AN INTERNAL MEDICINE RESIDENCY RESPONSE TO THE COVID-19 PANDEMIC IN LOUISIANA Seth M. Vignes, MD; Brittany L. Boudreaux, DO; Shane E. Sanne, DO; Catherine M. Hebert, MD; and Lee S. Engel, MD, PhD Department of Internal Medicine, Louisiana State University Health Sciences Center, New Orleans
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FIGURE 1: COVID-19 Cases in New Orleans March 2020 to February 2021 (Centers for Disease Control data: https://covid.cdc.gov/covid-data-tracker/#county-view)
ABSTRACT
The novel human coronavirus disease, COVID-19, was first identified in Wuhan China in December 2019 and quickly spread to the entire planet. While New Orleans enjoyed Mardi Gras in February of 2020, we were unaware that the ongoing mix of tourism and gathering of large crowds would fuel the spread of the COVID-19 pandemic to our city and state. New Orleans saw its initial and largest COVID peak to date in early April 2020. At the peak, all the hospitals in the greater New Orleans area quickly became inundated with patients affected by COVID-19. The goal of this article is to share our experience, our designed responses to the multitude of issues facing our internal medicine residency program, and the lessons we learned during the COVID-19 pandemic.
two interns and a cap of twenty patients’ maximum on each team that took call every four days. A separate night float resident and intern managed admissions from the Emergency Department and general floor call. There was no cap on new patient admits because there was no other hospitalist service available. Themedical intensive care unit (MICU) was a closed unit with resident teams from LSUHSC internal medicine programs, Tulane internal medicine programs and the LSUHSC emergency medicine program. We also had residents and interns on ambulatory rotations, consult rotations, quality improvement/patient safety rotations, and interns on emergency medicine rotations. Pre-pandemic at Touro Infirmary (Touro), LSUHSC internal medicine had four medicine ward teams with one resident and one intern each that took call every four days and one night float intern on Monday through Friday. We only had enough residency cap positions to maintain the ward services. We did not have any residents on consult or elective rotations at that site due to cap limitations. Pre-Pandemic at Ochsner-Kenner Medical Center (OKMC), LSUHSC internal medicine had four medicine ward teams with one resident and one intern each took call every four days. There were two night float interns who rotated every three days. We also had five other house officers on consult rotations. INITIAL COVID-19 PEAK RESPONSE AND MODELS
would need more medicine teams devoted to COVID-19 patients. At this point, to meet the demands of the rapidly increasing number of patients with COVID-19, we shifted from a reactionary model to a proactive model that would allow us to care for a maximum capacity of patients, cohort patients, cohort at-risk house officers and faculty (those who were pregnant or had underlying health issues, etc.), and reduce the need for continual schedule changes. We created two more medicine ward teams, giving us six ward teams (Teams 1 to 6). Team 1 was staffed by faculty and residents who were either pregnant or had underlying reasons that put them at greater risk of adverse outcomes from COVID-19, and we designated this the non-COVID team. Team 1 admitted all patients who tested negative for COVID, clinically did not appear to have COVID, and had clear alternate diagnoses. Teams 2 thru 6 admitted all the COVID patients on a rotating call system. We went from an every fourth night call to an every sixth night call. The call team took admits from the Emergency Department (ED) and transfers from the MICU. Patients with COVID-19 took longer to improve; therefore, one unforeseen benefit of the every sixth night call schedule was that the medicine teams were able to achieve more patient dispositions prior to their next call. These early days were characterized by fear of transmission, feelings of helplessness over patients who were decompensating, and lack of available testing. Resident and intern wellness benefited from the decrease in call-day frequency. UMC brought in a private locums hospitalist group towards the end of April, which helped reduce the burden on our academic ward teams. The MICU took direct admits from the ED and floor transfer for patientswho requiredmore care than couldbe provided on the medicine wards. Patients who were stepped up to the MICU, would usually go back to the same medicine teamwhen stabilized. The cap for the residents and interns on the medicine teams remained at twenty. However, at times more than twenty patients were admitted to the medicine teams and these patients were seen by the faculty attending physician without the residents to abide by ACGME regulations. Similar to previously published
INTRODUCTION
first few months after evaluating genome sequencing and cell phone tracking data. 2,3 As of this writing, there have been over four hundred thousand cases of COVID-19 with over nine thousand deaths in Louisiana. The largest peak in the New Orleans area occurred in April 2020 with other smaller peaks in July 2020 and January 2021 (Figure 1). Here we share the responses that the internal medicine residency program at Louisiana State University Health Sciences Center (LSUHSC) in New Orleans made to the pandemicwith regards to resident/intern-delivered patient care, communication, resident/intern education, resident/ intern wellness, residency recruitment, and the COVID-19 vaccination efforts that have ensued since March 2020. PATIENT CARE AND RESIDENCY STRUCTURE ATOURTEACHINGHOSPITALSPRE-PANDMIC AND DURING THE PANDEMIC
The novel human coronavirus disease, COVID-19, that was first identified in Wuhan China in December 2019, represents the fifth documented pandemic since the 1918 flu pandemic. 1 The initial rapid ascent of COVID-19 in New Orleans and Louisiana was likely the result of a combination of increased global tourism in our city and the gathering of large crowds for theMardi Gras celebration that occurred in February 2020. With the subsequent availability of testing, the first reported case of COVID-19 in Louisiana occurred on March 9, 2020 at the Veterans Administration Medical Center in New Orleans. By the following day, there were two more cases at separate New Orleans area hospitals. The World Health Organization declared coronavirus a pandemic on March 11, 2020. Reported coronavirus cases rapidly increased and the first Louisiana deathwas reported on March 14, 2020. During the following ten days, schools closed, hospitals limited visitors, bars and restaurants shut down, and drive through testing sites opened. Confirmed cases increased to over one thousand, and a “stay at home” order was issued for Louisiana. By the end of March, there were over four thousand COVID-19 cases in Louisiana and a few states set up interstate checkpoints to prevent travelers from New Orleans from entering. On April 1, 2020, Louisiana had the highest per capita deaths from COVID-19 in the U.S. A pre-publication report by researchers at Scripps Research Institute, Tulane University, and LSU Health Shreveport proposes that the coronavirus most likely arrived in New Orleans about two weeks before Mardi Gras 2 . These researchers suspects that one case source exploded into 50,000 confirmed cases over those
PRE-COVID-19 PANDEMIC STRUCTURE
Residents and interns from the Internal Medicine Residency programat LSUHSC in NewOrleans rotate at three hospitals for inpatient ward rotations (University Medical Center, Touro Infirmary, and Ochsner-Kenner Medical Center) in the greater New Orleans area that includes Orleans and Jefferson Parishes. University Medical Center (UMC) is unique in that it is an academic training hospital, where both LSUHSC and Tulane Health Sciences Center have independent internal medicine rotations. Pre-pandemic, LSUHSC internal medicine had four ward teams each with one resident and
Pandemic response at UMC
Following the first reported case of COVID-19 in New Orleans onMarch 9, 2020, a rapid increase in cases occurred at all three of our hospital sites. The initial rise COVID-19 at UMC occurred during the third week of March, 2020. At first we responded by cohorting all the patients with COVID-19 on one Medicine ward team. Two days later, we had two medicine teams that were devoted to COVID-19 patients and by the fourth week of March we quickly realized we
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J LA MED SOC | VOL 173 | SUMMER 2021
J LA MED SOC | VOL 173 | SUMMER 2021
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