With oncoming surge of patients with COVID-19, the health system and Department of Medicine decided that hospitalists would care for all hospitalized patients with COVID who did not require placement in an ICU. Dr. Caroline Kahle cared for the first patient at BJH thought to possibly have COVID-19. Though the patient tested negative for SARS-CoV-2, the experience was frightening. Security escorted her up to the ICU with the patient and Infection Prevention threatened quarantining her away from her children and family. She was finally released late that night. This imprinted on her the importance of wanting to keep hospitalists at home when they could be at home aiming to keep things as calm and organized as possible for them in their lives inside and outside of work.
Dr. Kahle wanted her colleagues to feel supported and appreciated. Importantly, she wanted her colleagues to feel safe and capable to manage the difficult workload caring for patients with COVID. For the first time ever, the institution agreed to limits on the number of patients receiving care from an individual hospitalist. This ensured hospitalists had time to carefully take their time in donning and doffing personal protective equipment (PPE) and keep themselves safe. The process of putting on a gown, ensuring the N95 mask fit well, adding a visor or other eye protection and then gloves before seeing a patient, and then removing it all afterward took extra time. The hospitalists also needed time to make numerous phone calls to converse with patients’ family members since no visitors were allowed. And finally, hospitalists needed to not rush as they held the hand of a dying patient.
The hospitalists handled the first surge well and benefited from a strong new leader in Michael Lin as the interim Chief of the Division of Hospital Medicine. He demonstrated his ingenuity and commitment by driving to every Home Depot and Lowes in the area to buy eye protection gear. Coming out of this experience and knowing more surges were likely to come, Dr. Kahle prioritized having a better plan going forward. Working with Dr. Thomas Ciesielski, they initiated an unprecedented collaboration between the Divisions of Hospital Medicine and General Medicine in the summer of 2020. Together, they developed a detailed strategy to approach staffing for subsequent surges. The main driver behind the countless early mornings and late nights of planning for Dr. Kahle was to continue to care for patients seamlessly and not have our patients feel the enormity of the surges stressing the system. She also thought it extremely important to try to keep some semblance of work-life balance for the amazing hospitalists who had shouldered the burden of caring for COVID patients from day 1. The plan initially still involved using only hospitalists to care for non-ICU patients with COVID, and augmented this with clear next steps as patient volumes increased. This comprehensive strategy included obtaining help from other Divisions within the Department of Medicine. Numerous hours of work were required to specify standard operating procedures and confirm support from everyone who might be needed. This strategy debuted successfully with the December 2020 surge. Finally, with the most recent omicron variant surge, Dr. Kahle obtained support from the CMO office of BJH to engage non-medicine services to keep patients who were asymptomatic or mildly symptomatic. This approach ensured the sickest patients with COVID would receive care from physicians who were not overstretched by patient volumes.
The Firm Teaching Service started caring for patients with COVID this past August of 2021. Leadership believed it was time for the medicine residents to learn how to manage this disease that is clearly here to stay. This began very slowly with small numbers, and then progressed to the teaching services managing 50+ patients with COVID.
The hardest part of managing COVID surges was getting people to understand the complexity of the hospitalists’ schedule and the size of the Division of Hospital Medicine. With about a hundred clinicians, and numerous teams spread across the South, North and Siteman buildings, the footprint covers about a third of all patients in the hospital. With hospitalists also being quarantined for possible or actual COVID and the need for replacements, Dr. Kahle worked 7 days per week coordinating hospitalist staffing to ensure patients received high quality care. Implementation of the COVID staffing plan required addressing an extensive number of variables. Constant adaptation was essential with the ability to know what lever could be pulled as patient volumes increased. It truly was a Tetris-like challenge.