EDITOR’S NOTE: Dr. David Jury is active in the Fundamentals of Critical Care Support course committee of the Society of Critical Care Medicine (SCCM) which made possible the contribution of this essay along with editorial support from Piyush Mathur, MD, FCCM who is a staff anesthesiologist and critical care physician at Cleveland Clinic. Both are SCCA members. In his role with the SCCA, Dr. Jury is rewriting the society's 7th edition. All opinions expressed in the article are the author’s only.
My intensive care unit workday begins with a handoff from my overnight telemedicine colleague. No sooner than getting off the phone with the overnight telemedicine physician, my pager goes off. Another sick COVID-19 patient in the emergency department (ED) needs an ICU admission. Patient’s breathing is very labored, and the ED physician has determined that the patient is going to require placing a breathing tube (intubation) to be put on a breathing machine (ventilator). Many of these patients require additional procedures such as placing a central venous access to safely deliver certain medications that COVID-19 patients often require. Often these invasive procedures give our patients the best chance of survival. In many instances these can be difficult decisions for patients or their families to make. This elderly patient has many chronic health problems including moderate dementia. This patient thus can't decide for themselves, and so this decision is going to fall on his daughter. We obtain a palliative medicine consult to help the patient's daughter make the right decision for her father.
Palliative medicine specializes in relief of symptoms, stress and pain of disease rather than a cure. We find their recommendations helpful in offering adjunct or alternative care for the sickest of my patients, as their focus is often more relevant to what's most important to the patient and to minimize their suffering. Palliative medicine service isn't always available in many hospitals, and certainly it's more limited on nights or weekends. Because of new CMS telemedicine guidelines, consults like these can be done remotely, dramatically increasing the palliative medicine clinicians reach and access to care for the patients with reimbursement.
The palliative medicine consultant is brought on the virtual visit platform, avoiding their risk of COVID19 exposure and quickly reviews the patient’s medical condition. Within a few short minutes we are able to sum up the patient's clinical condition, review treatment options and present this to the daughter who can make an informed decision. This type of multidisciplinary and timely care is what we've always strived to deliver for our patients. The difference is now remote access allows it to be delivered more consistently and with appropriate reimbursement.
The day is a busy one with new patients from overnight and old ones from before. I talk to the nurses first to get an overview of the patients and address their concerns. This often brings issues to my attention that may appear to be of small clinical significance to a physician but are paramount to a patient's nursing care. Afterwards I review all the new data such as laboratory results, X-rays and consultant physician notes, many of which can now be done remotely under the revised CMS guidelines limiting the physician’s exposure and simultaneously broadening their reach. From this I formulate a plan for each and every patient for the day. Then it's time for bedside rounds. For non COVID-19 patients, the multidisciplinary team of nurses, respiratory therapist, pharmacist and social work discuss each patient in detail with the patient so that they understand what the care plan is and have the opportunity to ask any questions about their care plan. Patient is the most important part of the team and participates up to the limit of their capacity. If they are unable to participate in a meaningful way, their designated decision maker is updated and engaged in a similar manner. For COVID19 patients, we still try to minimize multiple caregiver direct physical interactions to minimize exposure. I don full PPE before evaluating the patient and then update the patient about his/her care plan. Rest of the multidisciplinary team can make patient assessments virtually or using my evaluation.
On the other side of the unit and emotional spectrum, I feel rewarded as one of our COVID-19 patients is doing much better today! He was on the ventilator for almost two weeks but was liberated from it several days ago. Over the last few days his oxygen requirements have decreased and he's well enough to eat on his own although still very weak. Because of revised CMS guidelines the physical and occupational therapists can work with him virtually with electronic media like an iPad to help him regain strength and range of motion. I see him smile for the first time.
Moments like this are what I'm here for. Seeing these patients at their worst and helping them heal to reclaim their independence is rewarding and gratifying in ways that's hard to put into words. Case management is helping him get discharged home with oxygen, another item that revised CMS guidelines has simplified. The long day taking care of many such patients is physically exhausting and emotionally challenging. I called the Tele-intensivist and gave him a report. Tele-intensivists manage several hospital ICUs along with advance care providers (ACP) who work at each physical ICU location. ACP responsibilities are broad and diverse covering everything from overnight admissions to the ICU, rapid response team calls on the regular nursing floor, decompensating patients in the unit, to basic orders for pain, nausea, delirium, to just talking to and offering reassurance to the patients. Now with the updated CMS telemedicine the tele-intensivist can document and be directly reimbursed for their services via remote patient monitoring. This also offloads documentation burden from the in-house provider freeing them up to do procedures, address floor calls, or simply be present at the bedside for a patient that needs them. If several admissions arrive simultaneously the remote provider was always available to assist with order entry and decision making but now can be reimbursed for their admission sometimes using CPT code 99291.
Many of these interventions would not have been possible without CMS making several key temporary regulatory changes to help providers deal with the COVID-19 pandemic, effectively immediately. The goals have been clear and are there to support creation of temporary hospitals, facilitate out of state hiring of providers, increase access to telemedicine, increase availability of testing, and to minimize paperwork. Telemedicine is a great approach for the COVID-19 pandemic as it allows for the care of patients while practicing social distancing. Telemedicine isn’t new but providing the breadth and diversity of healthcare services that COVID-19 demands creates new challenges including documentation and reimbursement.
I love what I do. I'm intellectually stimulated, emotionally rewarded and challenged at the same time nearly every day. COVID-19 brings a new set of challenges to my occupation but I can't imagine doing anything else.
Programming Note: Listen to Dr. Jury on Talk Ten Tuesdays on June 15, 10-10:30 a.m. EST.