Can we redeploy specialists who don’t typically treat infectious diseases to care for patients battling the novel coronavirus? For example, can we create step-down nodes from highly sophisticated transplant surgery team to care for intubated patients in ICU, can these specialist manage to intubate, do their training and allow for some form of competency? It’s not unheard of and it doesn’t create a liability by itself for someone to step into a lower level of expertise if they have training in that level of expertise.
This is where individual hospital by-laws, rules and regulations, privilege forms – policies showcasing how to grant appropriate approvals that satisfies patient care and maintains compliance and ensures providers can give their all during this pandemic while minimizing exposure to malpractice suits and/or quality issues simply because they were called upon to help regardless of their specialties and board certs.
The Joint Commission has standards for temporary privileges under emergent and disaster situations. TJC will release by April 15, waivers to the standards to ensure patient care is managed appropriately. Healthcare entities should utilize all the avenues open to them under these standards and adapt the new changes and guidelines offered by CMS as soon as possible. They need administrators to work on plans to implement changes on a daily basis.
In most cases existing hospital by-laws, cover this disaster situation and have established processes on how to approve expedited privileging. These By-laws should have a policy on what kinds of privileges will be granted and what competency/education/training a provider has to have to be approved for these privileges. The Medical Staff office (MSO) has to take charge in defining, implementing and approving what is acceptable to help with this pandemic in their facilities. The MSO must develop very clear clinical protocols to manage quality of care. For instance, a nephrologist has critical care training, but if the physician has been working in an ambulatory setting for the past decade, they might not be an ideal candidate to help treat hospitalized COVID-19 patients.
The focus under this pandemic is ability to provide critical care to patients, have experience in managing ICU patients, follow protocols, demonstrate the ability to perform procedures required to help with this pandemic and identify which ABMS and AOA specialties have training requirements such as intubation. Healthcare entities should develop a privilege form specifying the scope and then describe what training will be considered to meet the competency requirements.
MSO’s can also create a team of care givers and ensure that one qualified critical care specialist is supervising the team and can include peers, MD/DO and APPs. As a supervising physician, this individual can review charts and guide the team, which in turn will help in expanding the service model. The average size a supervising physician can supervise is based on the respective state’s guidelines. In most cases, 5–9 medical professionals can be supervised by a qualified physician. The team can comprise of infectious disease consultants, who check on their patients daily and hospital’s pharmacists, who ensure their patients are getting the right medications.
As reported in the Modern Healthcare article from March 30, 2020, “Hospitals redeploy specialists to COVID-19 front lines”. Nationwide anesthesiologists, orthopedic surgeons and cardiologists are among the specialists heeding calls from overwhelmed hospitals to help tackle their COVID-19 surges. Health systems like Mount Sinai, Providence St. Joseph Health, Spectrum Health and Henry Ford Health System are rolling out plans that identify which specialists can treat COVID-19 patients and to what capacity. Not all doctors have the training required to ventilate a patient, but they can still monitor a COVID-19 patient who has yet to progress to that necessary stage.
How can healthcare entities source these essential providers?
- Start with taking an inventory of who is available, what their skills are and whether they’re willing to step up. The most obvious recruits are those with critical care backgrounds, especially anesthesiologists and critical care intensivists. A great potential source of these specialists will be from ambulatory surgery centers or freestanding emergency departments.
- Next, move towards identifying specialties that may be experiencing mandated idle time from the ban on non-emergent procedures- general surgeons, orthopedic surgeons and internal medicine subspecialists like cardiologists and oncologists. These physicians have skills that naturally transfer to caring for critically ill patients.
Although some of these regulations have been relaxed for now, please note that the CMS’ Conditions of Participation require hospitals to have plans in place that guide the use of volunteers in an emergency staffing situation. If these plans exist within an organization, it may be best to research and follow them even during the time of pandemic. Such plans should specify which independent doctors will be eligible to receive medical staff privileges at the facility.
Michigan-based Spectrum Health has brought on about 250 providers to triage patients over the phone who are concerned that they might have the coronavirus. The providers, which include physicians and advanced practitioners, are from various specialties including general surgery, orthopedic surgery, cardiology, neurology and oncology. “The providers are available to help with triage because routine appointments and non-emergent procedures have been postponed,” said Dr. Kristopher Brenner, Division Chief of Telehealth and Primary Care at the system. Spectrum Health briefly trained the providers on how to appropriately triage patients by following federal and state guidelines. More than 20,000 patients have been screened since March 16.