EHR v Covid-19. Nurses help families of ICU patients, from home

ICU rounds at PVH, photo credit: Lydia Baldwin

These are our healthcare heroes at work: From ICU rounds at Poudre Valley Hospital, part of UCHealth: Starting from the left standing we have Respiratory Therapy, Palliative Care PA, and Chaplain. Sitting from the left are RN, intensivist MD and Charge RN. In front of the intensivist (in green scrubs) is a telephone on the desk. The telephone is on ‘speaker’ and dialed in to a conference line. Also dialed in are: Pharmacist working remotely, Nurse Communication Liaison working remotely, Social Work.

So many great things going on here: Social distancing as much as practical (too much further and you can’t hear each other over the din of electronic alerts across the ICU), N95 masks (all day every day), reviewing data together from so many disciplines, discussing each patient in detail and taking immediate actions (placing orders, creating consensus on medical decisions, dividing tasks for rapid action).

In times of pandemic, the hospital follows infection prevention protocol and isolates very sick, very infectious patients. In this case, we have grouped and isolated all Covid-19 patients into a distinct unit, away from non-Covid patients. AND, in most cases, patients are not allowed to have visitors.

This is both good medical practice, and heartbreaking to families who cannot be present at a patient’s most desperate hour.

Out of this swirl of confusion, Julie Griffin, Nurse Manager of Care Management, thought: we have highly qualified nurses on-leave at home (orthopedic unit nurses with no post-op surgical patients; pregnant nurses for whom Covid infection would be particularly dangerous); how might they help share the burden of patient care with bedside nurses, and still minimize risk of contagion and exposure?

And so was born: Nurse Communication Liaison. Nurses from home, helping keep families connected, and reducing the burden on bedside nurses. We haven nurses helping with med/surg units as well as ICU’s. As described by ICU nurse Molly:

7AM: My day starts at 7: I review the Epic EHR chart from home for patients in the ICU. I read the notes from the nurses and the doctors overnight in our 12 bed unit. By the way, our unit has moved to double occupancy, and we’ve expanded to be a 23 bed unit. So much has changed, we’re so much busier.

8-10AM: I start receiving calls from family members and I give them updates on their loved ones, that I can, based on what I know. I am using Epic secure chat (a HIPAA-compliant text message service) to communicate with the ICU bedside nurses, social worker, respiratory therapy to get and give updates. I LOVE secure chat because it means the bedside nurse: who is gowned, gloved, doesn’t have to scrub out to answer another nuisance phone call interruption; they can catch up with chat-messages when there’s a break in the action.

10-11AM: Daily ICU rounds (picture above), where the team discusses every patient and I’m on the conference phone. It is a complete team with everyone pitching in.

11AM-430PM: We have designated ONE main contact family member for each ICU patient. We have found it can be overwhelming to have many family members calling each day for updates. I am so happy to be able to serve as the main contact for these family members and unburden our extremely busy bedside nurses to focus on their patients.

Some great unexpected moments:

Jamie: “Bedside nurses often spend 15 minutes on the phone with family. Multiply that by 5 patients and it becomes a big part of your day. We all wish we had more time to talk to families, but we’re often too busy caring for patients. I love helping connect with families and reassuring them.”

Jamie: “One gentleman was was not doing well. He was very quiet on the phone, and would never ask for anything. I spoke with his close friend at home, who noted that he was Jewish, and might appreciate a visit from a Rabbi or the Chaplain. I was able to arrange that.”

Jamie: “Being an ortho nurse on a medical unit, I was anxious at first. But communicating with the bedside nurses by secure chat and occasionally the phone, I found that even if I couldn’t answer families’ questions, I could always find out. Families are always so appreciative of the extra communication. I love this role. It is really awesome.”

Dawn: “The difference with this role is: There’s only the person on the phone. It is quiet at my home on my end. Normally when I’m at the bedside, I’m always trying to ‘wrap up the conversation’ with family: there are so many other things needing my attention. I can really feel good about being focused, connecting with family, and freeing up the bedside nurse to do their jobs.”

Dawn: “I was on the phone with the husband of a Covid patient. I noticed he would occasionally grunt, while we were talking about his wife. I had to ask him: ‘Are you okay?’ He told me he had had a fall, and had to pull on his pant-legs to go up the stairs. I recognized the signs of a major injury. It took some convincing, but I finally got him to call his doctor. Turns out the next day he was admitted and had emergency surgery himself.” As an ortho nurse, she was probably the perfect person to help.

Davida: “Sometimes you can remind the bedside nurse by secure chat: ‘his daughter would like to see his face today. Can you get the tablet in there for a Zoom visit?'”

Davida: “I feel really useful, being able to connect with PT, social work, bedside nurse all by non-interruptive but efficient Secure Chat, and then calling to make sure the family stays informed.”

Molly: “It is completely weird not to be an ICU bedside nurse right now. I think I will be better at charting in the future. Not being able to see the patient lets me understand what families want to know, that I rarely wrote down before: how do they look? are they following commands? can they squeeze? How scary this is for the family, and although it is a tricky role for us, it feels great to be helping.”

CMIO’s take? Thank you to our amazing UCHealth nurses: Lisa Claypool, Julie Griffin, Jamie Deschler, Davida Landgraf, Molly Carrell, Dawn Velandra for their experiences and stories.

UCHealth v Covid-19. The second surge (not what you think)

Mind the Brain Logo

https://medschool.cuanschutz.edu/psychiatry/about/in-the-news/psychiatry-news/mind-the-brain-mental-health-in-the-time-of-covid-19

I’m so proud to be part of a multi-disciplinary, talented group of clinicians. Our Department of Psychiatry is gearing up for what may become the second surge of our pandemic, as we relax the stay-at-home orders in Colorado:

Mental Illness. Depression. PTSD. Panic. Suicide.

These terms must no longer carry the stigma they do. There is no shame in reaching out for help. Appropriate and timely treatment can aid a person’s innate resilience and return him or her to health.

We have not experienced a pandemic of this scope for more than a century … We are psychologically inexperienced.

C. Neill Epperson MD

Read more of Dr. Epperson’s ideas and initiatives in this fight for mental health and the major investments UCHealth will be committing to improve the well-being of all residents of the State of Colorado. Welcome to the fight!

UCHealth v COVID-19. Patient success stories

https://www.uchealth.org/today/jbs-worker-with-covid-19-goes-home-after-son-prayed-outside-hospital-for-days

Thanks to the hard work of our outstanding nurses, staff, and physicians, many patients with Covid-19 are pulling through. Here’s a particularly poignant story from UCHealth’s own reporter, Katie McCrimmon. Have your tissues ready.

Dr. CT Lin’s Covid-19 advice for patients. KOSI 101 and Mile Hi Magazine

In the link below, it is the interview from April 12, 2020.

https://kosi101.com/mile-high-magazine-public-affairs/

I had the pleasure of being interviewed by Mile Hi Magazine last week in regards to questions about how patients can cope with Covid-19 at home.

I responded to such questions as:

  • So many people contract but recover, is this what our body is designed to do?
  • Can people determine whether they have the virus without a test on symptoms alone?
  • When contracted, quarantine is the first step. What’s next in terms for two weeks – nutrition, special foods to eat to help the immune system fight?
  • Any special foods we should be eating now to be in top immune condition should we contract?
  • Any over-the-counter medicine to take for the fever or diarrhea?
  • Should people change out bed linen during the two-three weeks period?
  • Once fever breaks, is this a key sign that its over?
  • Should people exercise while body is fighting the infection?
  • Once over, should person we wait a couple days to ensure no symptoms return?
  • If Covid-19 is a flu strain, will it mutate into another strain as flu does each season for next winter?
  • Anything else you feel is pertinent to help people feel they can get over it if infected.

I made one particular point at the end of the interview. I shared our family’s strategy for coping with the anxiety and stress during this pandemic:

  1. Exercise every day
  2. Play or make music every day
  3. Limit yourself to 30 minutes of news or social media daily
  4. Three Good Things. At dinner each of us discusses THREE THINGS we are grateful for, today. INSTEAD of our natural tendency to focus on the negative, this exercise helps us reframe our day in a positive light.

CMIO’s take? I challenge all of us to do THREE GOOD THINGS with our loved ones at dinner every night.

Viral Misinformation vs Actual Virus (Medium.com)

https://medium.com/swlh/misinformation-goes-viral-1aad951e4492

This article “Misinformation Goes Viral” from the Medium is written by a PhD in Cellular and Molecular Medicine from Johns Hopkins School of Medicine, working now in Neurobiology at the University of Utah. Worth reading, and forwarding.

I agree with his well-written article and his sound reasoning, as a Professor of Medicine at the University of Colorado School of Medicine, the Chief Medical Information Officer at UCHealth, and a General Internal Medicine doctor seeing patients (now primarily via Telehealth!) in clinic.

His article has a number of main points with detailed explanations:

  • Americans did not have Covid 19 prior to Jan 2020
  • The virus is not man-made
  • Models are not deliberately misleading people
  • Covid is NOT the flu
  • Bill Gates is not a Bond villain
  • 5G cell towers do not spread Covid
  • Healthcare workers are not paid off by big pharma
  • Herd immunity must be achieved through vaccination, not unchecked infection

CMIO’s take? Let science and rational thought triumph in these difficult times.

EHR analyst v Covid. Making a difference with Ear Guards made with 3D printing (Guest post: Guy Ristoff)

Guy Ristoff, his sister-in-law Mollie, and brother Bill

My name is Guy Ristoff.  I work for the EPIC IT Team at UCHealth (Colorado) as an Analyst.  I also have a 3D printer.  A few weeks ago, I started seeing a bunch of people posting in 3D printer Facebook groups about ear guards to use with surgical masks.  I thought it was a great idea for me to explore here at UCHealth.

 I contacted a unit I have done some EPIC build for and asked if they would want some.  I created my first 10, delivered them to the hospital, and hoped they liked them.  I then contacted Gwen Martinez from the Clinical Informatics team and she sent an email blast to a group of people about the ear guards.  Within 20 minutes, we started to get responses.  It was amazing!  The first few “orders” were coming from the Northern Region.  My brother lives in Wellington and has 3D printer as well.  I called and asked him if he would be interested in donating ear guards to the Poudre Valley and MCR.  He was excited to help!  His kiddos even got in on the fun by making thank you cards for the staff.   

As for production, I can make 17 of them per batch, which takes about 4 hours.  It is not a super-fast process, but it is a lot of fun making something that helps people be more comfortable.  My brother has made and dropped off 80 of them.  I have created 122 of them for the AMC and MHC campus so far.   I am dropping those in the mail and at the hospital today!  I will keep up production, so keep the orders coming.  I am just happy to be able to help!

Here is my machine making a batch of them

Example of a clinician wearing a mask protected by the ear guard

CMIO’s take? Thanks to all our creative Epic/IT team members like Guy, to step up and help in every way that they can. –CT Lin MD

EHR v Covid-19. Video Visits: How to Improve the Patient Experience

The new normal? No white coat during Video Visits! (c) CT Lin

Executive Summary: We have a global pandemic, daily policy changes, we work from home, have new video tech, and we are learning to communicate and build relationships in new ways. It is easy to forget that there may be a scared patient on the other end, counting on us. How might we improve the patient experience? Some ideas:

IDEA                                                    DETAILS

Secure Chat with your MAScrub your schedule together, days ahead for patients more appropriate for telehealth vs in-person visits, med rec, troubleshooting, visit focus
Arrange your room, selfSee tipsheet in Epic “Demonstrate Professionalism.“ How is: your room, your light, your clothing?
Eye Contactand, put a sticky note on PC cam to “LOOK HERE!”Arrange the camera at eye level if possible. For some, looking down = frowning? Eye contact on video visits is EVEN MORE important. “If I look away it is because I’m looking at information in your chart”. 
Avoid running lateIf you DO, inform your MA by Epic secure chat & they can inform patient
Greet the patientI like to raise my arms in surprise when we connect: every human connection now, is amazing. Maybe thank them for connecting with you. Ask if they’re in a safe private spot (eg: advise patient NOT to be driving!)
Talk, human to humanAsk: how are you coping (aside from medical concern)? Scared? Worried?  
Reflective ListeningEven more important now in this time of anxiety. You can reflect or say back Data, Ideas, Feelings, Values. It strengthens connection: for example  DATA: “It has been 5 days of worse symptoms?”  IDEAS: “so you think it might be gout?”  FEELINGS: “you’re worried about work? Hmm.”  VALUES: “so, what’s important to you is your family.”
PEARLSSome clinicians may have taken the Excellence in Communication course. The PEARLS acronym can also be helpful. Some examples:   Partnership: “We’ll get through this together.”  Empathy: (reflective listening, as above)  Apology: “I’m really sorry that happened.” “I’m sorry for my part in it.”  Respect: “You have worked really hard on this.”  Legitimization: “Anyone in your situation would feel that way.”  Support: “My team and I are here for you. We aren’t going anywhere.”
Physical Exam creativityTeach them to take a pulse “say beep when you feel it” and YOU can count. Patients may have a BP cuff, Pulse ox, flashlight, thermometer. 
Ask for help from familyOthers may help add to history or exam findings
They may ask about YOU as a human“How are YOU doctor? Are you staying safe?” So many surprising comments from patients worried about their doc. Thank them! 
Brief LIFE adviceDuring pandemic, consider: A) Limit news/social media to 30 min/day. B) Exercise daily. C) THREE GOOD THINGS exercise: proven to reduce depression, anxiety if done consistently “What 3 things are you grateful for today?” Can become a great family habit at dinner. 
AVS,
Open Notes
From My Health Connection, they can see your AVS (after visit summary) and your Progress note (called Clinical Note) to remind them of details of your visit. Maybe at end of visit, ask: “Sometimes I don’t explain myself well. Can you tell me what you’ve heard, so we’re on the same page?”
Reassurance and Hope“We’re going to get through this!” “Stay in touch with your loved ones.”
Ending the visitConsider: a handwave OR palms together, nod OR thumbs up OR “You Got This!” Forecast next steps or if your MA will call them after.
Secure chat with your MAHandoff any items after visit for continuity (referral, next visit, lab, etc)

Link to PDF of this document.

And, here is how our Medical Office looks now, deconstructed. One part is in my basement …

The deconstructed doctor’s office (c) CT Lin

And here’s Medical Assistant Becky, hard at work keeping both the patient and the doctor on track at her home. That virus has got no chance against us.

CMIO’s take? Hang in there! You Got This!

Thanks to all my colleagues for letting me “borrow” their ideas for this post.