02. How are hospitals and health systems working to physically protect hospitalists in response to COVID-19?

a. HOMERuN institutions

Most responding institutions implemented initiatives to mitigate the physical harms of the pandemic to a high degree, as further detailed here:

2. 1. Develop robust protocols for triaging, quarantining, and distancing to minimize exposure. Over 80% of responding institutions implemented triage/quarantine protocols. Examples included robust COVID-19 testing of all hospitalized patients with rapid turnaround time and creation of isolated COVID-19 units.
   2. Communicate and enforce guidelines for reducing risk of transmission. More than 80% of respondents felt their institutions provided access to updated COVID-19-related patient management recommendations. Examples included a centralized web-based repository for clinical guidelines, regularly updated as new information became available, and weekly virtual conferences with regular updates on new/evolving clinical guidelines.
   3. Modifying work by using telehealth when possible, workload redistribution by changes to scheduling, and re-deployment and/or augmentation of non-hospitalist health care workers to adapt to higher patient volumes and work intensification of caring for COVID-19 patients. Almost 70% of responding institutions established or increased the use of telemedicine in the inpatient setting. Examples included a robust increase in telehealth use to limit exposure to COVID-19 positive patients (e.g., newly acquired health IT infrastructure such as iPads set up inside/outside patient rooms to allow for distanced communication) and a change in workflow to include more phone encounters with both patients and staff. More than 90% of responding institutions noted changes in inpatient scheduling. Examples included decreasing the length of service blocks, supplemental physician and APP coverage from other services, and the use of virtual rounders to assist with documentation burden (e.g., preparation of daily progress notes and discharge summaries). Almost 70% of responding institutions reported some element of re-deployment of health care workers outside of their normal worksite (e.g., outpatient internists assigned to inpatient general medicine floors). Approximately 50% of respondents noted their institution had increased ancillary or consultant services for COVID-19 positive patients to allow for increased distribution of workload (e.g., palliative care consultation on all COVID-19 positive patients for goals-of-care discussion prior to potential need for ICU transfer).
   4. Provide sufficient access to personal protective equipment. 77% of responding institutions stated they had adequate access to PPE. Of note, the definition of adequate PPE differed, with several sites reporting access to new N95 masks daily, other sites reporting access to new N95 masks weekly (or more frequently if soiled/damaged), and several sites reporting access to N95 masks solely during aerosolizing procedures with use of surgical masks and face shields for the majority of their care of COVID-19 positive patients. Many sites reported augmented access to use of hospital scrubs.
   5. Ensure the availability of and easy access to hand hygiene products. All responding institutions reported adequate access to alcohol sanitizer and gloves.
   6. Communicate and enforce guidelines for reducing risk of transmission within the institution. More than 90% of responding institutions stated they had access to adequate guidelines to reduce transmission. Examples included the required use of a phone app for attestation of health to demonstrate proof of health upon entry into the hospital, social distancing policies displayed prominently in elevators and floors throughout the hospital, and universal masking policies.
   7. Communicate and enforce return-to-work guidelines for infected workers. Over 85% of respondents were aware of their institution’s return-to-work guidelines.

b. What is known:

Protective system/structural strategies to address provider safety (and thereby impact provider wellness) were the most common approaches to preserving physician wellness and seem the most useful first steps to be considered. Ensuring access to hand hygiene products and adequate PPE were highly implemented, but these are also practices we presume were previously well-established and available prior to the pandemic; though there was marked increase in demand as the pandemic progressed. Despite significant focus on both practices,  and though 100% of responding institutions reported adequate access to hand hygiene supplies, only 77% reported adequate access to PPE, potentially due to supply chain issues or due to variable adaptation of Centers for Disease Control and Prevention (CDC) guidelines.

Newly developed safety protocols (i.e., patient triaging, universal employee masking, etc.) were established quickly though they were often changed as more information was verified about the transmission of the virus. In fact, many respondents noted that their faculty occasionally became overwhelmed by the amount of information sent to them daily, especially as information continuously changed. Few of our sites reported examples of how to message updated protocols and information to faculty efficiently, though most were starting to message less frequently and in a more targeted fashion over time.

Whereas many institutions used re-deployment of staff to cover inpatient needs, use of new telehealth initiatives and increasing ancillary staff were more limited in adoption (possibly due to the additional resources involved).

c. What is not known:

Though Press-Ganey and other guidelines provide general tips, there are few data on the best ways to implement these programs. It remains unknown how often resource constraints impact the ability of the institution to offer/implement specific strategies (e.g., access to PPE or telehealth services and adequate ancillary staffing). Additionally, the impact of any of the approaches on measures of provider physical wellness (e.g., days lost from work, infection rates) is unknown.