Aine Cryts

Before the novel coronavirus was declared a pandemic in March, Deanna Tith spent her days as a medical secretary and team leader at Newton, MA-based health system Atrius Health. Most of her time was devoted to scheduling surgeries, coordinating with the surgeons on her team, and taking patients’ vital signs. 

But now Tith’s days are spent at home staffing Atrius Health’s Covid-19 triage line, where she answers calls from patients about the infectious disease caused by the coronavirus. She’s part of a home-based workforce that includes 65 registered nurses, 17 medical secretaries, and one licensed practical nurse who triage calls from symptomatic patients with Covid-19 and what Jane Connor, RN, associate chief nursing officer, calls the “worried well,” or people who are anxious and uncertain about the highly infectious disease. 

Approximately 85 percent of the calls are from patients with symptoms of Covid-19, while 15 percent of the calls come from patients who are worried about navigating life safely during the pandemic, says Connor. Tith and the other staff answering patient calls are only working from home, which means they’re not at Atrius Health practices seeing patients in person. 

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The triage team, which received its first call March 9, fielded 11,000 calls from patients during a busy three weeks from the end of March to mid-April. During that time, fewer than 100 patients were directed to the emergency department. The number of staff answering patient calls has flexed up and down, in response to patient need, says Connor.

In mid-April, Massachusetts was “right in the middle of a surge [of Covid-19 cases],” said Governor Charlie Baker, as 

 by WBUR, Boston’s NPR news station. At 528 cases per 100,000 people, at that time, the state had the third most cases per capita in any state. During the surge in cases, Connor saw an increase in talk time while the number of calls went down. That’s likely because it was a sicker population of patients who were calling the triage line, she explains. 

Keeping patients out of the ED; responding to questions

Keeping patients out of the emergency department was the initial goal, according to Connor. Triage team members can connect patients with resources such as drive-through testing, care in their homes, telehealth consults, urgent care, or a hospital visit, if necessary. Connor also wanted to keep staff members and other patients safe from the highly contagious disease. That meant phone-based triage was the right approach, she says. 

The nurses and medical secretaries on the triage team also answer many questions from patients who are anxious and uncertain about living safely during the pandemic. For example, Deborah Helen, RN, clinical patient safety and risk management specialist, who works on the team, explains that it’s easier for a mother to tell an 11-year old child than a toddler why she can’t hug them if she has Covid-19. 

Patients also ask about breastfeeding and pet safety, among other concerns. To respond to these questions, Helen and her team access the latest information from the CDC and the Massachusetts Department of Public Health. As of May 6, most people two years of age and older who can’t safely practice physical distancing in public are required to wear a face mask or face covering in Massachusetts. But convincing young children to wear a mask can be a challenge. Her advice? Color the masks and make it fun.

Patients who have Covid-19 are concerned about keeping their children and other family members safe, says Helen. She recommends that they use a separate bathroom from other family members, if that’s possible. 

Speaking in a clear and concise manner and providing examples to patients is important, explains Helen. Connor says that patients who are really anxious can be referred to a nurse practitioner, physician assistant, or doctor for a consult by video or phone. 

Patients who call one of the Atrius Health practices because they’re symptomatic or have questions about Covid-19 are immediately patched through to a member of the home-based triage team. Each member of the triage team has access to a list of scenarios that help them provide the most up-to-date, accurate information about Covid-19. For example, if a patient thinks they have the disease, the nurse or medical secretary will ask about their symptoms to determine if access to a Covid-19 test or a telehealth visit with a physician is appropriate.

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Every weekday morning before their shifts start at 8 a.m., triage team members participate in a 30-minute “virtual huddle” meeting where they learn about new symptoms, testing criteria, and guidance from state and federal agencies about Covid-19, says Connor. When patients call outside those hours, their calls are picked up by a different team of medical secretaries and nurses who have gone through the same training protocols as the weekday team. Connor adds that patients who call during the weekend and after-hours can also have access to a nurse practitioner or a physician assistant by video.

Smaller practices that want to set up a phone-based triage team should ensure they have coverage between the hours of 7 a.m. and 7 p.m. at a minimum, advises Connor. That’s because the majority of calls arrive before people leave for work and after work in the evening, she explains. 

Take-aways about the Covid-19 triage call team

Helen says the ability to alleviate patients’ fear is the most rewarding part of taking calls on the Covid-19 triage line. “This is new to everyone. We’re all nervous about this virus and how it can impact our lives and our families’ lives,” she explains. 

The team huddle, where team members can ask questions at the start of the day, helps ensure everyone’s communicating a consistent message with patients, says Helen. Patients have found the telephone-based care and telehealth visits to be so convenient that they don’t want them to end, she adds. 

What’s next for the Covid-19 triage call team? Connor says Atrius Health continues to evaluate patient call volume on a daily basis. One variable she uses to adjust staffing levels is the length of the calls from patients. She expects call volume to go down over the summer, but Atrius Health is planning for a potential Covid-19 symptom surge in the fall. “[We] will be prepared to bring our team back together at any time to restart our call center when needed,” says Connor. 

 that the state’s three-day average of Covid-19 deaths is 67 as of May 22, signaling the eighth day of decline. Hospitalizations of patients with Covid-19 are also trending downward.

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Curious about launching a remote patient monitoring program at your practice? Here’s a compelling reason to start one: remote patient monitoring costs approximately $1,500 a year per patient, while a single hospital admission can cost thousands of dollars.

Katie Nunn, CEO of Bright Ideas Medical Consulting, defines remote patient monitoring as collecting data from patients and receiving the data at the physician practice remotely. Examples of data collected from patients include weight, activity level, blood pressure, respiration, and blood-glucose levels, said Dunn during an April 16 session at MGMA20 | The Operations Conference, which took place virtually. Nunn counselled that this is a passive approach to monitoring, which means the physician office won’t be notified if the patient’s heart rate increases rapidly. Rather, it’s likely the practice will deploy a nurse who monitors patients’ vital signs on a daily basis using a dashboard.

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People with moderate to severe asthma may be at higher risk of getting seriously ill from Covid-19, the infectious disease caused by the novel coronavirus. That’s according to the U.S. Centers for Disease Control and Prevention (CDC). 

The best way for patients with moderate-to severe-asthma to prevent succumbing to Covid-19, as with all patients, is to avoid exposure to the virus. 

To reduce the risk that his patients with asthma will contract Covid-19, Matt Dougherty, MD, a St. Louis physician, is using telehealth to treat patients. He starts by thanking his patient for participating in a telehealth visit because the doctor’s office may not be the safest place to go right now. Dougherty explains that participating in a telehealth visit can keep them safe and out of the emergency room or a hospital that may be filled with people who can put them at greater risk.

"I have found that families really appreciate that we realize the limitations of what we can do in the office right now and love that we’re trying alternative ways to keep [them] healthy proactively,” says Dougherty.

What follows are eight additional tips from clinicians on establishing an empathetic connection with patients during a telehealth visit.

Tips from clinicians during the surge in telehealth demands.

Establishing empathy via telemedicine

One of the main differences between providing care in ordinary times and during a pandemic, such as the world is experiencing with the novel coronavirus, is the need to depart from what’s done in the best interests of the individual patient when there are limited resources, says Carl Coleman, JD, professor at Seton Hall University School of Law in Newark, N.J. He specializes in the legal, ethical, and public policy implications of medical treatment, research, and public health.

“When there are limited resources, it’s not possible to give everything to patients that might benefit them. Thinking about it from that perspective, it’s about what’s best for the community. That’s the shift-to a thoughtful use of limited resources to achieve the best outcome for the population as a whole,” says Coleman, acknowledging that this requires a mental shift in perspective.

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, and other parts of the country to increase resource capacity. Of primary concern are access to doctors and nurses to treat patients with Covid-19, and the availability of ventilators and hospital beds.

 the Society of Critical Care Medicine, there may be more than 200,000 ventilators in the United States, but shortages are expected. In response, U.S. automakers Ford and General Motors are partnering with ventilator manufacturers to ramp up production, but the 

 that these efforts will likely deliver ventilators after the peak of Covid-19 cases projected to occur in mid-April.

Kathy Butler, JD, a St. Louis-based attorney at Greensfelder, Hemker, and Gale law firm, says that her healthcare clients are looking at ways to stretch their resources by looking at alternative treatment sites and considering the need to double up patients on ventilators. 

The Hastings Center, a bioethics research institute and think tank based in Garrison, N.Y. 

 that healthcare organization’s institutional ethics services conduct focused preparation for the “[t]he foreseeable uncertainty and distress that clinicians and teams will face under contingency or crisis conditions call for focused preparation.”

“The real crisis is going to be in the hospital setting,” says Coleman. “The thing that people are most worried about is that there aren’t enough ventilators, or there soon will not be enough in some places. So, decisions will have to be made about who should get priority for a ventilator and potentially taking people off ventilators who aren’t responding in order to give them to those with [a] better prognosis.”

He stresses that access to critical care or a ventilator aren’t decisions that should be made by individual physicians. Key aspects of guidance should include the following:

A transparent process for applying the guidelines

A required separation between the person who decides about access to resources and the physician caring for the patient.

The people participating in developing this guidance for healthcare organizations should include medical ethicists, doctors, nurses, administrators, lawyers, and social workers, advises Coleman.

In addition to paying attention to their healthcare organization’s protocols, Kathryn Zeiler, JD, law professor at Boston University, advises physicians to look for guidance from their state’s department of public health, as well as the American Medical Association and their state’s medical association. These guidelines, especially about triage, should be short and very clear, she adds.

AMA’s guidance on triage decisions during pandemics 

the American Medical Association’s (AMA) guidance on public health emergencies, such as pandemics, the “commitment of fidelity to the individual patient is counterbalanced by the need to protect the welfare of a population of patients... and to be prudent stewards of limited societal resources entrusted to them.”

She explains that the guidelines tell doctors what to take into account and what not to take into account regarding triage.

Here are two circumstances doctors should take into account:

The allocation of any scarce resource, including their time, based on the urgency of the patient's need as the doctor assesses it. 

The likelihood and anticipated duration of the benefit of the doctor’s intervention and the change in the patient’s quality of life. 

Zeiler also gives two examples of characteristics a doctor can’t take into account:

Social worth. These considerations come into play when a doctor is presented with, for example, a patient who’s a scientist developing a cure for Covid-19 and the person who picks up the trash. The doctor shouldn’t take into account a person's employment, she explains.

The person’s contribution to the illness. For example, if the patient says they haven’t practiced social distancing, a doctor can’t take that into account in determining triage. 

Kay Van Wey, JD, a Dallas-based personal-injury attorney and patient safety advocate, points out that practices will also need to keep in mind access to care for patients who are managing chronic or other non-Covid-19-related conditions. Covid-19 testing will strain resources at lab testing facilities, in particular. 

Her advice to clinicians is to document their decision-making. For example, if a patient needs a STAT lab test but the lab is closed, the clinician can recommend that the patient order an at-home test online, and that should be documented. In addition, the clinician can advise the patient to go to the emergency room if their symptoms get worse and have a nurse call the patient the next day to check in. 

Patients with symptoms of Covid-19 will also be calling physician practices. Butler advises physicians to triage these patients based on their symptoms and related comorbidities and direct them to the appropriate level of care, per the Centers for Disease Control and Prevention’s 

. For example, an otherwise healthy patient in her thirties will likely be told to manage the condition at home and, hopefully, survive. She contrasts that with a patient with a heart condition or diabetes who’s having trouble breathing; that patient needs to go to the emergency room because they may crash and need someone to help them.

Individual physicians should not be determining critical care and ventilator use.

Author | Aine Cryts

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