It’s Been a Busy Year
for Hospital Medicine
Hospitalists are always on the frontlines caring for patients with many types of illnesses. COVID-19 broke the mold, significantly increasing the number of hospitalized patients and thus the work for the hospitalists. But it also created some opportunities they were able to take advantage of.
For one thing, according to clinical professor Neera Ahuja, MD, chief of the hospital medicine division, “hospitalists have become experts in the care of COVID-19 patients. It’s almost protocolized. We have protocols around quarantining, around discharge. We know what meds to start, when to start them, when patients are turning the corner and improving. It’s almost like a checklist. We start with ‘Do they need oxygen? Do they have enough oxygen that they now need steroids? Have we started remdesivir? Do they need IV fluids?’ and so on.
“We have become very comfortable using personal protective equipment when we see any patient in the hospital because we know the risk of COVID-19 is there,” she continues. “We have to wear masks when we see patients, so it’s impossible for them to see our facial expressions. When we’re at the bedside, showing compassion has had to change a bit.”
Tracking the COVID-19 Numbers
Clinical assistant professor of hospital medicine William Collins, MD, carved out a useful data-driven path during spring 2020. As COVID-19 began to grow in numbers, he says, “we were trying to understand all the different ways that we could gather data about our patients and then streamline it. I’ve been working with professor of biomedical informatics Manisha Desai, PhD, and Yingjie Weng, MHS,and the Quantitative Sciences Unit to regularly update how many patients we’ve seen, their demographics, length of stay, and if they are having to come back into the hospital soon after discharge.”
They have also focused on preventing additional illness and addressing long-term follow-up. Collins details those efforts: “We have also looked at how we should use anticoagulation to prevent thrombotic events in COVID-19 patients, who appear to be at higher risk for deep vein thromboses and pulmonary emboli. I was part of a national, NIH-sponsored clinical trial looking at what’s the best strategy for preventing clots in COVID-19 patients. We’re also looking at longer-term symptoms in COVID-19 patients, which seems to be a big area in the coming year. As we move past the pandemic stage, there are going to be a lot of people who are profoundly affected by COVID-19. There’s a big push to understand how to best serve those patients.”
Introducing Point-of-Care Ultrasound for COVID-19 Patients
Creative initiatives sometimes follow emergencies. One that Ahuja is particularly proud of is using bedside ultrasound for COVID-19 patients, following a national trial led by clinical assistant professor of hospital medicine Andre Kumar, MD, MEd.
Ahuja explains that “patients with COVID-19 would have to get X-rays and CT scans, especially when our numbers were very high and we weren’t sure what was happening. Kumar hypothesized that it would be easier to bring a portable ultrasound to the bedside and diagnose COVID-19 pneumonia that way. Sure enough, ultrasound has shown specific findings in the lungs in patients with COVID-19. Through March 2021, Kumar was finalizing his findings and working on the publication. There were some limitations: You have to have someone trained in ultrasound do the procedure and be exposed to COVID-19 patients. But it saved patients from radiation and could be done more conveniently than bringing a COVID-19 patient down to radiology.”
COVID Surge Team Staffing
Even before the first cases arrived in the U.S., clinical associate professor Jeffrey Chi, MD, started thinking about how to manage the division’s personnel needs during a surge. “We were hearing stories of hospitals abroad being overwhelmed,” he said. “We thought about how to anticipate what patient volumes would be like and if we would have the staffing we need. The hospital service was already quite busy pre-COVID-19. When the pandemic arrived, our faculty stepped up and everyone sacrificed, adding many additional weeks of service on top of their existing schedules.”
“When the pandemic arrived, our faculty stepped up and everyone sacrificed, adding many additional weeks of service on top of their existing schedules”
Sacrifice came with the unusual territory, Chi explains. “We are a young division. Many of us have children under the age of 6. In fact, four or five more were born during COVID-19. Faculty were self-isolating from families at home. Everyone was completely overwhelmed but recognized that these were unique circumstances and part of the job to help our community. Staffing needs could change with little notice and at times we were operating at 120% of our normal capacity. Without extra available faculty, the existing staff were asked to work more, sometimes as much as three weeks without a day off. Thankfully, other divisions and departments like gastroenterology, oncology, and neurology were able to help out by taking additional patients to offload our service to allow more capacity for the COVID-19 patients.”
The surge team finally shut down in late February 2021.
Keeping the Train Running
Chi pointed to the contribution that the medical residents have made during the pandemic. Associate residency program director and clinical associate professor Poonam Hosamani, MD, as Chi says, “was instrumental in getting buy-in from the residents to mobilize when they were needed.”
Hosamani talks about what the residents did: “I cannot highlight enough all of the amazing work that residents did caring for COVID-19 patients; they kept the train running. After we created the COVID-19 surge team for the internal medicine wards in December 2020, the residents did an amazing job creating workflows for that team. They created tons of materials about how to care for COVID-19 patients for those rotating through, then others added to those materials as they had a rotation with COVID-19 patients.”
It was important for medical students, with whom hospital medicine has a very strong presence in the preclinical years, to be able to continue their education despite COVID-19. Hosamani says that “the curriculum was quickly revised to teach communication skills to early students remotely through a telemedicine lens because they couldn’t have the usual encounters with standardized patients.
Students were able to apply these skills to clinical encounters in our free clinics that they staff, as well as in shadowing encounters with providers in the community.”
Students were eventually able to have bedside time with patients during COVID-19. Hosamani credits Chi and clinical associate professor Jason Hom, MD, with “spearheading retaining that critical part of our curriculum. It was a heroic effort and took a lot of hard work to get students to be able to see patients in person,” she says.
Keeping Staff Members Involved Remotely
As is the case for all divisions, hospital medicine staff have been working remotely. Division chief Ahuja recognizes the drawbacks of this situation, in large part because, she says, “they don’t see their faculty physicians anymore. My division manager, Elsie Wang, has really been creative in terms of keeping them engaged.”
Wang points out that staff had previously become familiar with using collaboration platforms like Slack, Jabber, and Zoom. “I used our daily Zoom team huddles to share any updates I had learned in the course of the previous day. One thing that I tried to do for the staff beyond being transparent and sharing information was trying to engage them in different ways. I tried to encourage creativity with a little bit of a surprise each morning: During our huddles we would do scavenger hunts, acrostic poems about COVID-19, and drew inspiration from the Stanford Medicine shield to create our own to share. We basically tried to flex a different muscle.” Staff also helped faculty transition to the online environment and put some thought into transitioning orientations online. “It was a complete team effort,” Wang says. “A stretch project.”
Jumping Into Clinical Trials
To Ahuja, initiating clinical trial work seemed like the right thing to do despite being in the middle of COVID-19. She explains, “We thought: Let’s study what we do and do what we study. Professor of pediatrics Kari Nadeau, MD, PhD, was a brilliant part of our decision to get involved in clinical research. She is hospital medicine’s senior director of clinical research.”
They started out with a series of trials aimed at COVID-19. Ahuja describes their early trials: “We started in March 2020 with the National Institute of Allergy and Infectious Diseases–funded Adapted COVID-19 Treatment Trial (ACTT). ACCT-1 got remdesivir approved by the FDA. It was a real privilege to study that drug. I was the Stanford site’s principal investigator. ACTT-2 brought us baricitinib, a drug that was used in rheumatoid arthritis that showed promise in COVID-19, and we’re doing deeper studies of it in ACTT-4. ACTT-3 brought us interferon beta, and we’re not sure that is going to be efficacious after all. There are several other studies that our division has done and is doing for hospitalized COVID-19 patients.”
Clinical associate professor Nidhi Rohatgi, MD, MS, takes up the story of hospital medicine’s clinical trials at Stanford Hospital: “We had strong support from multidepartmental collaborators across Stanford Medicine. Professor of cardiovascular medicine Ken Mahaffey, MD, and the Stanford Center for Clinical Research (SCCR) were instrumental in helping us with our clinical trials. I enrolled the first patient for ACTT-1 in March 2020 when we were just learning about COVID-19.” She is site principal investigator for an ongoing trial “finding more therapeutic options for COVID-19, especially as new strains of the virus are appearing. We hope to reach a point where we have enough therapeutics that will lower the mortality rate.”
ValleyCare Gets Involved in Clinical Trials
When hospital medicine first launched their clinical trial efforts,they realized that one-third of their division was at Stanford Health Care – ValleyCare, and they decided to see if they could launch their trials there as well.
Clinical assistant professor of hospital medicine Evelyn Ling, MD, MS, led the ValleyCare launch. “We had no experience with clinical trials. It was a collaborative effort with Kari Nadeau and SCCR. Everyone—pharmacy, labs, nursing—was so eager to work with us. It was awesome to be a part of the remdesivir trial, now standard of care for COVID-19 patients.”
Ling foresees bringing non-COVID-19 trials to ValleyCare soon, as well as observational studies and chart reviews.
Introducing AI to Enhance Important Patient Care Planning
According to Ahuja, several members of her division have been working on various modalities of clinical medicine with AI (artificial intelligence). “One question we addressed is whether we can predict early on which patients are going to die within six months in order to introduce the idea of palliative care or hospice to them sooner, with the goal of optimizing their quality of life near the end of life. We’re looking at predictive features in the electronic medical record such as age, associated comorbidities, the number of visits to the ER or admissions to the hospital, and how severe the progression of their disease has been.”
Clinical assistant professor Ron Li, MD, is leading the AI projects along with clinical assistant professor Samantha Wang, MD; assistant professor Jonathan Chen, MD, PhD; and clinical professor Lisa Shieh, MD, PhD. Professor of biomedical informatics Nigam Shah, MBBS, PhD, and clinical associate professor of primary care and population health Winnie Teuteberg, MD, collaborated on the advance care planning project. A second AI project, as described by Li, “tries to identify patients at risk of having to go to the ICU or having an acute event in the next six to 18 hours. The goal is to decrease the rate of unexpected mortality in the hospital.”
Both of these AI projects are resulting in basic redesigns of workflows and clinical teams, making teams less hierarchical, more collaborative, and more democratized. Li says that they “are showing that we can creatively use a machine learning model to make a prediction and redesign a workflow and a team that solves a pretty important problem.”
A Few Notable Contributors to the Greater Good
Ahuja recognizes the important contributions of three additional members of the division of hospital medicine that go beyond the division’s clinical and research efforts. She says this about them: “Clinical associate professor Errol Ozdalga, MD, has led Medicine Grand Rounds via Zoom every week during COVID-19 and in the process has increased attendance to record levels. Two of our faculty have significant new roles with Stanford Hospital and Stanford ValleyCare: Niraj Seghal, MD, is new to our division, a clinical professor, senior associate dean, and Stanford Hospital’s chief medical officer; clinical associate professor David Svec, MD, MBA, is ValleyCare’s recently appointed chief medical officer.”
Clearly it’s been a busy and rewarding year in hospital medicine.