Family Medicine Leaders During COVID

Describe what you/your faculty/department/program/clinic did that demonstrated that family physicians are leaders in health systems.
Throughout the course of the pandemic, including current and ongoing efforts, the Department of Family and Community Medicine (FCM) has played an integral, and recognized role, in the pandemic response at The Ohio State University. This was true in both the inpatient and outpatient ambulatory settings.

The Ohio State University has two centrally located hospitals in the metro area. The smaller hospital is a very busy community based hospital providing for patients that are underserved. The FCM residency program has established a robust inpatient service at this hospital. The Medical Director of Inpatient Services reached out to our Director of Family Medicine Inpatient Services to address the needs of the hospital and the community when the number of patients being admitted was increasing. We were in a unique position to respond as our FM training provides for urgent and emergency care, inpatient, ICU and obstetrical skills. The response to the inpatient needs was met through the process outlined:

1. Identification of inpatient team: A survey was sent to all faculty to determine their skill levels to create additional inpatient teams. There were many recent residency graduates that were able to easily transition to inpatient care. Current inpatient attending physicians were trained to work in the ED if needed. There was a small subset that trained for ICU or OB care as needed. Each faculty member was assigned to a team based on these skills levels. New inpatient teams were designed to meet the expected surge in hospitalized patients. We planned to deploy these additional teams in a step-wise fashion, based on inpatient volume and need.
2. Inpatient surge teams in order of deployment:
   • 1 additional FM resident team to double the current inpatient capacity
   • 1 FM independent hospitalist
   • 1 FM attending on night float (estimated 30 pts cross cover) in addition to the current resident night float coverage
3. Training of inpatient teams: Online materials were distributed and required for all team members related to ICU care, ventilator management, Palliative care, and current COVID 19 treatment guidelines to enhance the inpatient team skills.
4. Activation of surge inpatient team: Mid-November, the hospital administration reached out to the department in conjunction with general internal medicine to request that we activate the first level of our planned surge deployment. The FM surge team would consist of an attending physician and a resident physician. They would be assigned patients in a rotation with the other hospital services. The attending would be required to be in the hospital and perform the same duties as the resident during their coverage period. The attending would staff all admissions overnight. At the end of the coverage period the attending physicians were given two days off to catch up prior to returning to their regular clinical duties. During their time on the service and their recovery time, an outpatient physician was assigned to cover all of their outpatient care and clinical communications. The department of Family and Community Medicine provided this extra team until the end of January. At that time, our hospital census had improved.

In the ambulatory arena FCM supported/developed/implemented a number of initiatives that were integral to the institutions response to coronavirus:

1. Support of inpatient teams: To support the additional FCM inpatient team managing coronavirus patients, the outpatient providers assumed electronic health record in-basket coverage during a faculty member's time on service, plus two additional days for them to decompress. This way any provider responsible for managing coronavirus patients in the inpatient setting would not have to worry about anything else.
2. Acute care management: Early in the pandemic, the institution was concerned with respect to how to safely manage acute patients in the ambulatory setting to help decompress the ED but to do so in a manner that provided the type of care that was necessary. The Department of FCM in partnership with General Internal Medicine, developed and implemented a drive-up upper respiratory clinic for this purpose. This clinic was staffed by FCM nurse practitioners working at the coronavirus swab station, who could take vitals, and evaluate/auscultate patients helping to formulate a team-based plan. In addition, all offices developed their own process for seeing patients who may be COVID positive. This included the last appointment of the day being reserved for such patients, and/or evaluating such patients in the parking lot. Full PPE was provided and all faculty continue to participate in managing acute patient needs throughout the pandemic. Due to this success, FCM was asked to help develop a plan to discharge stable coronavirus patients from the hospital sooner, or ED without admitting them with close primary care follow up to ensure safety.
3. Vaccine prioritization committee: Due to the recognition FCM’s contribution to ongoing coronavirus efforts, FCM was asked to provide representation to the institutions vaccine prioritization committee. This committee, of which there were 15 members, outlined the process for equitable and equal vaccine distribution. Of great import, was the decision of the committee to vaccinate based on exposure risk, not job title. As such, cafeteria workers delivering food to patients, patient transport associates, and environmental employees for example were prioritized ahead of some clinicians, based on risk. This allowed for an equitable distribution of this scarce resource. FCM was one of only a limited number of specialties to be asked to participate on this committee.
4. Staff/patient vaccination: FCM was instrumental in staffing the centrally located coronavirus vaccination clinic at Ohio State when vaccine became available. Physicians, clinical pharmacists, and staff all participated in helping to provide coronavirus vaccines to patients in need. As a result of this work, as of February 1, 2021, over 30,000 doses had been provided accounting for 1 of every 933 of all vaccinations in the United States, based on a total of 28 million doses as reported by NBC news. This would not have been possible without the total engagement of the FCM in helping to support this endeavor.
5. Monoclonal antibody treatment: The use of monoclonal antibodies to reduce COVID disease burden has played a large role at our institution. The Clinical pharmacist team implemented a daily review protocol of new COVID-positive patients in FCM and evaluated them for referral for monoclonal antibody treatment. This was all done behind the scenes allowing providers to focus on front facing patient needs. It is estimated that the use of monoclonal antibodies has resulted in close to 100 less admission to OSU hospitals allowing room for other patients who needed care.
6. Chronic coronavirus patients, also known as COVID long haulers: Intuitional leadership asked FCM to help establish a coronavirus long haul clinic for patients with chronic symptoms related to coronavirus infection. This is an ongoing initiative that is still under development

It is clear that FCM met and continues to meet the need of the community and institution during this time of crisis. Throughout, health system leadership has recognized the important contributions of family medicine, and as such continues to consult the department with respect to ongoing and evolving endeavors.

How did you communicate with health systems leaders during the process?
At a hospital level, The Director of the Family Medicine Inpatient service was in continual communication with both the Medical Director of the hospital, as well as the Director of the Internal Medicine Inpatient service. Given our longstanding relationship with hospital leadership and relatively small pool of physicians in our community hospital, very frequent direct conversation was easily accomplished, in additional to the scheduled formal meetings. During the height of the surge, the Director of the FCM inpatient service sent out weekly emails to residents and inpatient attendings with any pertinent updates. If there were any urgent updates, separate meetings or emails were sent out.

At the University level, FCM leadership was present on the daily leadership coronavirus update call, and was represented throughout on committees (vaccine prioritization, acute ambulatory response) allowing for communication at the highest levels. Furthermore, due to longstanding relationships between institutional leadership and FCM, direct real time communication by email and text was encouraged and utilized.

What type of feedback have you received about your efforts?
This is a message from the Medical Director of the hospital: “I wanted to be sure that you and all of the family medicine residents and attendings know just how much I appreciated your department's willingness to step up to provide extra coverage at East Hospital during the COVID pandemic inpatient surge. It was the 'can-do' attitude of your doctors that helped us accommodate our patients and serve our community. In difficult months where it is easy to fall back on grumbling and complaining, all I ever heard from the family medicine team was 'What can we do to help?' You really set an example by coming back early from your maternity leave to cover the family medicine surge service. I'm hoping that COVID will be behind us soon, but your team's response to it played an integral role in ensuring the community's access to high quality medical care during these difficult times.”

What type of impact do you think this will have on your health systems leaders’ perception of family medicine?
This has clearly resulted in a positive reflection on family medicine. FCM answered the call when asked without hesitation. FCM stood up a new inpatient team in weeks, and developed and implemented ambulatory protocols that ensured safe patient care without loss of access. As a result FCM was brought into ever more increasing decision making needs and continues to be an invited participant at the institutional level. Going forward, the work FCM did during this pandemic will reflect positively on what family medicine is able to provide which will result in ever increasing recognition and support of health system needs.

What type of advice would you give to other family physicians or family medicine faculty about helping health systems leaders see the value of family medicine?
Volunteer when the call goes out. Don’t say no, and look for a way to engage but also enhance and expand needs of patients and the health system not previously recognized.