The Remote Resident: Preserving PPE, Minimizing Exposures, and Maintaining Education
In the early days of the COVID-19 pandemic, the University of Colorado’s (CU) Internal Medicine Residency was scrambling to create a new backup system that would be resilient in the face of increasing patient loads and – if resident started to get sick – decreasing resident ranks. Samuel Porter, MD, their Chief Resident for Quality and Safety, created a model of the proposed system and discovered a glaring problem. Residents with even mild symptoms, or even asymptomatic residents who had visited an endemic geographic area, were required to be removed from duty for two weeks of quarantine. Bringing in residents from their electives to cover would rapidly deplete the backup pool – in the worst possible scenarios, within a matter of weeks. Furthermore, the program decided to remove at-risk residents (residents with chronic lung disease, immunosuppression, or pregnancy) completely from clinical duties – however, this would result in still further depletion of the pool of residents available to staff surge hospital services.
The COVID-19 pandemic has brought unique challenges to medical training programs, and we grappled with many of them at CU. How much risk exposure is acceptable for trainees? How can hospitals work to allocate sufficient personal protective equipment (PPE) to protect trainees even as some hospitals face shortages for frontline clinical staff? How, would programs create an environment in which all our trainees felt safe, while still staffing all the services we needed to staff?
Since the pandemic began, nearly every internal medicine residency program in the United States had to adjust its rotation structure to shuffle residents to those services that needed additional help. In tandem, many programs sought a way to protect high-risk residents from COVID exposure. As far as we were aware, there was minimal guidance on how to tackle this challenge. At CU, we tackled these issues creatively with a novel remote rounding structure that enabled virtual rounding on inpatient services from home. This allowed the backup strategy to be more elastic, kept at-risk residents safe, and reduced in-hospital demand for PPE. Our goal was to maximize our available resources while still providing excellent care for our patients and keeping our trainees safe.
Remote Rounding went through several iterations at different sites (the University Hospital and the VA). Separately, residents piloted both “split-duties” and “split-list” approaches. In the “split-duties” approach, the remote residents covered all the team’s patients and performed almost all duties traditionally done by interns that could be accomplished at home: checking morning vital signs and labs, entering the team’s orders, writing notes, and coordinating discharges. The team’s attending and other in-house resident saw and examined patients, answered pages from nursing staff, and interacted with consultants. In the “split-list” approach, the remote residents assumed care for several patients on the census, performing every duty except examining them; the attending physician and the counterpart in-house resident provided all aspects of care for the team’s remaining patients. Ultimately, feedback showed that the “split-duties” approach was preferred. This maximized the functions of both the in-person residents and the remote residents. Although the residents who were in-hospital had to carry an entire list of patients, the remote residents freed them from the burden of many of their usual clerical tasks which allowed them to spend more time with patients – especially important given the amount of time spent donning and doffing PPE.
Technical barriers such as an occasional bad cellphone connection or the difficulty getting a consistent video feed could sometimes lead re-work. It became clear that high-quality communication connection was essential in order to best reproduce the usual rounding experience. While resident teams were able to develop workarounds and stopgaps for a number of problems, the finding serves as yet another need for the healthcare industry to develop reliable, high fidelity communication tools for digital healthcare to succeed.
The pilot was ultimately successful according to subjective feedback from early adopters. One senior hospitalist-track resident, who has a chronic lung disease, recalled his internal struggle when the residency first asked him to step away from clinical duties in the hospital, likening it “to being an experienced soldier who was told that the rest of his company was being deployed into battle, but he would have to remain behind.” The Remote Resident experiment was a way to provide direct clinical care while reducing his risk of contracting COVID-19. For both Dr. Porter it was also a way to test a novel inpatient care-delivery model, Dr. Porter viewing it as “one of the horizons of innovation to which the COVID-19 pandemic has pushed us closer.”
The CU group also tested a Remote Resident Admitter role, focusing on admitting COVID-19 patients. As masks and respirators often made interviews difficult in noisy negative pressure rooms, these patients were typically being interviewed via virtual modalities anyway. By calling patients using hospital room phones to obtain histories, the remote resident fit right in. While it was the supervising attending that examined the patient, the resident could still craft the medical plan, preserving resident autonomy. This also allowed residents to gain valuable insight into both the bundled care pathways that were created for this new disease process and the clinical research studies into which patients were recruited, capitalizing on a unique educational opportunity. Residents who participated in this role gave universally positive feedback.
The approach was also in line with a hospital directive that a single provider examines patients with COVID-19 each day, as a way to conserve PPE. By eliminating a node of demand for PPE, teams with a remote resident effectively reduced the internal demand for PPE by 50% (with possibility to further conserve the PPE supply if scaled), all while maintaining their usual workflows.
A final version of the Remote Resident involved working at CU’s Remote Patient Monitoring Program. Select patients with COVID-19 discharging from inpatient services were given small devices resembling wristwatches paired with finger pulse oximetry probes. Using a cellphone app, real-time vital signs were transmitted to the University’s Virtual Health Center. Residents worked with technicians to address medical issues that arose in the patients and coordinate care with the patients’ primary care providers, under the supervision of the Virtual Health Center’s daily attending physician.
Ultimately, nine residents participated since the project was started in early April, with the ability to scale up as needed. The project was so well received that Geoff Connors, MD, Program Director for CU’s Internal Medicine Residency, spoke about it to graduating residents and their families. “Our program’s residents stepped up to protect the most vulnerable of their colleagues. And those same at-risk residents, they themselves then went and created a very effective and very new way for them to keep providing care to patients in this unprecedented time.”
As the number of COVID-19 cases nationwide continues to increase, and in anticipation of a second wave in the coming fall, the CU group’s success highlights how a remote-access care model can keep high-risk resident physicians part of a hospital’s provider workforce and conserve PPE, all while reducing their chances of contracting COVID-19 and continuing their clinical education. Now that the infrastructure for this model is in place, the group plans to use it as needed if a second wave arises or PPE supplies become strained.
Said Chief Resident Sam Porter about the experience, “I was part of a phenomenal group of chiefs who were challenged to be creative in a lot of different ways to confront the pandemic. This project was one of my favorites. Our team developed something innovative and useful in a matter of weeks that made everyone feel a lot better about our chances of besting a surge. Who knows – maybe our work will lay the foundation for more work on remote inpatient care in the future, even after the threat of a pandemic has subsided.”
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