recruitment, and the COVID-19 vaccination efforts that have ensued since March 2020. PATIENT CARE AND RESIDENCY STRUCTURE AT OUR TEACHING HOSPITALS PRE- PANDMIC AND DURING THE PANDEMIC PRE-COVID-19 PANDEMIC STRUCTURE Residents and interns from the Internal Medicine Residency program at LSUHSC in New Orleans 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 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. The medical 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.
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 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 patients who requiredmore care than could be provided on the medicine wards. Patients who were stepped up to the MICU, would usually go back to the same medicine team when 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 reports on reorganizing a medicine residency program in response to COVID-19 and on internal medicine resident work absence during the COVID-19 pandemic 4,5 , coverage for our extra medicine ward teams was accomplished by pulling residents and interns off most consult services, ambulatory rotations, and quality improvement rotations. We added more house officers to the pulmonary consult service and the infectious disease consult service. We maintained 37
INITIAL COVID-19 PEAK RESPONSE AND MODELS
PANDEMIC RESPONSE AT UMC
Following the first reported case of COVID-19 in New Orleans on March 9, 2020, a rapid increase in cases occurred
Made with FlippingBook Digital Publishing Software