Preparation is key for disaster management. It includes identifying heath-care worker capability, surge capacity, disposable medical resources, and expert consultation availability.
Staff
Dr. Mary Jane Reed
In disaster, the hospital transitions to a mass casualty strategy, repurposing noncritical care staff to a tiered critical care model focusing on disaster triage and mass critical care. The goal is to provide care to minimize mortality.
Stuff
Critical care supplies improve survival and are implemented quickly and easily. Essential supplies include personal protective equipment, basic modes of mechanical ventilation, hemodynamic support, antimicrobial therapy or other disease-specific countermeasures, oxygen, and prophylactic treatments.
Structure
Disaster critical care can be delivered in noncritical care areas. Hospital policies should establish surge capacity strategies.
System
Providing quality lifesaving care to appropriately triaged patients by utilizing minimal qualifications for survival, predetermined ICU admission criteria, and dynamic protocols using the highest level of evidence available scalable to local resources.
Inappropriate triage results in suboptimal care and can lead to increased mortality.
Virtual critical care can augment critical care capacity and capability.
The implementation of mass critical care requires hospitals to rapidly increase its patient volume above its normal capacity. The essential four components are staff, stuff, space, and structure. Effective mass critical care requires a different mindset than critical care in day-to-day operations.
Patrick Moon, MD; and Alexis MacDonald, MD
(Drs. Reed and Tripp's Fellows)
Mary Jane Reed, MD, FCCP, and Michael Tripp, MD, FCCP
Steering Committee Members
Practice Operations
Dr. Haala Rokadia
Over the years since telemedicine (TM) was developed in the 1960s, it has transformed into more mobile, compact, and interconnected forms. However, its widespread adoption has been limited by the regulatory, compensatory, and licensing status quo. The emergence of the COVID-19 pandemic and its necessity for physical distancing has brought TM into the limelight. With restrictions on TM use lifted by CMS, the scope of TM could extend from outpatient to inpatient care to emergency triaging and management of chronic medical conditions.
Dr. Humayun Anjum
In February 2020, the comprehensive 2020 COVID-19 ICD 10 coding guidelines were released. To date, CMS has approved approximately 80 codes, which can be used with telehealth and non face-face-to-face (NFTF) encounters. They include telephone calls, online digital E/M services, interprofessional telephone/internet/electric health record consultations, digitally stored data services/remote physiologic monitoring, remote reporting of self-measure blood pressure, and remote physiologic monitoring treatment management services. Some of the key "rules of the game" are highlighted below.
- For telephone visits in the outpatient setting use the codes 99441 (5-10 minutes), 99442 (11-20 minutes), and 99443 (21-30 minutes).
- For interactive real-time audio and video telecommunication (RAVT) in the outpatient setting, use the codes normally used for outpatient E/M: 99201-99215.
- For using RAVT to perform an initial visit for an inpatient, use the codes that are normally used for inpatient E/M: 99221-99223.
- For using RAVT to perform a subsequent visit for an inpatient, use the codes that are normally used for subsequent hospital care service E/M: 99231-99233.
- Seeing a critically ill patient without being in the patient's room is allowed, as a physical exam is not required for either 99291 or 99292. Be sure to use 99292 for each 30 minutes beyond the initial 74 minutes and document the time spent on the patient.
The details of the coding/billing guidelines are intricate and full of nuances and for a better understanding on how to utilize TM both in an inpatient and outpatient setting, consider the following resources:
1. CHEST Experience presentation entitled "TELE MEDICINE/TELE HEALTH IN THE ERA OF PANDEMIC" at the CHEST Annual Meeting 2020.
1. Coding and Billing Guidelines by ATS:
https://www.thoracic.org/about/newsroom/newsletters/coding-and-billing/resources/2020/mostrecentcbqapril.pdf
2. Coding specific for management of COVID patients by the AMA:
https://www.ama-assn.org/system/files/2020-05/covid-19-coding-advice.pdf
Humayun Anjum, MD, FCCP
Vice-Chair, Practice Operations
Haala Rokadia, MD, FCCP
Practice Operations NetWork Steering Committee Member
Transplant
Physical therapy teleconsultations
Dr. Joshua Diamond
The COVID 19 pandemic led the health-care community to rapidly adopt telecommunication tools allowing provision of care equivalent to in-person visits. Implementation of telemedicine visits demonstrated that providers can simultaneously distance and connect with patients to provide expert care.
The University of Pennsylvania lung transplant team adapted video communications to provide individualized physical therapy (PT) recommendations for lung transplantation candidates. The evaluation includes a systems review, musculoskeletal screen, submaximal aerobic capacity testing, and performance of the short physical performance battery test (SPPBT), a frequently used frailty evaluation tool focused on lower extremity function and balance. In the era of social distancing, telemedicine capabilities have made this crucial aspect of pretransplant evaluation possible.
In advance, patients are emailed a document outlining the telemedicine PT assessment, including the SPPBT. Patients receive videos of the SPPBT to ensure they understand the test and can prepare their home to safely perform the tasks. We are able to highlight the patient's functional capabilities and detail accurate assessments of their deficits. Our teleconsultations utilize BlueJeans for connectivity and typically last about 30 minutes. At this time, we are billing for these pretransplant visits but not for posttransplant PT follow-up.
Dr. Derek Zaleski
Patient experiences with the PT teleconsultations have been overwhelmingly positive. Patients and their families appreciate the uninterrupted evaluation time and the individualized recommendations for improving their deficits. The providers can devote their full attention to the patient directly in front of them. Importantly, patients and providers report they have never felt a stronger connection than through these telemedicine encounters. Longitudinal telemedicine PT assessments will enable us to better monitor our patients throughout the lung transplantation process.
Joshua Diamond, MD
Steering Committee Member
Derek Zaleski, PT, DPT
Women's Lung Health
SARS-COV-2 and pregnancy
The SARS-COV-2 pandemic has brought on many fears and uncertainties with new information emerging daily, including the effect during pregnancy. At the time of this article,however, data pertaining to COVID-19 and pregnancy remain limited. Pregnant women do not seem to have a higher infection rate than the general population. In a correspondence where pregnant women admitted for delivery underwent universal screening in NY, 1.9% of women were symptomatic and tested positive, and 13.7% of the asymptomatic patients were found to be SARS-COV-2 positive.1 Furthermore, unlike H1NI, data suggest that pregnant women infected with SARS-COV-2 currently do not seem to have worse outcomes than the average person.2,3 As of now, there have not been any reports of maternal fetal vertical transmission from COVID-19 or any other coronavirus variants.4 Postpartum testing of infants has yielded a very small number of babies who have tested positive for virus, but this more likely represents transmission after birth. There are currently no specific FDA-approved medications for the treatment of moderate-severe infections with COVID-19 in pregnant women, although there are several clinical trials underway. Patients with moderate to severe symptoms should seek medical attention, while those with mild symptoms should continue with conservative therapies, as well as maintaining proper hygiene.5 Delivery methods and timing remain unchanged with cesarean delivery as currently indicated per established guidelines.5
Mariam Louis, MD
Steering Committee Member
Jorge Trabanco, MD
1. N Engl J Med. 2020 Apr 13;382:2163-4. April 13, 2020, DOI: 10.1056/NEJMc2009316
2. N Engl J Med. 2020 Jun 18; 382:e100. April 17, 2020 DOI: 10.1056/NEJMc2009226
3. Acta Obstet Gynecol Scand. 2020 Jul;99(7):823-829. 2020 Apr 7. doi: 10.1111/aogs.13867. [Epub ahead of print]
4. Arch Pathol Lab Med. 2020 Apr 27. doi: 10.5858/arpa.2020-0211-SA. [Epub ahead of print]
5. ACOG practice advisory, Novel Coronavirus 2019 (COVID-19) April 23, 2020.