reported a supply of 2 weeks or less. The most common approaches to PPE stewardship focused on reuse of masks and face shields if not obviously soiled, centralizing PPE distribution, and disinfecting or sterilizing masks. Ten sites (20%) were utilizing 3-D printed masks, while 10% used homemade face shields or masks.

Characteristics of COVID-19 RIUs

Forty-six hospitals (90% of all respondents) in our cohort had developed RIUs at the time of survey administration. The earliest RIU implementation date was February 10, 2020, and the most recent was launched on the day of our survey. Admission to RIUs was primarily based on clinical factors associated with known or suspected COVID-19 infection (Table 2). The number of non–critical care RIU beds among locations at that time ranged from 10 or less to more than 50. The mean number of hospitalist attendings caring for patients in the RIUs was 10.2, with a mean 4.1 advanced practice providers, 5.5 residents, and 0 medical students. The number of planned patients per attending was typically 5 to 15. Nurses and physicians typically rounded separately. Medical distancing (eg, reducing patient room entry) was accomplished most commonly by grouped timing of medication administration (76% of sites), video links to room outside of rounding times (54% of sites), the use of video or telemedicine during rounds (17%), and clustering of activities such as medication administration or phlebotomy. The most common criteria prompting discharge from the RIU were a negative COVID-19 test (59%) and hospital discharge (57%), though comments from many respondents suggested that discharge criteria were changing rapidly.

auerbach03660722e_t2.jpg

Effects of Isolation Measures on In-Room Encounters and Diagnostic Processes

More than 90% of sites reported decreases in in-room encounter frequency across all provider types whether as a result of policies in place or not. Reductions were reported among hospitalists, advanced practice providers, residents, consultants, and therapists (Table 3). Reduced room entry most often resulted from an established or developing policy, but many noted reduced room entry without formal policies in place. Nearly all sites reported moving specialty consultations to phone or video evaluations. Diagnostic error was commonly reported, with missed non–COVID-19 medical diagnoses among COVID-19 infected patients being reported by 22 sites (46%) and missed COVID-19 diagnoses in patients admitted for other reasons by 22 sites (45%).

auerbach03660722e_t3.jpg

In this study of medical wards at academic medical centers, we found that, in response to the COVID-19 pandemic, hospitals made several changes in a short period of time to adapt to the crisis. These included implementation and rapid expansion of dedicated RIUs, greatly expanded use of inpatient telehealth for patient assessments and consultation, implementation of other approaches to minimize room entry (such as grouping in-room activities), and deployment of ethics consultation services to help manage issues around potential scarcity of life-saving measures such as ventilators. We also found that availability of PPE and timely testing was limited. Finally, a large proportion of sites reported potential diagnostic problems in the assessment of both patients suspected and those not suspected of having COVID-19.

RIUs are emerging as a primary modality for caring for non-ICU COVID-19 patients, though they never involved medical students; we hope the role of students in particular will increase as new models of training emerge in response to the pandemic.⁷ In contrast, telemedicine evolved rapidly to hold a substantial role in RIUs, with both ward and specialty teams using video visit technology to communicate with patients. COVID-19 has been viewed as a perfect use case for outpatient telemedicine,⁸ and a growing number of studies are examining its outpatient use^9,10; however, to date, somewhat less attention has been paid to inpatient deployment. Although our data suggest telemedicine has found a prominent place in RIUs, it remains to be seen whether it is associated with differences in patient or provider outcomes. For example, deficiencies in the physical examination, limited face-to-face contact, and lack of physical presence could all affect the patient–provider relationship, patient engagement, and the accuracy of the diagnostic process.

Our data suggest the possibility of missing non–COVID-19 diagnoses in patients suspected of COVID-19 and missing COVID-19 in those admitted for nonrespiratory reasons. The latter may be addressed as routine COVID-19 screening of admitted patients becomes commonplace. For the former, however, it is possible that physicians are “anchoring” their thinking on COVID-19 to the exclusion of other diagnoses, that physicians are not fully aware of complications unique to COVID-19 infection (such as thromboembolism), and/or that the above-mentioned limitations of telemedicine have decreased diagnostic performance.

Although PPE stockpile data were not easily available for some sites, a distressingly large number reported stockpiles of 2 weeks or less, with reuse being the most common approach to extending PPE supply. We also found it concerning that 43% of hospital leaders did not know their stockpile data; we believe this is an important question that hospital leaders need to be asking. Most sites in our study reported test turnaround times of longer than 6 hours; lack of rapid COVID-19 testing further stresses PPE stockpile and may slow patients’ transition out of the RIU or discharge to home.

Our study has several limitations, including the evolving nature of the pandemic and rapid adaptations of care systems in the pandemic’s surge phase. However, we attempted to frame our questions in ways that provided a focused snapshot of care. Furthermore, respondents may not have had exhaustive knowledge of their institution’s COVID-19 response strategies, but most were the directors of their hospitalist services, and we encouraged the respondents to confer with others to gather high-fidelity data. Finally, as a survey of large academic medical centers, our results may not apply to nonacademic centers.

Approaches to caring for non-ICU patients during the COVID-19 pandemic are rapidly evolving. Expansion of RIUs and developing the workforce to support them has been a primary focus, with rapid innovation in use of technology emerging as a critical adaptation while PPE limitations persist and needs for “medical distancing” continue to grow. Although rates of missed COVID-19 diagnoses will likely be reduced with testing and systems improvements, physicians and systems will also need to consider how to utilize emerging technology in ways that can improve clinical care and provider safety while aiding diagnostic thinking. This survey illustrates the rapid adaptations made by our hospitals in response to the pandemic; ongoing adaptation will likely be needed to optimally care for hospitalized patients with COVID-19 while the pandemic continues to evolve.

Thanks to members of the HOMERuN COVID-19 Collaborative Group: Baylor Scott & White Medical Center – Temple, Texas - Tresa McNeal MD; Beth Israel Deaconess Medical Center - Shani Herzig MD MPH, Joseph Li MD, Julius Yang MD PhD; Brigham and Women’s Hospital - Christopher Roy MD, Jeffrey Schnipper MD MPH; Cedars-Sinai Medical Center - Ed Seferian MD, ; ChristianaCare - Surekha Bhamidipati MD; Cleveland Clinic - Matthew Pappas MD MPH; Dartmouth-Hitchcock Medical Center - Jonathan Lurie MD MS; Dell Medical School at The University of Texas at Austin - Chris Moriates MD, Luci Leykum MD MBA MSc; Denver Health and Hospitals Authority - Diana Mancini MD; Emory University Hospital - Dan Hunt MD; Johns Hopkins Hospital - Daniel J Brotman MD, Zishan K Siddiqui MD, Shaker Eid MD MBA; Maine Medical Center - Daniel A Meyer MD, Robert Trowbridge MD; Massachusetts General Hospital - Melissa Mattison MD; Mayo Clinic Rochester – Caroline Burton MD, Sagar Dugani MD PhD; Medical College of Wisconsin - Sanjay Bhandari MD; Miriam Hospital - Kwame Dapaah-Afriyie MD MBA; Mount Sinai Hospital - Andrew Dunn MD; NorthShore - David Lovinger MD; Northwestern Memorial Hospital - Kevin O’Leary MD MS; Ohio State University Wexner Medical Center - Eric Schumacher DO; Oregon Health & Science University - Angela Alday MD; Penn Medicine - Ryan Greysen MD MHS MA; Rutgers- Robert Wood Johnson University Hospital - Michael Steinberg MD MPH; Stanford University School of Medicine - Neera Ahuja MD; Tulane Hospital and University Medical Center - Geraldine Ménard MD; UC San Diego Health - Ian Jenkins MD; UC Los Angeles Health - Michael Lazarus MD, Magdalena E. Ptaszny, MD; UC San Francisco Health - Bradley A Sharpe, MD, Margaret Fang MD MPH; UK HealthCare - Mark Williams MD MHM, John Romond MD; University of Chicago – David Meltzer MD PhD, Gregory Ruhnke MD; University of Colorado - Marisha Burden MD; University of Florida - Nila Radhakrishnan MD; University of Iowa Hospitals and Clinics - Kevin Glenn MD MS; University of Miami - Efren Manjarrez MD; University of Michigan - Vineet Chopra MD MSc, Valerie Vaughn MD MSc; University of Missouri-Columbia Hospital - Hasan Naqvi MD; University of Nebraska Medical Center - Chad Vokoun MD; University of North Carolina at Chapel Hill - David Hemsey MD; University of Pittsburgh Medical Center - Gena Marie Walker MD; University of Vermont Medical Center - Steven Grant MD; University of Washington Medical Center - Christopher Kim MD MBA, Andrew White MD; University of Washington-Harborview Medical Center - Maralyssa Bann MD; University of Wisconsin Hospital and Clinics - David Sterken MD, Farah Kaiksow MD MPP, Ann Sheehy MD MS, Jordan Kenik MD MPH; UW Northwest Campus - Ben Wolpaw MD; Vanderbilt University Medical Center - Sunil Kripalani MD MSc, Eduard E Vasilevskis MD, Kathleene T Wooldridge MD MPH; Wake Forest Baptist Health - Erik Summers MD; Washington University St. Louis - Michael Lin MD; Weill Cornell - Justin Choi MD; Yale New Haven Hospital - William Cushing MA, Chris Sankey MD; Zuckerberg San Francisco General Hospital - Sumant Ranji MD.

Avoiding repeated complete blood count (CBC) tests in the face of clinical and lab stability is a focus of the Choosing Wisely^® initiatives launched by the American Board of Internal Medicine Foundation¹ and endorsed by the Society of Hospital Medicine.² However, specific scenarios in which daily morning labs can be safely avoided have not been identified. The goal of this study was to identify situations in which routine CBC testing can be avoided in patients with community-acquired pneumonia (CAP), one of the most common reasons for hospital admission.³

This was a retrospective study of 50 patients with CAP discharged from our hospital between February 1, 2015 and May 1, 2015. We performed chart abstractions collecting daily vital signs, lab results, provider notes including assessments and plans (A&Ps), and order entry logs, as well as documentation indicating whether a lab result or clinical finding appeared to affect clinical management (eg, a new order or documentation of changing plans). Both escalations and de-escalations were included as management changes. For example, if the note stated “Persistent leukocytosis, add vancomycin,” then the clinical action of expanded antibiotic coverage would be attributed to the CBC.

We defined clinical stability based on Definition B of the Pneumonia Patient Outcomes Research Team (PORT) study criteria.⁴ We used descriptive statistics and likelihood ratios to characterize the utility of CBC testing in terms of producing clinical management changes. Likelihood ratios were calculated with the “test” representing a CBC being ordered or not ordered and the outcome being any change in management independent of whether it was due to the CBC.

Of 50 patients, 33 (66%) were female, the mean age was 75 years, the mean length of stay was 2.8 days, and the median CURB-65 score,⁵ an estimate of mortality in CAP used for decision-making about inpatient versus outpatient treatment, was 1 (25^th to 75^th interquartile range: 1, 2); no patients had a CURB score greater than 3 (Table 1). Forty-one (82%) patients met PORT clinical stability criteria prior to discharge, and 30 (75% of stable patients) had CBCs obtained.

jhm012050336_t1.jpg

On days after admission, 94 subsequent CBCs were obtained. Of these CBCs, 6 (6.4%) were associated with management changes indicated in documentation or orders (Table 2). In 2 of the 6 patients, management changes were likely relevant to pneumonia. In the first case, the patient had a white blood cell count (WBC) of 15.4 on the planned day of discharge but no accompanying clinical changes. Her discharge was potentially delayed pending a repeat CBC which again showed a WBC 14.7; the patient was then discharged without any additional changes in plan. In the second case, the patient experienced new-onset altered mental status on hospital day 3 and increasing O₂ requirement with a rising WBC noted on hospital day 4. Repeat chest x-ray, repeat blood cultures, and an ultrasound for parapneumonic effusion were obtained, and the patient’s symptoms and signs resolved over a period of days without changes in treatment. In the 4 other cases, available documentation suggested the hemoglobin abnormalities found represented chronic or incidental illnesses, specifically iron deficiency anemia, iatrogenic anemia due to fluid resuscitation and hemodilution, previously known chronic lymphocytic leukemia, and thrombocytopenia due to acute infection. In all 6 instances, CBC values improved without treatment intervention.

jhm012050336_t2.jpg

Though small, our initial study suggests the potential opportunity for savings if Choosing Wisely^® recommendations for CBC testing were implemented in patients with community-acquired pneumonia.

Our study has several limitations. Note-writing practices and ordering patterns likely varied between providers, and documentation bias may play a role in our results. However, we defined whether a CBC was associated with changes in clinical decision-making or management by incorporating a number of mutually reinforcing elements of the medical record. We recognize, however, that our approach may not capture undocumented clinical issues or other cognitive (eg, reassurance of clinical resolution) reasons why CBCs were obtained.

Even with these limitations, the likelihood of a CBC value meaningfully changing clinical management among patients with CAP appears to be quite low as evidenced by the case descriptions, particularly when obtained in stable patients by PORT criteria and on the day of discharge. Whether clinical stability as measured by PORT score can be used to target patients in whom CBC testing is unnecessary is difficult to discern from our data, as the overall utility of CBCs obtained after admission was quite low and the rate of changes in management was also low. However, even if CBCs are not particularly costly, unnecessary testing may produce harm in the form of prolonged length of stay, making even one unnecessary CBC potentially extremely expensive. More research involving larger-scale studies are needed to determine the “number needed to screen” for the daily CBC in CAP to determine if the cost savings from overtesting and treatment outweigh the potential benefit of a single CBC that changes management.

Disclosure

Nothing to report.

Avoiding repeated complete blood count (CBC) tests in the face of clinical and lab stability is a focus of the Choosing Wisely^® initiatives launched by the American Board of Internal Medicine Foundation¹ and endorsed by the Society of Hospital Medicine.² However, specific scenarios in which daily morning labs can be safely avoided have not been identified. The goal of this study was to identify situations in which routine CBC testing can be avoided in patients with community-acquired pneumonia (CAP), one of the most common reasons for hospital admission.³

This was a retrospective study of 50 patients with CAP discharged from our hospital between February 1, 2015 and May 1, 2015. We performed chart abstractions collecting daily vital signs, lab results, provider notes including assessments and plans (A&Ps), and order entry logs, as well as documentation indicating whether a lab result or clinical finding appeared to affect clinical management (eg, a new order or documentation of changing plans). Both escalations and de-escalations were included as management changes. For example, if the note stated “Persistent leukocytosis, add vancomycin,” then the clinical action of expanded antibiotic coverage would be attributed to the CBC.

We defined clinical stability based on Definition B of the Pneumonia Patient Outcomes Research Team (PORT) study criteria.⁴ We used descriptive statistics and likelihood ratios to characterize the utility of CBC testing in terms of producing clinical management changes. Likelihood ratios were calculated with the “test” representing a CBC being ordered or not ordered and the outcome being any change in management independent of whether it was due to the CBC.

Of 50 patients, 33 (66%) were female, the mean age was 75 years, the mean length of stay was 2.8 days, and the median CURB-65 score,⁵ an estimate of mortality in CAP used for decision-making about inpatient versus outpatient treatment, was 1 (25^th to 75^th interquartile range: 1, 2); no patients had a CURB score greater than 3 (Table 1). Forty-one (82%) patients met PORT clinical stability criteria prior to discharge, and 30 (75% of stable patients) had CBCs obtained.

jhm012050336_t1.jpg

On days after admission, 94 subsequent CBCs were obtained. Of these CBCs, 6 (6.4%) were associated with management changes indicated in documentation or orders (Table 2). In 2 of the 6 patients, management changes were likely relevant to pneumonia. In the first case, the patient had a white blood cell count (WBC) of 15.4 on the planned day of discharge but no accompanying clinical changes. Her discharge was potentially delayed pending a repeat CBC which again showed a WBC 14.7; the patient was then discharged without any additional changes in plan. In the second case, the patient experienced new-onset altered mental status on hospital day 3 and increasing O₂ requirement with a rising WBC noted on hospital day 4. Repeat chest x-ray, repeat blood cultures, and an ultrasound for parapneumonic effusion were obtained, and the patient’s symptoms and signs resolved over a period of days without changes in treatment. In the 4 other cases, available documentation suggested the hemoglobin abnormalities found represented chronic or incidental illnesses, specifically iron deficiency anemia, iatrogenic anemia due to fluid resuscitation and hemodilution, previously known chronic lymphocytic leukemia, and thrombocytopenia due to acute infection. In all 6 instances, CBC values improved without treatment intervention.

jhm012050336_t2.jpg

Though small, our initial study suggests the potential opportunity for savings if Choosing Wisely^® recommendations for CBC testing were implemented in patients with community-acquired pneumonia.

Our study has several limitations. Note-writing practices and ordering patterns likely varied between providers, and documentation bias may play a role in our results. However, we defined whether a CBC was associated with changes in clinical decision-making or management by incorporating a number of mutually reinforcing elements of the medical record. We recognize, however, that our approach may not capture undocumented clinical issues or other cognitive (eg, reassurance of clinical resolution) reasons why CBCs were obtained.

Even with these limitations, the likelihood of a CBC value meaningfully changing clinical management among patients with CAP appears to be quite low as evidenced by the case descriptions, particularly when obtained in stable patients by PORT criteria and on the day of discharge. Whether clinical stability as measured by PORT score can be used to target patients in whom CBC testing is unnecessary is difficult to discern from our data, as the overall utility of CBCs obtained after admission was quite low and the rate of changes in management was also low. However, even if CBCs are not particularly costly, unnecessary testing may produce harm in the form of prolonged length of stay, making even one unnecessary CBC potentially extremely expensive. More research involving larger-scale studies are needed to determine the “number needed to screen” for the daily CBC in CAP to determine if the cost savings from overtesting and treatment outweigh the potential benefit of a single CBC that changes management.

Disclosure

Nothing to report.

Avoiding repeated complete blood count (CBC) tests in the face of clinical and lab stability is a focus of the Choosing Wisely^® initiatives launched by the American Board of Internal Medicine Foundation¹ and endorsed by the Society of Hospital Medicine.² However, specific scenarios in which daily morning labs can be safely avoided have not been identified. The goal of this study was to identify situations in which routine CBC testing can be avoided in patients with community-acquired pneumonia (CAP), one of the most common reasons for hospital admission.³

This was a retrospective study of 50 patients with CAP discharged from our hospital between February 1, 2015 and May 1, 2015. We performed chart abstractions collecting daily vital signs, lab results, provider notes including assessments and plans (A&Ps), and order entry logs, as well as documentation indicating whether a lab result or clinical finding appeared to affect clinical management (eg, a new order or documentation of changing plans). Both escalations and de-escalations were included as management changes. For example, if the note stated “Persistent leukocytosis, add vancomycin,” then the clinical action of expanded antibiotic coverage would be attributed to the CBC.

We defined clinical stability based on Definition B of the Pneumonia Patient Outcomes Research Team (PORT) study criteria.⁴ We used descriptive statistics and likelihood ratios to characterize the utility of CBC testing in terms of producing clinical management changes. Likelihood ratios were calculated with the “test” representing a CBC being ordered or not ordered and the outcome being any change in management independent of whether it was due to the CBC.

Of 50 patients, 33 (66%) were female, the mean age was 75 years, the mean length of stay was 2.8 days, and the median CURB-65 score,⁵ an estimate of mortality in CAP used for decision-making about inpatient versus outpatient treatment, was 1 (25^th to 75^th interquartile range: 1, 2); no patients had a CURB score greater than 3 (Table 1). Forty-one (82%) patients met PORT clinical stability criteria prior to discharge, and 30 (75% of stable patients) had CBCs obtained.

jhm012050336_t1.jpg

On days after admission, 94 subsequent CBCs were obtained. Of these CBCs, 6 (6.4%) were associated with management changes indicated in documentation or orders (Table 2). In 2 of the 6 patients, management changes were likely relevant to pneumonia. In the first case, the patient had a white blood cell count (WBC) of 15.4 on the planned day of discharge but no accompanying clinical changes. Her discharge was potentially delayed pending a repeat CBC which again showed a WBC 14.7; the patient was then discharged without any additional changes in plan. In the second case, the patient experienced new-onset altered mental status on hospital day 3 and increasing O₂ requirement with a rising WBC noted on hospital day 4. Repeat chest x-ray, repeat blood cultures, and an ultrasound for parapneumonic effusion were obtained, and the patient’s symptoms and signs resolved over a period of days without changes in treatment. In the 4 other cases, available documentation suggested the hemoglobin abnormalities found represented chronic or incidental illnesses, specifically iron deficiency anemia, iatrogenic anemia due to fluid resuscitation and hemodilution, previously known chronic lymphocytic leukemia, and thrombocytopenia due to acute infection. In all 6 instances, CBC values improved without treatment intervention.

jhm012050336_t2.jpg

Though small, our initial study suggests the potential opportunity for savings if Choosing Wisely^® recommendations for CBC testing were implemented in patients with community-acquired pneumonia.

Our study has several limitations. Note-writing practices and ordering patterns likely varied between providers, and documentation bias may play a role in our results. However, we defined whether a CBC was associated with changes in clinical decision-making or management by incorporating a number of mutually reinforcing elements of the medical record. We recognize, however, that our approach may not capture undocumented clinical issues or other cognitive (eg, reassurance of clinical resolution) reasons why CBCs were obtained.

Even with these limitations, the likelihood of a CBC value meaningfully changing clinical management among patients with CAP appears to be quite low as evidenced by the case descriptions, particularly when obtained in stable patients by PORT criteria and on the day of discharge. Whether clinical stability as measured by PORT score can be used to target patients in whom CBC testing is unnecessary is difficult to discern from our data, as the overall utility of CBCs obtained after admission was quite low and the rate of changes in management was also low. However, even if CBCs are not particularly costly, unnecessary testing may produce harm in the form of prolonged length of stay, making even one unnecessary CBC potentially extremely expensive. More research involving larger-scale studies are needed to determine the “number needed to screen” for the daily CBC in CAP to determine if the cost savings from overtesting and treatment outweigh the potential benefit of a single CBC that changes management.

Disclosure

Nothing to report.

Recent publications in the medical literature and lay press have stirred controversy regarding the use of inpatient ‘very important person’ (VIP) services.^1-3 The term “VIP services” often refers to select conveniences offered in addition to the assumed basic level of care and services provided by a hospital. Examples include additional space, enhanced facilities, specific comforts, or personal support. In some instances, these amenities may only be provided to patients who have close financial, social, or professional relationships with the hospital.

How VIP patients interact with their health system to obtain VIP services has raised unique concerns. Some have speculated that the presence of a VIP patient may be disruptive to the care of non-VIP patients, while others have cautioned physicians about potential dangers to the VIP patients themselves.^4-6 Despite much being written on the topics of VIP patients and services in both the lay and academic press, our literature review identified only 1 study on the topic, which cataloged the preferential treatment of VIP patients in the emergency department.⁶ We are unaware of any investigations of VIP-service use in the inpatient setting. Through a multisite survey of hospital medicine physicians, we assessed physician viewpoints and behavior regarding VIP services.

The Hospital Medicine Reengineering Network (HOMERuN) is a nation-wide learning organization focused on measuring and improving the outcomes of hospitalized patients.⁷ We surveyed hospitalists from 8 HOMERuN hospitals (Appendix 1). The survey instrument contained 4 sections: nonidentifying respondent demographics, local use of VIP services, reported physician perceptions of VIP services, and case-based assessments (Appendix 2). Survey questions and individual cases were developed by study authors and based on real scenarios and concerns provided by front-line clinical providers. Content, length, and reliability of physician understanding were assessed by a 5-person focus group consisting of physicians not included in the survey population.

Subjects were identified via administrative rosters from each HOMERuN site. Surveys were administered via SurveyMonkey, and results were analyzed descriptively. Populations were compared via the Fisher exact test. “VIP services” were defined as conveniences provided in addition to the assumed basic level of care and services (eg, private or luxury-style rooms, access to a special menu, better views, dedicated personal care attendants, hospital liaisons). VIP patients were defined as those patients receiving VIP services. A hospital was identified as providing VIP services if 50% or more of respondents from that site reported the presence of VIP services.

jhm012030177_t1.jpg

Of 366 hospitalists contacted, 160 completed the survey (44%). Respondent characteristics and reported prevalence of VIP services are demonstrated in Table 1. In total, 78 respondents (45%) reported the presence of VIP services at their hospital. Of the 8 sites surveyed, a majority of physicians at 4 sites (50%) reported presence of VIP services.

Of respondents reporting the presence of VIP services at their hospital, a majority felt that, from a patient safety perspective, the care received by VIP patients was the same as care received by non-VIP patients (Table 2). A majority reported they had felt pressured by a VIP patient or a family member to order additional tests or treatments that the physician believed were medically unnecessary and that they would be more likely to comply with VIP patient’s requests for tests or treatments they felt were unnecessary. More than one-third (36%) felt pressured by other hospital employees or representatives to comply with VIP services patient’s requests for additional tests or treatments that the physicians believed were medically unnecessary.

jhm012030177_t2.jpg

In our study, a majority of physicians who reported the presence of VIP services at their hospital felt pressured by VIP patients or their family members to perform unnecessary testing or treatment. While this study was not designed to quantify the burden of unnecessary care for VIP patients, our results have implications for individual patients and public health, including potential effects on resource availability, the identification of clinically irrelevant incidental findings, and short- and long-term medical complications of procedures, testing and radiation exposure.

Prior publications have advocated that physicians and hospitals should not allow VIP status to influence management decisions.^3,5 We found that more than one-third of physicians who reported the presence of VIP services at their hospital also reported receiving pressure from hospital representatives to provide care to VIP patients that was not medically indicated. These findings highlight an example of the tension faced by physicians who are caught between patient requests and the delivery of value-based care. This potential conflict may be amplified particularly for those patients with close financial, social, or professional ties to the hospitals (and physicians) providing their care. These results suggest the need for physicians, administrators, and patients to work together to address the potential blurring of ethical boundaries created by VIP relationships. Prevention of harm and avoidance of placing physicians in morally distressing situations are common goals for all involved parties.

Efforts to reduce unnecessary care have predominantly focused on structural and knowledge-based drivers.^4,8,9 Our results highlight the presence of additional forces. A majority of physician respondents who reported the presence of VIP services at their hospital also reported that they would be more likely to comply with requests for unnecessary care for a VIP patient as compared to a non-VIP patient. Furthermore, in case-based questions about the requests of a VIP patient and their family for additional unnecessary care, a significant portion of physicians who reported they would comply with these requests listed the VIP status of the patient or family as a factor underlying this decision. Only a minority of physicians reported their decision to provide additional care was the result of their own medically-based concerns. Because these cases were hypothetical and we did not include comparator cases involving non-VIP patients, it remains uncertain whether the observed perceptions accurately reflect real-world differences in the care of VIP and non-VIP patients. Nonetheless, our findings emphasize the importance of better understanding the social drivers of overuse and physician communication strategies related to medically inappropriate tests.^10,11

Demand for unnecessary testing may be driven by the mentality that “more is better.”¹² Contrary to this belief, provision of unnecessary care can increase the risk of patient harm.¹³ Despite physician respondents reporting that VIP patients requested and/or received additional unnecessary care, a majority of respondents felt that patient safety for VIP patients was equivalent to that for non-VIP patients. As we assessed only physician perceptions of safety, which may not necessarily correlate with actual safety, further research in this area is needed.

Our study was limited by several factors. While our study population included hospitalists from 8 geographically broad hospitals, including university, safety net, and community hospitals, study responses may not be reflective of nationwide trends. Our response rate may limit our ability to generalize conclusions beyond respondents. Second, our study captured physician perceptions of behavior and safety rather than actually measuring practice and outcomes. Studies comparing physician practice patterns and outcomes between VIP and non-VIP patients would be informative. Additionally, despite our inclusive survey design process, our survey was not validated, and it is possible that our questions were not interpreted as intended. Lastly, despite the anonymous nature of our survey, physicians may have felt compelled to respond in a particular way due to conflicting professional, financial, or social factors.

Our findings provide initial insight into how care for the VIP patient may present unique challenges for physicians, hospitals, and society by systematizing care inequities, as well as potentially incentivizing low-value care practices. Whether these imbalances produce clinical harms or benefits remains worthy of future studies.

Disclosure

Nothing to report.

Recent publications in the medical literature and lay press have stirred controversy regarding the use of inpatient ‘very important person’ (VIP) services.^1-3 The term “VIP services” often refers to select conveniences offered in addition to the assumed basic level of care and services provided by a hospital. Examples include additional space, enhanced facilities, specific comforts, or personal support. In some instances, these amenities may only be provided to patients who have close financial, social, or professional relationships with the hospital.

How VIP patients interact with their health system to obtain VIP services has raised unique concerns. Some have speculated that the presence of a VIP patient may be disruptive to the care of non-VIP patients, while others have cautioned physicians about potential dangers to the VIP patients themselves.^4-6 Despite much being written on the topics of VIP patients and services in both the lay and academic press, our literature review identified only 1 study on the topic, which cataloged the preferential treatment of VIP patients in the emergency department.⁶ We are unaware of any investigations of VIP-service use in the inpatient setting. Through a multisite survey of hospital medicine physicians, we assessed physician viewpoints and behavior regarding VIP services.

The Hospital Medicine Reengineering Network (HOMERuN) is a nation-wide learning organization focused on measuring and improving the outcomes of hospitalized patients.⁷ We surveyed hospitalists from 8 HOMERuN hospitals (Appendix 1). The survey instrument contained 4 sections: nonidentifying respondent demographics, local use of VIP services, reported physician perceptions of VIP services, and case-based assessments (Appendix 2). Survey questions and individual cases were developed by study authors and based on real scenarios and concerns provided by front-line clinical providers. Content, length, and reliability of physician understanding were assessed by a 5-person focus group consisting of physicians not included in the survey population.

Subjects were identified via administrative rosters from each HOMERuN site. Surveys were administered via SurveyMonkey, and results were analyzed descriptively. Populations were compared via the Fisher exact test. “VIP services” were defined as conveniences provided in addition to the assumed basic level of care and services (eg, private or luxury-style rooms, access to a special menu, better views, dedicated personal care attendants, hospital liaisons). VIP patients were defined as those patients receiving VIP services. A hospital was identified as providing VIP services if 50% or more of respondents from that site reported the presence of VIP services.

jhm012030177_t1.jpg

Of 366 hospitalists contacted, 160 completed the survey (44%). Respondent characteristics and reported prevalence of VIP services are demonstrated in Table 1. In total, 78 respondents (45%) reported the presence of VIP services at their hospital. Of the 8 sites surveyed, a majority of physicians at 4 sites (50%) reported presence of VIP services.

Of respondents reporting the presence of VIP services at their hospital, a majority felt that, from a patient safety perspective, the care received by VIP patients was the same as care received by non-VIP patients (Table 2). A majority reported they had felt pressured by a VIP patient or a family member to order additional tests or treatments that the physician believed were medically unnecessary and that they would be more likely to comply with VIP patient’s requests for tests or treatments they felt were unnecessary. More than one-third (36%) felt pressured by other hospital employees or representatives to comply with VIP services patient’s requests for additional tests or treatments that the physicians believed were medically unnecessary.

jhm012030177_t2.jpg

In our study, a majority of physicians who reported the presence of VIP services at their hospital felt pressured by VIP patients or their family members to perform unnecessary testing or treatment. While this study was not designed to quantify the burden of unnecessary care for VIP patients, our results have implications for individual patients and public health, including potential effects on resource availability, the identification of clinically irrelevant incidental findings, and short- and long-term medical complications of procedures, testing and radiation exposure.

Prior publications have advocated that physicians and hospitals should not allow VIP status to influence management decisions.^3,5 We found that more than one-third of physicians who reported the presence of VIP services at their hospital also reported receiving pressure from hospital representatives to provide care to VIP patients that was not medically indicated. These findings highlight an example of the tension faced by physicians who are caught between patient requests and the delivery of value-based care. This potential conflict may be amplified particularly for those patients with close financial, social, or professional ties to the hospitals (and physicians) providing their care. These results suggest the need for physicians, administrators, and patients to work together to address the potential blurring of ethical boundaries created by VIP relationships. Prevention of harm and avoidance of placing physicians in morally distressing situations are common goals for all involved parties.

Efforts to reduce unnecessary care have predominantly focused on structural and knowledge-based drivers.^4,8,9 Our results highlight the presence of additional forces. A majority of physician respondents who reported the presence of VIP services at their hospital also reported that they would be more likely to comply with requests for unnecessary care for a VIP patient as compared to a non-VIP patient. Furthermore, in case-based questions about the requests of a VIP patient and their family for additional unnecessary care, a significant portion of physicians who reported they would comply with these requests listed the VIP status of the patient or family as a factor underlying this decision. Only a minority of physicians reported their decision to provide additional care was the result of their own medically-based concerns. Because these cases were hypothetical and we did not include comparator cases involving non-VIP patients, it remains uncertain whether the observed perceptions accurately reflect real-world differences in the care of VIP and non-VIP patients. Nonetheless, our findings emphasize the importance of better understanding the social drivers of overuse and physician communication strategies related to medically inappropriate tests.^10,11

Demand for unnecessary testing may be driven by the mentality that “more is better.”¹² Contrary to this belief, provision of unnecessary care can increase the risk of patient harm.¹³ Despite physician respondents reporting that VIP patients requested and/or received additional unnecessary care, a majority of respondents felt that patient safety for VIP patients was equivalent to that for non-VIP patients. As we assessed only physician perceptions of safety, which may not necessarily correlate with actual safety, further research in this area is needed.

Our study was limited by several factors. While our study population included hospitalists from 8 geographically broad hospitals, including university, safety net, and community hospitals, study responses may not be reflective of nationwide trends. Our response rate may limit our ability to generalize conclusions beyond respondents. Second, our study captured physician perceptions of behavior and safety rather than actually measuring practice and outcomes. Studies comparing physician practice patterns and outcomes between VIP and non-VIP patients would be informative. Additionally, despite our inclusive survey design process, our survey was not validated, and it is possible that our questions were not interpreted as intended. Lastly, despite the anonymous nature of our survey, physicians may have felt compelled to respond in a particular way due to conflicting professional, financial, or social factors.

Our findings provide initial insight into how care for the VIP patient may present unique challenges for physicians, hospitals, and society by systematizing care inequities, as well as potentially incentivizing low-value care practices. Whether these imbalances produce clinical harms or benefits remains worthy of future studies.

Disclosure

Nothing to report.

Recent publications in the medical literature and lay press have stirred controversy regarding the use of inpatient ‘very important person’ (VIP) services.^1-3 The term “VIP services” often refers to select conveniences offered in addition to the assumed basic level of care and services provided by a hospital. Examples include additional space, enhanced facilities, specific comforts, or personal support. In some instances, these amenities may only be provided to patients who have close financial, social, or professional relationships with the hospital.

How VIP patients interact with their health system to obtain VIP services has raised unique concerns. Some have speculated that the presence of a VIP patient may be disruptive to the care of non-VIP patients, while others have cautioned physicians about potential dangers to the VIP patients themselves.^4-6 Despite much being written on the topics of VIP patients and services in both the lay and academic press, our literature review identified only 1 study on the topic, which cataloged the preferential treatment of VIP patients in the emergency department.⁶ We are unaware of any investigations of VIP-service use in the inpatient setting. Through a multisite survey of hospital medicine physicians, we assessed physician viewpoints and behavior regarding VIP services.

The Hospital Medicine Reengineering Network (HOMERuN) is a nation-wide learning organization focused on measuring and improving the outcomes of hospitalized patients.⁷ We surveyed hospitalists from 8 HOMERuN hospitals (Appendix 1). The survey instrument contained 4 sections: nonidentifying respondent demographics, local use of VIP services, reported physician perceptions of VIP services, and case-based assessments (Appendix 2). Survey questions and individual cases were developed by study authors and based on real scenarios and concerns provided by front-line clinical providers. Content, length, and reliability of physician understanding were assessed by a 5-person focus group consisting of physicians not included in the survey population.

Subjects were identified via administrative rosters from each HOMERuN site. Surveys were administered via SurveyMonkey, and results were analyzed descriptively. Populations were compared via the Fisher exact test. “VIP services” were defined as conveniences provided in addition to the assumed basic level of care and services (eg, private or luxury-style rooms, access to a special menu, better views, dedicated personal care attendants, hospital liaisons). VIP patients were defined as those patients receiving VIP services. A hospital was identified as providing VIP services if 50% or more of respondents from that site reported the presence of VIP services.

jhm012030177_t1.jpg

Of 366 hospitalists contacted, 160 completed the survey (44%). Respondent characteristics and reported prevalence of VIP services are demonstrated in Table 1. In total, 78 respondents (45%) reported the presence of VIP services at their hospital. Of the 8 sites surveyed, a majority of physicians at 4 sites (50%) reported presence of VIP services.

Of respondents reporting the presence of VIP services at their hospital, a majority felt that, from a patient safety perspective, the care received by VIP patients was the same as care received by non-VIP patients (Table 2). A majority reported they had felt pressured by a VIP patient or a family member to order additional tests or treatments that the physician believed were medically unnecessary and that they would be more likely to comply with VIP patient’s requests for tests or treatments they felt were unnecessary. More than one-third (36%) felt pressured by other hospital employees or representatives to comply with VIP services patient’s requests for additional tests or treatments that the physicians believed were medically unnecessary.

jhm012030177_t2.jpg

In our study, a majority of physicians who reported the presence of VIP services at their hospital felt pressured by VIP patients or their family members to perform unnecessary testing or treatment. While this study was not designed to quantify the burden of unnecessary care for VIP patients, our results have implications for individual patients and public health, including potential effects on resource availability, the identification of clinically irrelevant incidental findings, and short- and long-term medical complications of procedures, testing and radiation exposure.

Prior publications have advocated that physicians and hospitals should not allow VIP status to influence management decisions.^3,5 We found that more than one-third of physicians who reported the presence of VIP services at their hospital also reported receiving pressure from hospital representatives to provide care to VIP patients that was not medically indicated. These findings highlight an example of the tension faced by physicians who are caught between patient requests and the delivery of value-based care. This potential conflict may be amplified particularly for those patients with close financial, social, or professional ties to the hospitals (and physicians) providing their care. These results suggest the need for physicians, administrators, and patients to work together to address the potential blurring of ethical boundaries created by VIP relationships. Prevention of harm and avoidance of placing physicians in morally distressing situations are common goals for all involved parties.

Efforts to reduce unnecessary care have predominantly focused on structural and knowledge-based drivers.^4,8,9 Our results highlight the presence of additional forces. A majority of physician respondents who reported the presence of VIP services at their hospital also reported that they would be more likely to comply with requests for unnecessary care for a VIP patient as compared to a non-VIP patient. Furthermore, in case-based questions about the requests of a VIP patient and their family for additional unnecessary care, a significant portion of physicians who reported they would comply with these requests listed the VIP status of the patient or family as a factor underlying this decision. Only a minority of physicians reported their decision to provide additional care was the result of their own medically-based concerns. Because these cases were hypothetical and we did not include comparator cases involving non-VIP patients, it remains uncertain whether the observed perceptions accurately reflect real-world differences in the care of VIP and non-VIP patients. Nonetheless, our findings emphasize the importance of better understanding the social drivers of overuse and physician communication strategies related to medically inappropriate tests.^10,11

Demand for unnecessary testing may be driven by the mentality that “more is better.”¹² Contrary to this belief, provision of unnecessary care can increase the risk of patient harm.¹³ Despite physician respondents reporting that VIP patients requested and/or received additional unnecessary care, a majority of respondents felt that patient safety for VIP patients was equivalent to that for non-VIP patients. As we assessed only physician perceptions of safety, which may not necessarily correlate with actual safety, further research in this area is needed.

Our study was limited by several factors. While our study population included hospitalists from 8 geographically broad hospitals, including university, safety net, and community hospitals, study responses may not be reflective of nationwide trends. Our response rate may limit our ability to generalize conclusions beyond respondents. Second, our study captured physician perceptions of behavior and safety rather than actually measuring practice and outcomes. Studies comparing physician practice patterns and outcomes between VIP and non-VIP patients would be informative. Additionally, despite our inclusive survey design process, our survey was not validated, and it is possible that our questions were not interpreted as intended. Lastly, despite the anonymous nature of our survey, physicians may have felt compelled to respond in a particular way due to conflicting professional, financial, or social factors.

Our findings provide initial insight into how care for the VIP patient may present unique challenges for physicians, hospitals, and society by systematizing care inequities, as well as potentially incentivizing low-value care practices. Whether these imbalances produce clinical harms or benefits remains worthy of future studies.

Disclosure

Nothing to report.