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1.
Respir Care ; 66(1): 138-143, 2021 01.
Article in English | MEDLINE | ID: covidwho-1067868

ABSTRACT

BACKGROUND: The high frequency of aerosolizing procedures in the ICU, including endotracheal intubation, places clinical staff at elevated risk of contracting the 2019 coronavirus (COVID-19). Use of an intubation checklist can reduce exposure risk and thus acts as a potential safeguard. Specific, step-by-step guidance to perform safe endotracheal intubation in the setting of COVID-19 are limited. This article outlines the development and refinement of a COVID-19 intubation checklist and operational protocol for ICU staff at a single center in the United States. METHODS: A standard pre-intubation checklist was adapted and refined by consensus using a multidisciplinary and iterative process, then distributed to local staff for clinical use. Subsequent mock intubation training sessions were held using the new checklist to ensure proficiency. Planned debriefing sessions helped identify several previously unanticipated issues, allowing for further refinement of the intubation checklist and inclusion of all stakeholders. RESULTS: A COVID-19 intubation checklist helped optimize safety during a high-risk situation by minimizing aerosolization of secretions, the number of staff required in the room, the time spent in the room, and the frequency of donning/doffing personal protective equipment. CONCLUSIONS: We present a checklist for use during high-risk intubations of COVID-19 patients, which serves as a pragmatic bedside tool for clinicians. The process of checklist development may also serve as a model for facilities preparing their own pandemic protocols.


Subject(s)
COVID-19/transmission , Checklist , Infectious Disease Transmission, Patient-to-Professional/prevention & control , Intubation, Intratracheal/methods , Practice Guidelines as Topic , Health Personnel , Humans , Infection Control/methods , Intensive Care Units , Personal Protective Equipment , Respiratory Insufficiency/therapy , SARS-CoV-2 , United States
2.
Pain Physician ; 23(4S): S205-S238, 2020 08.
Article in English | MEDLINE | ID: covidwho-777187

ABSTRACT

BACKGROUND: The COVID pandemic has impacted almost every aspect of human interaction, causing global changes in financial, health care, and social environments for the foreseeable future. More than 1.3 million of the 4 million cases of COVID-19 confirmed globally as of May 2020 have been identified in the United States, testing the capacity and resilience of our hospitals and health care workers. The impacts of the ongoing pandemic, caused by a novel strain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have far-reaching implications for the future of our health care system and how we deliver routine care to patients. The adoption of social distancing during this pandemic has demonstrated efficacy in controlling the spread of this virus and has been the only proven means of infection control thus far. Social distancing has prompted hospital closures and the reduction of all non-COVID clinical visits, causing widespread financial despair to many outpatient centers. However, the need to treat patients for non-COVID problems remains important despite this pandemic, as care must continue to be delivered to patients despite their ability or desire to report to outpatient centers for their general care. Our national health care system has realized this need and has incentivized providers to adopt distance-based care in the form of telemedicine and video medicine visits. Many institutions have since incorporated these into their practices without financial penalty because of Medicare's 1135 waiver, which currently reimburses telemedicine at the same rate as evaluation and management codes (E/M Codes). Although the financial burden has been alleviated by this policy, the practitioner remains accountable for providing proper assessment with this new modality of health care delivery. This is a challenge for most physicians, so our team of national experts has created a reference guide for musculoskeletal and neurologic examination selection to retrofit into the telemedicine experience. OBJECTIVES: To describe and illustrate musculoskeletal and neurologic examination techniques that can be used effectively in telemedicine. STUDY DESIGN: Consensus-based multispecialty guidelines. SETTING: Tertiary care center. METHODS: Literature review of the neck, shoulder, elbow, wrist, hand, lumbar, hip, and knee physical examinations were performed. A multidisciplinary team comprised of physical medicine and rehabilitation, orthopedics, rheumatology, neurology, and anesthesia experts evaluated each examination and provided consensus opinion to select the examinations most appropriate for telemedicine evaluation. The team also provided consensus opinion on how to modify some examinations to incorporate into a nonhealth care office setting. RESULTS: Sixty-nine examinations were selected by the consensus team. Household objects were identified that modified standard and validated examinations, which could facilitate the examinations.The consensus review team did not believe that the modified tests altered the validity of the standardized tests. LIMITATIONS: Examinations selected are not validated for telemedicine. Qualitative and quantitative analyses were not performed. CONCLUSIONS: The physical examination is an essential component for sound clinical judgment and patient care planning. The physical examinations described in this manuscript provide a comprehensive framework for the musculoskeletal and neurologic examination, which has been vetted by a committee of national experts for incorporation into the telemedicine evaluation.


Subject(s)
Coronavirus Infections , Neurologic Examination/methods , Orthopedics/methods , Pain/diagnosis , Pandemics , Pneumonia, Viral , Telemedicine/methods , Betacoronavirus , COVID-19 , Humans , Neurologic Examination/trends , Orthopedics/trends , SARS-CoV-2 , Telemedicine/trends , United States
3.
Telemed J E Health ; 27(3): 261-268, 2021 03.
Article in English | MEDLINE | ID: covidwho-719185

ABSTRACT

Background: The cororavirus disease 19 (COVID-19) pandemic has strained intensive care unit (ICU) material and human resources to global crisis levels. The risks of staffing challenges and clinician exposure are of significant concern. One resource, telecritical care (TCC), has the potential to optimize efficiency, maximize safety, and improve quality of care provided amid large-scale disruptions, but its role in pandemic situations is only loosely defined. Planning and Preparation Phase: We propose strategic initiatives by which TCC may act as a force multiplier for pandemic preparedness in response to COVID-19, utilizing a tiered approach for increasing surge capacity needs. The goals involved usage of TCC to augment ICU capacity, optimize safety, minimize personal protective equipment (PPE) use, improve efficiencies, and enhance knowledge of managing pandemic response. Implementation Phase: A phased approach utilizing TCC would involve implementing remote capabilities across the enterprise to accomplish the goals outlined. The hardware and software needed for initial expansion to cover 275 beds included $956,670 for mobile carts and $173,106 for home workstations. Team role deployment and bedside clinical care centering around TCC as critical care capacity expand beyond 275 beds. Surge capacity was not reached during early phases of the pandemic in the region, allowing refinement of TCC during subsequent pandemic phases. Conclusions: Leveraging TCC facilitated pandemic surge planning but required redefinition of typical ICU staffing models. The design was meant to workforce efficiencies, reduce PPE use, and minimize health care worker exposure risk, all while maintaining quality care standards through an intensivist-led model. As health care operations resumed and states reopened, TCC is being used to support shifts in volume and critical care personnel during the pandemic evolution. The lessons applied may help health care systems through variable phases of the pandemic.


Subject(s)
COVID-19 , Delivery of Health Care/organization & administration , Telemedicine , Critical Care , Humans , Intensive Care Units , Pandemics , Surge Capacity , Telemedicine/economics , Telemedicine/instrumentation
5.
Crit Care Nurse ; 40(4): 25-31, 2020 Aug 01.
Article in English | MEDLINE | ID: covidwho-422945

ABSTRACT

BACKGROUND: The coronavirus disease 2019 pandemic has exacerbated staffing challenges already facing critical care nurses in intensive care units. Many intensive care units have been understaffed and the majority of nurses working in these units have little experience. OBJECTIVE: To describe how the skilled tele-intensive care unit nurses in our health system quickly changed from a patient-focused strategy to a clinician-focused approach during the coronavirus disease 2019 crisis. METHODS: We modified workflows, deployed home workstations, and changed staffing models with the goal of providing additional clinical support to bedside colleagues while reducing exposure time and conserving personal protective equipment for those caring for this highly contagious patient population. The unit changed focus and granted more than 300 clinicians access to technology that enabled them to care for patients remotely, added nearly 200 mobile carts, and allowed more than 20 tele-intensive care unit nurses to work from home. RESULTS: Tele-intensive care unit nursing provided clinical knowledge to the nurses covering current and expanded critical care units. Using technology, virtual rounding, and increased collaboration with nurses, tele-intensive care unit nursing minimized the risk to bedside nurses while maintaining a high level of care for patients. CONCLUSION: Tele-intensive care unit nurses provided a proactive, holistic approach to caring for critically ill patients via camera as part of their routine workflow. In addition, during the coronavirus disease 2019 pandemic, these nurses created a new strategy in virtual health care to be implemented during a crisis.


Subject(s)
Coronavirus Infections/nursing , Intensive Care Units , Pandemics , Pneumonia, Viral/nursing , Telemedicine , COVID-19 , Coronavirus Infections/epidemiology , Humans , Nursing Evaluation Research , Pneumonia, Viral/epidemiology
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