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In and Out of the Hospital, Neurohospitalists Shift Course for the Surge in COVID-19

When a longtime patient developed worrisome neurological symptoms in March, W. David Freeman, MD, FAAN, a neurologist at Mayo Clinic in Jacksonville, FL, interfaced with him via telemedicine. The virtual visit averted a trip to a hospital emergency room teeming with potentially contagious patients during the COVID-19 pandemic.

Dr. Freeman's patient, who had had a brain aneurysm before age 40 several years ago, had slurred speech and numbness and weakness on one side of his body. To arrange a virtual consultation, Mayo Clinic's Connected care team guided the patient, a former Florida resident who now lives in another state, in how to access telehealth software on his home computer and interact with Dr. Freeman.

With those symptoms, "first, we're always thinking about transient ischemic attack, a warning sign of the potential for a severe stroke," said Dr. Freeman, professor of neurology and neurosurgery at Mayo Clinic, where he is medical director of the neurosciences intensive care unit. "Seizure can be another mimic."

Before the virtual visit, symptoms had resolved, but Dr. Freeman advised the patient to check in via telemedicine to assess his neurological status on the National Institutes of Health Stroke Scale, as he would with a clinic visit. After a reassuring televisit and recommendations, Dr. Freeman and the patient agreed to schedule an in-person visit back in the clinic a few months later.

On the hospital side, Dr. Freeman was one of the first physicians at Mayo Clinic in Florida to use a telemedicine robot positioned in the emergency department to examine acute stroke patients remotely for administration of intravenous recombinant tissue plasminogen activator. Nowadays, these telepresense robots can be equipped with a stethoscope and ultrasound port, which may allow a nurse, respiratory therapist, and physician to listen to the lungs from another location. Such a telemedicine robot enabled Leslie V. Simon, DO, an emergency medicine physician and department chair, to develop a process that led to the first virtual diagnosis of COVID-19 at Mayo Clinic in Florida, with minimal use of personal protective equipment and exposure to staff, Dr. Freeman said.

Respiratory distress can be seen on observation by using the visual camera on the telemedicine robot if a patient is breathing heavily or in distress, without the stethoscope, Dr. Freeman explained. However, "not all patients can be examined this way, if they are uncooperative or already on a breathing tube and require a proxy examiner such as a nurse in personal protective equipment."

In addition, "COVID-19 has also forced us to rethink and consolidate nursing and medical staff trips into an admitted patient's room," administering medications every four to eight hours, if possible, instead of spacing them out every one to two hours.

Triaging Patients Remotely

As the coronavirus pandemic continues to strain the resources of health care systems across the country, neurologists are turning to telemedicine to triage patients remotely. With sophisticated technologies, they can replicate more of a traditional doctor's visit by observing and communicating with patients without risking a life-threatening infection.

Limiting the number of in-person interactions by using telemedicine and other methods also preserves the limited supply of personal protective equipment for front-line workers and enables them to carry out their job duties as safely as possible.

"We're in a crisis," said Jana Wold, MD, associate professor of neurology and director of the veterans' affairs stroke program at the University of Utah Clinical Neurosciences Center in Salt Lake City. "We're trying to keep our workforce well and as minimally exposed as possible. Otherwise, we won't have a workforce."

Despite having to expend additional time and effort setting up the camera and other equipment for telemedicine, nurses and other staff "recognize that these are unique and unprecedented times," added Dr. Wold, who is also director of the adult neurology residency program. Health care workers are fully aware that "this is the time to be innovative and to use technology in ways that we haven't before."

Telemedicine in the ED

Telemedicine isn't a new phenomenon for many academic medical centers, including the University of Utah School of Medicine, which operates a broad telestroke network with 27 sites in the traditional hub-spoke model.

"But this is a first for us to use it in our own emergency department, as we would normally just see these patients in person," she said. 

Asked how patients and families perceive the telehealth rollout in the emergency setting, Dr. Wold said: "The system is too early in use to know, but we have heard that the ED providers have been appreciative."

The trend toward incorporating technology in medical education while practicing social distancing "allows our trainees to see the patient over the camera and not in person, decreasing their overall exposure risk," Dr. Wold added.

At NewYork-Presbyterian/Weill Cornell Medical College, situated at the epicenter of the U.S. coronavirus outbreak, most neurologists with outpatient office hours have converted those appointments to telemedicine visits, said Louise M. Klebanoff, MD, vice chair of clinical operations in the department of neurology.

In her experience, video-based visits are more suited for established patients. She is more comfortable using telemedicine for patients she previously examined and found to be stable with a baseline abnormality.

For new patients, however, those types of visits are not as straightforward for Dr. Klebanoff, a general neurologist who welcomes diagnostic challenges that present with the management of headaches and migraines, neck and back pain, pinched nerves, dizziness, and vertigo.

"Without actually examining the patient, it is really difficult to do the type of evaluation I need to do," she said. "When assessing a patient for dizziness, the physical examination allows me to determine if they have low blood pressure causing light-headedness, trouble walking, or benign positional vertigo."

A Coronavirus Isolation Protocol

For truly urgent medical needs, Dr. Klebanoff said, patients should still visit the hospital emergency room. A coronavirus isolation protocol has been instituted at New York-Presbyterian/Weill Cornell Medical College.

"At this time, our ED is separating COVID-19 patients from non-COVID patients," she said. "We have assigned attending physicians who are usually doing outpatient appointments to rotate through the ER to care for these patients."

At least one attending physician in every subspecialty is available for telephone consultations on an as-needed basis. Patient assessments in the emergency department will be followed with office appointments once that becomes a possibility. Hospitalists, as well as attending physicians specializing in stroke and critical care, are working as part of inpatient teams treating COVID-19 patients, Dr. Klebanoff said.

Anticipating a Patient Surge

The mounting difficulties facing neurology peers on the country's east coast are on the mind of S. Andrew Josephson, MD, FAAN, professor and chair of neurology at the University of California, San Francisco.

As a neurohospitalist, Dr. Josephson is preparing for "a large surge" in his region, just in case, by planning and changing workflows to be "a step ahead of the acceleration" in growth of coronavirus cases.

On the outpatient side, providers are conducting very few in-person visits, except for the most urgent cases. "We are almost purely telehealth at this point," Dr. Josephson said.

He noted that a shelter-in-place order in San Francisco, coupled with many patients watching young children at home during school closures, have made virtual visits much more convenient for faculty, staff, and patients while also halting spread of the virus.

Around hospitalized patients, clinical teams are more conscious than ever of the need to wear personal protective equipment while tending to those who have endured a stroke, complications from epilepsy, and other neurological emergencies during the pandemic. Amid a widespread U.S. shortage of masks and gowns, Dr. Josephson said, one clinician is typically tasked with performing a hands-on patient exam in a room of the intensive care unit while other providers observe through a glass window.

In addition, within the hospital, we have "expanded our ability to do video visits." Only one provider may be in the room with a patient, but the rest of them, including trainees, and a multidisciplinary team—for instance, a respiratory therapist, social worker, and chaplain—could be beaming in via telemedicine to participate in the visit. This approach saves the available personal protective equipment for first responders directly seeing patients while also preventing the virus from infecting patients and staff, Dr. Josephson said.

The Centers for Medicare and Medicaid Services is now allowing reimbursement for virtual visits to be billed at the same rates as face-to-face clinical encounters Such modifications mean providers won't be forced to choose between the usual reimbursement and the need to adhere to social distancing guidelines, Dr. Josephson said.

He noted that the AAN has disseminated information about these relevant changes on its website.

For the very few patients seated in outpatient waiting rooms, the medical center is helping them maintain social distancing by rearranging chairs far apart and cleaning the areas more frequently. Even before patients and employees enter, Dr. Josephson said, they must answer questions about symptoms potentially suspicious for coronavirus, such as fever and cough. Those with symptoms are directed to respiratory screening clinics to determine whether they need to undergo further testing.

Preserving the Workforce

Conducting departmental meetings virtually from his office, he has been able to interact with his colleagues remotely, most of whom are working from home.

"We also want to make sure that we're preserving our workforce," he said, foreseeing backup plans to substitute for faculty and residents who may become ill.

At EvergreenHealth in Kirkland, WA, regional care coordination between hospitals has ramped up since the first US cases of coronavirus were confirmed at its facility on February 28, said David Likosky, MD, FAAN, executive medical director of the EvergreenHealth Neuroscience Institute.

Close collaboration with various area hospitals, the health department, and other governmental agencies has helped plan the allocation of resources to where they are most in demand. No one hospital can do it all alone without reliance on others in a public health emergency of this magnitude, said Dr. Likosky, who is also director of stroke and neurohospitalist programs.

For surge planning in the hospital setting, neurointensivists help back up pulmonary critical care specialists; neurohospitalists back up the neurointensivists and clinic neurologists (who may have lighter schedules) back up the neurohospitalists. 

Working Across Subspecialties

"You can see how this cascades out in a tiered fashion to meet the needs of our patients," Dr. Likosky said. So far, he added, EvergreenHealth—along with Washington state's aggressive and early social distancing and cancellation of elective surgeries and visits—has flattened the resource need curve enough that, while there has been a significant strain, patients have not gone without ventilators or appropriate nursing care.

At Cleveland Clinic, telemedicine visits have also become the norm during the pandemic for evaluating neurological conditions and titrating medications for previously examined patients. In addition, "there are ongoing preparations for the possibility that neurologists may need to help with the shortage of providers to care for critically ill patients," said Marisa McGinley, DO, a neurologist and assistant professor of medicine in the Cleveland Clinic Lerner College of Medicine.

"The current plan for redeployment would be for neurologists to aid with caring for non-ICU patients," Dr. McGinley said. "In order to prepare neurologists for these types of duties, educational sessions are being designed to provide useful information about potential situations they may encounter."