With the COVID-19 pandemic top of mind all over the world, healthcare providers are doing everything they can to provide care to patients while at the same time try to ensure safety for staff.
One such example is Northwell Health, a 23 hospital system comprised of both tertiary and community hospitals in New York that spans over five boroughs and three counties with a catchment area of three million people. By early April, Northwell Health had approximately 2,804 confirmed positive cases of COVID-19 across its network. With numbers changing daily, Northwell Health estimates that approximately 25% of COVID-19 positive patients were in the ICU with approximately two-thirds (88%) of those patients on ventilators in Acute Respiratory Distress Syndrome (ARDS). Northwell Health has an extensive TeleHealth program so that it is able to gather data in every one of its ICUs and it has an established acute lung injury center that includes VV ECMO programs for respiratory distress, commonly associated with COVID-19 cases.
Northwell’s Saurabh Chandra, MD, PhD, Medical Director of Telehealth Services, and Iris Berman, RN, MSN, CCRN-K, VP of TeleHealth, share their team’s insight and experience on the COVID-19 pandemic situation to date and detail how they are using TeleHealth solutions to design virtual care strategies to combat it.
Q1: We are all hyper alert to the status updates on COVID-19 but can you give us a brief situational overview as a healthcare provider to the crisis at hand?
It’s a rapidly changing situation of course but, we can share the key facts that make CoVID-19 so alarming for healthcare providers. While the estimated mortality rate of COVID-19 is lower (3-4%) than past similar life-threating respiratory viruses such as Severe Acute Respiratory Syndrome (SARS) or Middle East Respiratory Syndrome (MERS) which were approximately 10% and 20% respectively, the contagiousness of COVID-19 is much, much higher. It’s the combination of the two that makes it so difficult to control, anticipate how bad it will get or try to determine when exactly it will end.
At the same time, much is unknown about COVID-19 and uncertainty is difficult to prepare for or align hospital resources against. Combined with that, our data tracking the outbreak can be inaccurate or underestimated because thousands of unsuspected cases are yet to be confirmed with tests (because testing is so difficult) and others with the virus may not have sought medical attention. Right now, we know that 180 countries globally already have the virus. In the U.S., we estimate that over 200 million Americans will get this virus at some point in time and a vaccine is about a year away.
The priority now is to slow down the spread of COVID-19 so we don’t overwhelm our healthcare systems, our ventilator capacities, our critical care capacities. This is of paramount importance to ensure quality care and safety of our patients and staff through this pandemic.
Q2: What is the potential impact of the coronavirus on critical care resources in particular? Can you explain why concerns are so high for the ICU?
Concerns are high because when we look at published data on past pandemic models, it’s been estimated consistently that about 25 to 30% of patients will require critical care. When we assess the number of critical care beds available in the United States with the expected rise of cases and with the average duration of intubation in CoVID-19 (greater than 10 days) for patients in the ICU, the best case scenario is that we will have less than half the expected need for ICU beds. The availability of ventilators is another key concern. Estimates for patients that would require ventilators with CoVID-19 ranges widely from 10 to 50%. In a moderate model, we could see an appropriate match but, more realistic or severe models indicate that we could potentially see a massive gap.
Additionally, even with conservative modeling of safe 12:1 patient-to-doctor ratios, there’s a mismatch. This creates alarming concern for not only patient quality and safety but also increases the moral burden and burnout of our teams exponentially. Based on the current American Health Association (AHA) COVID-19 model, only 51% of ICU beds are predicted to be safely staffed with only 13% of the required ventilators. And, this model assumes that everyone can work and only 25% of patients require a ventilator. However, there is a risk that more than 20 percent of our team members will be unable to work and more than 25 percent of patients will require a ventilator. At current state, if that becomes the case, it would outstrip our resources.
Q3: In what ways are you leveraging TeleHealth in the ICU for the COVID-19 pandemic? What might other healthcare providers learn from your experience?
Northwell Health started its TeleHealth program in 2014 with services that include: TeleICU; TeleStroke; TeleSNF; TeleHospitalist; pediatric, neuro and trauma critical care consultation; and, TelePsychiatry. It was a huge benefit for us as a healthcare provider to have an established and extensive TeleHealth network in place before going into this crisis. We have one of the largest cohorts of patients in the NY area so it gives us the ability to quickly combine experiences from many hospitals to get ahead of the learning curve and allows us to leverage TeleHealth in a unique manner.
We are using Telehealth strategies to not only care for patients but also our own healthcare providers in our system. These include: expanding access to critical care services; triage and transfer; access to specialty services; standardization of care; maintaining critical care workforce; and, minimizing exposure to the bedside team. For example, we use TeleHealth solutions to monitor COVID-19 patients that are outside our critical care unit, expanding access to critical care services. This type of monitoring and consultation from a remote, central location allows us to rapidly assess the acuity of that patient and make the determination to transfer the patient to a tertiary center if needed while minimizing direct contact and potential cross-contamination.
Access to specialty services is another big benefit, particularly because COVID-19 symptoms include respiratory distress. With TeleHealth services, we can provide remote consultation from our acute lung injury center experts. This enables us to leverage our resources most effectively especially at a time like this when resources and ICUs are overwhelmed. More importantly, our centralized TeleICU opens a dialogue amongst our staff on best practices (i.e. what works and what doesn’t) and disseminates our collective knowledge on COVID-19. This helps standardize the level of care in our healthcare system. It ensures that each and every patient in our health system is benefiting from that collective knowledge across our entire system in real-time. We have also leveraged TeleHealth in the ambulatory setting in hopes of decreasing exposure for our at-risk populations, keeping our emergency rooms (ERs) from full overload, and conserving PPE by allowing home visits with TeleHealth where appropriate.
In addition to our centralized TeleICU, there are two key things we’re doing to minimize some of the risk for our staff as well. First, we are asking different hospitals in our network to provide a list of their critical care providers (including doctors, specialists) and providing both access and rapid training on software so they can see their own patients from their own building. Second, we’ve developed a TeleHealth strategy to minimize the exposure to the bedside team, which is typically the nurses who have the greatest risk of getting COVID-19 from frequent and close interaction with patients.
The TeleICU nurse has a unique responsibility at the bedside so we created a new workflow to minimize exposure to the team and reduce cross-contamination. We knew this was critical as personal protective gear such as masks and face shields are becoming rationed with the growth of the COVID-19 crisis. Now, the bedside RN is encouraged to call the TeleICU team before entering the patient room so that we can monitor and guide them through what they are doing and facilitate bundled care. The TeleICU team stays on-camera with the healthcare team while they are at the patient bedside to provide real-time support for our nursing staff. This helps reduce stress for staff, helps us maintain our COVID-19 personnel checklist log, and ensures consistency on things such as hourly safety rounds on patient vitals and ventilator checks. It also enables us to educate and monitor Personal Protective Equipment (PPE) requirements related to COVID-19 in real-time for compliance.
Q4: How might the TeleHealth and TeleMedicine landscape change with this COVID-19 outbreak and declaration of a state of emergency in the US?
The COVID-19 outbreak has really been a collective call-to-action for everyone. It made us re-examine healthcare processes on a global scale. At Northwell Health, we’ve seen first-hand how TeleHealth strategies have helped us adapt to this CoVID-19 challenge and contribute in a very meaningful way. Most prominently for us perhaps is how we were able to leverage existing TeleHealth solutions better while also devising new ways of working that we hadn’t implemented before to help us best help support and care for patients and protect our staff when social distancing became the new norm. We’re sharing our experience in the hopes of helping other hospitals deal with this crisis.
With the President’s declaration of a “State of Emergency” and the “TeleHealth Services During Certain Emergency Periods Act” (TSDCEPA), we have seen the lifting of certain established limitations for care in homes and geographic regions since the Health and Human Services (HHS) department signed the waiver. This will largely determine how the regulatory and reimbursement implications play out and if TeleHealth will become designated as an essential service. Right now, we don’t have that designation formally. Also, we believe this will better inform long-term decisions by CMS (the Centers for Medicare & Medicaid Services) for use of TeleHealth beyond the COVID-19 emergency.
Q5: What is needed to facilitate more virtual care solutions in the future?
With COVID-19, we’ve seen temporary hospitals become a reality and mobile monitoring a necessity. We’ve realized through this crisis how important it is operationally to know where all our technology devices are and that they are able to connect and that our health tech solutions are supported. We’re doing really well with TeleHealth at Northwell but, at some point, as we increase the bandwidth of TeleHealth, interoperability and support become increasingly more important. Looking forward, we see many possibilities and potential for TeleHealth and TeleMedicine solutions. We would advocate that health tech solutions continue to advance so that TeleHealth strategies can be 24/7 regardless of location if we’re ever going to be able to keep up with the demand for the technology. The sooner we can get that done simply - the easier it will be for us provide anytime/anywhere care for every service line and every patient.
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