Categories
Committees

Improving Your Camera Appearance On Video Conferencing

The COVID-19 pandemic has changed business meetings forever. Committees and workgroups previously always met in person in a conference room but the need for social distancing has led to conference calls now replacing in-person meetings. Whether you use WebEx, Zoom, GoToMeeting, Blue Jeans, or some other meeting application, you are now on video camera and how you use that camera can greatly influence how you present yourself to other people. Lighting, background, and camera position can make the difference between you coming across as a professional or as a dud. Here are some tips to make sure that you use video conferencing to best effect.

Be aware of what is behind you

Video conferencing from your kitchen with a stack of dirty dishes behind you or from your basement with that poster of dogs playing poker that you’ve had since college is not going to project a image of competence and dedication to the job. Also, be aware of a plain wall that can create an institutionalized presence. A window with people or cars passing by can be distracting. I prefer an uncluttered bookshelf (just be careful what book titles are on that shelf!).

Be aware of what you are doing

When my mind starts to wander during video conferences, I start to scroll through the various participants to see what people are doing. Inevitably, someone is eating, or doing a crossword puzzle, or watching television. It is easy to forget that just because you are alone in a room, everyone is still watching you. Also, many video cameras will have auto-focusing lenses. if you move, particularly from front to back, you will become blurred for a moment while the lens refocuses. If you move back and forth frequently, then you will appear blurred more often than you appear in focus.

Get the correct camera position

The camera should be lined up horizontal and level with your face. This can be tricky if you are using your cell phone since it is often too easy to just lay the phone flat on your desk next to your computer screen or prop your phone up on the desk below your face. You end up giving the conference call attendees a great view up your nose and of your ceiling. A camera mounted to the top of the computer monitor works well. Don’t forget that when you are talking to other person on a video conference, look at the camera and not the other person – it is very tempting to look at the person whose face is appearing on your computer screen but when you do that, your eyes will appear to be looking down to the other person. It is better to look directly at the camera so that the other person perceives that you are having eye-to-eye contact with them. When I video conference with patients during telemedicine visits, I position their video image in the top of my computer screen, just below my camera, so that they perceive me looking at them. I give them warning that I will sometimes be looking away from them as I enter information into the electronic medical record that I have pulled up on a second monitor.

Lighting makes a big difference

I have moderated our our College of Medicine’s weekly continuing medical education webcast, MedNet for 18 years, and moderated its predecessor satellite television program, OMEN-TV (Ohio Medical Education Network) for 4 years before that. I’ve spent a lot of time in television studios over the past 22 years and have come to appreciate the importance of lighting. Most people don’t have formal studio lights at home but a couple of well-positioned floor lamps or table lamps can make a big difference. If you want to spend a little money, you can get a good quality basic 3-light set of studio lights with umbrellas for about $50. Here is how I have my office set up for video conferencing with the blinds shut, overhead fluorescent lights turned off, and a 3-light studio lighting set. Different lighting can affect how you look on a video conference:

  1. Natural window light. Different types of light bulbs will have a different color of light and this can affect how you appear on a video conference. Natural sunlight is ideal so if you can position yourself so that you are facing directly toward a window, you can get good, even lighting on your face. However, many offices are laid out so that the person is not facing directly at a window because it can create eye strain when a computer monitor is set up on the desk with the sunlight coming directly into the person’s eyes. Therefore most offices will have a window to the side of the desk. This can create asymmetric lighting of a person’s face during a video conference resulting in a shadow across half of the face, such as you see in this photo (I apologize for the stern look). If the sun is shining directly in the window, then that will further accentuate the shadows on one side of the face and cause glare on the other side of the face.
  2. Overhead ceiling light. This is what is generally installed in most offices and is very functional for most day-to-day office work. However, it can create glare on the top of the head, particularly if you happen to be bald or have a large forehead. Furthermore, this will create shadows from your eyebrows that can make you look sinister.
  3. Computer light. One of the problems with using your computer as a light source is that the amount of light and the color of the light can vary from moment to moment, depending on what is on the computer screen at any given time. When doing a video conference, you can’t get away entirely from the computer screen since you will usually be watching other people on video or looking at PowerPoint presentations when you are on camera. But if you rely entirely on the computer screen light, it will make it look like you are living in a cave.
  4. Studio lights. A basic studio light set up will include a right frontal light, a left frontal light, and a back light. The left and right lights will generally be mounted slightly above the subject and the back light will be close to the floor behind the subject. By using umbrellas on the left and right lights, you can diffuse and soften the light. If the light is still to bright, you can reverse the lights and umbrellas so that only light reflected off of the umbrella reaches the subject. If you don’t have studio lights, then a couple of lamps can work nearly as well. This photo uses a 2-light studio lighting set (with the back light turned off).
  5. Be aware of what you are wearing. If you have a dark background, you should be wearing lighter colored clothing. Otherwise, you will fade into whatever is behind you. A back light can help offset this by creating more definition to the border between you and the background but back lights are often impractical in a regular office. If you keep a jacket or sweater in your office that contrasts nicely with the office background, then you don’t have to be constantly planning your wardrobe around whether and where you’ll be doing a video conference later in the day. Ideally, you should choose a background that creates contrast with your skin tone – if you are have a  light complexion, then a dark background is optimal but if you have a dark complexion, then a lighter background helps to create contrast. If you don’t have a choice in the background, then using a back light can help to provide some contrast to help separate your face from the background.

Put the camera at the right distance.

Ideally, the camera should be 2-3 feet from you. You will amplify your nose and chin due to distortion if the camera is too close. If the camera is too far away, then you will appear small and this can negatively affect how others perceive you on a video conference. However, each camera is a little different so you have to experiment a bit to find the right distance. Also, if the camera is too close, then it accentuates things that you may not want accentuated, like your 5 o’clock shadow (all physicians at our hospital were required to shave their beards during the COVID-19 outbreak this year so that they could be fit-tested for N-95 masks so I’ve recently experienced the 5 o’clock shadow for the first time in 35 years!). If your entire face fills the video screen, the people viewing you on a video conference will perceive that you are very close to them and it can create a sense that you are encroaching on personal space.

Humans most effectively communicate with a combination of sound plus visuals. Facial expressions, body positioning, and hand gestures can greatly enhance speech alone. In order to optimize your presence and be as persuasive as possible during a video conference, you need to be aware of how you appear on camera.

April 12, 2020

Categories
Emergency Department Inpatient Practice Intensive Care Unit

With COVID-19, Hope For The Best But Prepare For The Worst

In August 2004, my family was vacationing on the North Carolina Outer Banks. I had been following Tropical Storm Alex as it came north from the Caribbean toward the island that we were staying on. On August 3rd, it was looking like the storm was going to head out over the Atlantic the next afternoon and miss Cape Hatteras. Not wanting to take any chances, I decided to get up early the next morning, pack up the kids, and head inland for the day, just to be sure. When I woke up at 5 AM, the first thing I heard on TV was that overnight, the storm had picked up wind speed, was moving across the ocean faster than expected, and had turned inland – directly toward our rental house in the town in Salvo. The second thing that I heard was that there was that storms overnight had caused sand and water to block the only road on the island leading to the bridge to mainland. The news announcer said to all of the people now stuck on Hatteras Island “Hope for the best but prepare for the worst.”

Having 4 children, my wife and I were used to buying in bulk and since this was at the beginning of our planned 2-week vacation, we were already pretty well stocked with food and supplies. We filled up all of the bathtubs with water for bathing and filled up as many bottles as we could find with drinking water.

By the time the storm hit us, Alex was now a level 2 hurricane. The eye wall passed over our rental house and as the wind changed direction with the passage of the eye, we moved all of the kids from a bedroom in one corner of the house to bedrooms in other corners. As the power went out, the wind sounded like a freight train and I watched as siding and parts of roofs were torn off of houses around us. A 2×4 board flew through the air like a missile across the street. Picnic tables, bicycles, and and lawn furniture were flung a hundred yards like toys. The roads all turned into rivers. Meanwhile, we played games with the kids and fed them Cheerios to keep them distracted.

It seemed like the end of the world and I wanted to be almost anywhere other than where we were.

But by afternoon, the wind died down, the clouds cleared, and the sun came out. All of a sudden, it was just another beautiful day on the Outer Banks. Over the next 3 days, the power returned, the flood waters subsided, and the sand was cleared from the roads. The bridge re-opened and the people staying in Salvo came out and cheered when one of the first vehicles that crossed the bridge to the island was a Budweiser truck.

COVID-19 is a lot like Hurricane Alex. The patient surge is coming and we can’t just wish it away. Just as the news announcer said on TV in the morning of August 4, 2004, we should hope for the best but prepare for the worst. But also like Hurricane Alex, the COVID-19 surge is going to pass; the clouds and pandemic storm is going to eventually subside; and life will be back to normal once more.

April 1, 2020

Categories
Inpatient Practice Intensive Care Unit

Reducing Hospital Employee Exposures To COVID-19 Patients

Having patients with COVID-19 in the hospital can be disturbing to the doctors, nurses, and respiratory therapists who take care of them. The good news is that isolation procedures work and proper use of personal protective equipment can dramatically reduce the chance of getting healthcare workers infected. Even though that risk is low, there are certain simple steps you can take that will reduce the risk even further. By taking these steps, you not only reduce healthcare worker exposures but you can also conserve personal protective equipment (masks, gowns, gloves). Here are a few:

  1. Use the right personal protective equipment (PPE) and be sure that it is used correctly.
  2. Minimize blood draws. If you don’t need daily labs, don’t send the nurses in to draw them. When you do get labs, try to cluster all of the lab tests that you need in a single phlebotomy.
  3. To anticoagulant a patient, use oral apixaban, oral rivaroxaban, or subcutaneous enoxaparin instead of a heparin drip. The problem with heparin drips is that you have to do frequent PTT blood tests. Other anticoagulants do not require testing.
  4. Use a sliding scale of subcutaneous insulin rather than an insulin drip. Insulin drips require the nurse to check the patient’s blood glucose every 1-2 hours whereas the SQ insulin sliding scale may only need to be done every 6 hours.
  5. Synchronize medications. Ordering a Q6 hour medication plus a Q8 hour medication means that a nurse has to go into a patient room 7 times a day. If that Q6 hour medication can be stretched out to be given Q8 hours, then a nurse only has to enter a patient’s room 3 times a day. Even better, use medications that only have to be given once a day whenever possible. This is particularly true of empiric antibiotics where there may be multiple equally appropriate antibiotic choices – some that have to be given 3 or 4 times a day and some that only have to be administered once a day.
  6. Use meter dose inhalers instead of nebulizer treatments. Nebulizers can result in aerolsolization of viral particles, at least in theory. Meter dose inhalers for bronchodilator treatments reduce the amount of time that a respiratory therapist has to be in a room to deliver a bronchodilator treatment.
  7. Have patients self-administer meter dose inhalers (or nebulizer treatments). The respiratory therapist can often observe the patient from a door window or a video monitor to ensure that the patient uses proper technique.
  8. Minimize the rounding team. If bedside rounds normally consist of the attending physician, a nurse, a resident, and a physician assistant, then reduce that to just the attending physician and just once a day.
  9. Don’t use physical and occupational therapy if you don’t need it. Frequently, admission order sets will include PT and OT for nearly every admission. Only order it if you really need it.
  10. Don’t order tests that you don’t need. “Routine” daily chest x-rays are usually unnecessary.
  11. Don’t order tests that can be done later. If a chest x-ray shows a suspicious pulmonary nodule and a chest CT is recommended for confirmation, that CT can wait a few weeks.
  12. Empiric treatment is OK. If a patient has epigastric pain, rather than ordering an endoscopy right away, give the patient some empiric omeprazole to minimize procedures.
  13. Utilize inpatient telemedicine for consults. There are two ways to do this, by a regular telemedicine visit or by an eVisit.
    1. CPT 99451 is for an eVisit and reimburses at 1.04 RVUs. There has to be an order for the consult and the consultant has to put a note in the medical record. The consultant must document his/her time and it must be > 5 minutes. This is a way to get reimbursed for the so-called “curbside consult”. An example would be “What follow up should occur for the incidental 5 mm pulmonary nodule that was seen on my patient’s CT scan?”
    2. CPT G0425 (30 minutes ), G0426 (50 minutes), and G0427 (70 minutes) are for initial inpatient telemedicine consults. For follow up inpatient consult visits, use CPT G0406 (15 minutes ), Go407 (25 minutes), and G0408 (35 minutes). These codes are based on the amount of time communicating with the patient
  14. Can you run your pumps outside of the patient’s door? continuous infusion pumps are forever alarming or needing infusion rates to be frequently adjusted. If the infusion pumps can be placed outside of a door with the tubing running under the door then the pumps can be adjusted without the nurse having to enter the room.
  15. Eliminate visitors. Visitors can bring COVID with them and many visitors have often had close contact with COVID patients before they were admitted, making them especially high risk. By eliminating visitors, there are fewer members of the public in patient care areas who can infect hospital staff. Furthermore, there are fewer times that the patient’s door is opened and no additional personal protective equipment consumed by the visitors.
  16. Be sure that the healthcare personnel are getting enough rest. When a nurse, RT, or physician works too long of a shift or too many shifts, fatigue can set in and with fatigue brings mistakes. Mistakes with isolation procedures can create infection risks.

March 31, 2020

Categories
Epidemiology

Droplets, Fomites, and COVID-19

The disease COVID-19 is caused by the virus SARS-CoV-2. This is a member of the coronavirus family. These are viruses that can infect humans, other mammals, and birds. Most coronaviruses are rather benign respiratory viruses that account for about 5-10% of annual colds and flu-like illnesses. But occasionally, a coronavirus will successfully jump from one species of mammal to humans. When this happens, humans have never encountered that particular strain of coronavirus and so we have no immunity against it. Recent examples of coronaviruses making this zoonotic jump include SARS (from bats) and MERS (from camels). Although we do not know for sure, it is believed that SARS-CoV-2 originated in bats.

Coronavirus are transmitted the same way as other respiratory viruses are transmitted, by droplets of respiratory secretions. There are two ways that droplets can spread the virus. Either an infected person can cough or sneeze in another person’s face with the result that those respiratory droplets land on the second person’s nose, lips, or face. Or, the the infected person can get those respiratory droplets on their hands by coughing into their hand or touching their nose or mouth with their hand; when the infected person’s hand then touches a surface such as a door knob, light switch, keyboard, or television remote control, then those droplets get passed to those surfaces.

Those surfaces now become fomites. A fomite is any surface that that can serve as a intermediary conduit to get a virus or bacteria from an infected person into another person so that the infection spreads. Fomites are coronaviruses best friends. Certain types of surfaces make better fomites than others. For example, copper surfaces kill viruses whereas stainless steel surfaces do not kill viruses. Smooth surfaces, such as metal of glass, make better fomites than porous surfaces, such as upholstery or fabric, because viruses and bacteria tend to get wedged in between the fibers of fabrics making them harder to be picked up by another person’s hands.

Face masks can help prevent spread of viral-laden droplets from an infected person to an non-infected person, both in the hospital and in public. In the hospital, doctors, nurses, and respiratory therapists wear masks when caring for patients with respiratory viruses such as coronaviruses because they often have to get close to infected patients who can cough or sneeze in their faces. So in the hospital, it is the uninfected people who should wear masks.

In public, it is just the opposite; the infected person should wear the mask and not the average uninfected person. As long as you are maintaining social distancing by standing 6 feet from someone who is infected, even if that person coughs, those droplets are going to fall to the ground by gravity before they reach you. By having the infected person wear the mask, when they cough, they cough into the mask, thus substantially reducing the ability of those respiratory droplets to reach someone else. In fact, when healthy people wear masks when they are out in public, those masks get moist from the humidity of breath and most masks tend to get colonized with bacteria and fungus that can then make that previously healthy person sick.

So, it turns out that most respiratory viruses don’t get transmitted through the air, they get transmitted by fomites. And that means that the most important way to prevent spread of those viruses is by washing one’s hands after touching fomites.

If I could only have one thing to reduce the spread of COVID-19, it would not be a surgical mask or a face shield, or an N-95 mask. What I would want instead is soap and water.

March 30, 2020

Categories
Epidemiology Intensive Care Unit

Re-Using N-95 Masks In The Time Of COVID-19

The geniuses at Battelle have done it again. This time, they have invented a process for sterilizing and re-using N-95 masks using vaporized hydrogen peroxide. Battelle Memorial Institute is a non-profit scientific research and development institute here in Columbus, Ohio that is located about 3 blocks from the OSU hospital. Researchers at Battelle were the ones who invented the photocopier (and then launched Xerox Corporation), the cruise control for automobiles, the first nuclear fuel for nuclear-powered submarines, and the reusable insulin pen for injecting insulin for diabetics. In full disclosure, about 25 years ago, I had a grant from Battelle to assist with development of inhaled chemotherapy for lung cancer and that led to my receipt of the endowed Battelle Professorship in Inhalational Therapeutics that I held until assuming my position as the medical director of our hospital.

N-95 refers to a mask that can filter 95% of airborne particles. In medicine, we use N-95 masks when we care for patients with infectious diseases that are transmitted by airborne routes, such as tuberculosis, disseminated varicella, and measles virus. The virus that causes COVID-19 is the SARS-CoV-2 virus and this is believed to be transmitted by droplet spread rather than by airborne spread. Normally, viruses spread by droplets do not require the use of N-95 masks; a simple surgical mask with a plastic face shield will suffice. However, certain medical procedures, such as endotracheal intubation, can result in aerosolization of droplets containing viral particles and that is when the N-95 masks are needed.

For an N-95 mask to work properly, a healthcare worker must be fit tested to determine which specific type of N-95 mask fits tightly against the face. If a type of mask does not pass the fit test, then it will not filter out 95% of airborne particles and is no better than a regular surgical mask. Everyone’s face is shaped a little differently so different people will need different N-95 mask types. All healthcare workers who use these masks are required to get fit tested once a year to ensure that the mask that they are wearing actually does what it is supposed to do. Recently, OSHA declared that men who wear beards should not be fit tested because beards can interfere with a tight fit of the masks. For many years, I always passed my fit test with a specific type of N-95 mask despite my beard but because of OSHA’s rules, I was not able to be fit tested last year. Two weeks ago, our hospital required all men who could be involved in the care of a COVID-19 patient to shave their beards (so that they can be fit tested for N-95 masks) and thus, I shaved for the first time in 37 years!.

N-95 masks have come to the forefront of public consciousness recently because the COVID-19 outbreak is causing many hospitals to run low on N-95 masks. A misconception has arisen that N-95 masks are safer than regular surgical masks plus a face shield. For day-to-day care of patients with COVID-19, this really is not true because unless you are performing a procedure such as endotracheal intubation, an N-95 mask is unnecessary. Overuse of N-95 masks in situations when they are not necessary now will result in inadequate supples of these masks in situations when they are necessary in the future. In addition, the over emphasis on N-95 masks could lead the public to overlook the single most important way to prevent the spread of viruses spread by droplets, namely washing one’s hands after they touch various surfaces that those droplets land on (such as door handles and elevator buttons).

With supplies dwindling, Battelle invented a process for sterilizing N-95 masks so that they can be reused up to 20 times. They built the equipment to process 160,000 masks per day and this would greatly improve the nation’s N-95 mask inventory. However, medical equipment is overseen by the Food and Drug Administration. The FDA would only grant Battelle’s mask sterilization equipment limited approval, meaning that they are only permitted to sterilize 10,000 masks per day and only here in Central Ohio. That’s good news for our hospital because now we can count on a steady supply of masks in the upcoming weeks of the COVID-19 surge. But it is bad news for every other hospital in the United States.

Desperate times call for desperate measures. This may be a time for the FDA to take the desperate measure of cutting through bureaucracy.

March 29, 2020

 

Categories
Intensive Care Unit

Preparing For ICU Surge Capacity In The Time Of COVID

The COVID-19 pandemic has created enormous demand on the world’s intensive care units. As of today, Central Ohio is still in the very early stages of the outbreak whereas countries such as Italy, Spain, China, and Iran have had large numbers of patients. About 10% of those infected eventually need admission to an intensive care unit so it is the ICUs that get the highest volume of hospitalized patients. When the infection peaks in your community, the hospital has to be prepared for the possibility that the demand for ICU beds could exceed the supply of ICU beds. Here are some of the things to consider in preparation for the peak demand:

Alternate Sites for Intensive Care

The physical characteristics of a hospital room is the first consideration. Not all rooms are as equally adapted to ICU rooms as others. The first consideration is whether there is monitoring capability – those rooms that already have monitors can more easily become ICUs. The second consideration is whether the room has a medical gas supply built into the wall. Many rooms will have oxygen supplies but most ventilators need both oxygen and compressed air supplies in order to blend to a specific oxygen concentration that is delivered to the patient. Wall suction is also necessary. Because COVID-19 patients require droplet isolation, the room should have a door (as opposed to just a curtain).

As you plan for alternative areas for ICU surge care, make up a table of various patient care areas with these various characteristics in mind. Each hospital will be a bit different depending on the availability of monitors, doors, and medical gas supplies in different areas. Some locations may be able to fully meet all specifications for an ICU to care for COVID-19 ICU patients and others may only meet specifications for non-COVID-19 ICU patients. In general, these are the areas that may be considered as ICU expansion areas:

  1. Existing step-down units
  2. Cardiac care units
  3. Other med-surg nursing units
  4. Surgical pre/post-op recovery rooms
  5. Endoscopy pre/post-op recovery rooms
  6. Cardiac cath lab pre/post-op recovery rooms
  7. Operating rooms

Alternate Nursing and Respiratory Therapy Staff

Just having physical beds does not complete an intensive care unit. You have to also have nurses and respiratory therapists. In times of crisis, many hospital areas will not be active so recruiting operating room nurses, endoscopy nurses, and outpatient clinic nurses should be considered. Not all of these will be adept at caring for critically ill patients with COVID-19 ARDS so alternative staffing models need to be considered: for example, one critical care nurse could be supervising 2-3 recovery room nurses. Respiratory therapists may be more of a limiting factor and may need to be augmented with other health care workers (nurses, NPs, PAs, etc.) who are tangentially familiar with respiratory therapy duties. Also consider identifying nurses and respiratory therapists who have recently retired. EMTs may be another potential resource.

Ventilators

Even if you have enough beds, nurses, and respiratory therapists, if you don’t have ventilators, you cannot treat COVID-19 patients with ARDS.  So where do you find ventilators when you run out? There are several possibilities:

  1. BiPAP machines. These are not ideal but can be adapted to function similarly to a regular ventilator
  2. Children’s hospitals. COVID-19 primarily affects adults; the older the person, the sicker they tend to get. Children generally do not get as sick. Consequently, there may be extra ventilators at children’s hospitals.
  3. Home respiratory therapy companies. They may have extra ventilator inventory that could be loaned to the hospital.
  4. Home ventilator patients. Many of these patients will have a back-up ventilator on hand in case of malfunction of their primary ventilator.
  5. Gas-powered ventilators. These are often stored in regional disaster caches. The are not a great substitute for a regular ventilator but may be better than rationing ventilators in times of extreme demand.

Alternates to Critical Care Physicians

In some countries, intensive care units are staffed by anesthesiologists but in the United States, ICUs are primarily staffed by critical care physicians. If COVID-19 results in a doubling or tripling of ICU beds, then there will need to be other physicians who can step in. Some of the possibilities include hospitalists, anesthesiologists, emergency medicine physicians, and sleep medicine specialists. Often, it is not necessarily the specific specialty of the physician but instead how old they are. Most internal medicine, surgery, and anesthesiologists do several months of residency training in intensive care units and so those physicians recently out of residency may be more able to stand in for critical care physicians.

The COVID-19 pandemic is not going to last forever but the next 2 months will bring challenges to our nation’s hospitals and particularly our intensive care units. By preparing now and establishing various metrics that would trigger use of these alternate resources, we will be able to match our communities’ COVID-19 needs to the critical care resources of our hospitals.

March 29, 2020

Categories
Committees

Conference Call Etiquette In Times Of COVID-19

All of us who work in hospitals or just about businesses of any kind have changed most of our former in-person committee meetings to conference calls using WebEx, Go To Meeting, Blue Jeans, etc. These programs can be pretty powerful tools that can keep the hospital or company running smoothly while maintaining social distancing for epidemiologic purposes. But for them to work efficiently, it is essential that attendees obey some basic conference call etiquette:

  1. If you are not speaking, put your phone on mute to avoid background noise
  2. Do not type while the phone is unmuted. Typing sounds are amplified on the phone
  3. If calling in from home, go to a room away from barking dogs, television noise, or talking family members to avoid background noise
  4. Avoid being outdoors when calling in because noise from wind, sirens, and passing cars can be amplified
  5. When speaking on the conference call, it is better to speak into the telephone handset than to through the speakerphone as your voice will be picked up better
  6. Avoid calling in from a moving automobile using Bluetooth. Not only can the conference call result in distracted driving but car engine noise and roadway noise can be very distracting
  7. Do not put your phone on hold. Many companies will have default “elevator music” play when the phone is on hold and this music will drown out anyone else on the conference call
  8. If you are the host of the meeting, be facile with the mute buttons. If your conference call program has an option for “mute on entry” and “mute all” then using these options to eliminate background noise and beep sounds when people call in or hang up
  9. Use video judiciously. Too many people using video can tie up bandwidth. If you are using video, don’t forget that you are on video – it is amazing how many embarrassing things people do when they thing they are alone in their office (brushing their teeth, making faces, etc.)

March 28, 2020

Categories
Epidemiology Outpatient Practice

Setting Up A COVID-19 Testing Station

In the era of COVID-19, there is a surge in demand for outpatient testing for the virus. When doing tests for regular influenza, patients generally come into their physicians offices and get a nasopharyngeal swab for a flu test in the physician’s office. But with COVID, it is necessary to reduce contact of suspected patients with other patients as well as with office staff. Furthermore, testing requires specialized masks, face shields, and disposable gowns that are generally not available in regular physician offices.

To meet the demand for testing while protecting our healthcare workers and community, we developed drive-up “swabbing stations” to do the tests. The goals were to minimize the time that patients were present in the testing area and minimize the staff exposure to the patients.

The challenge is that in order to track, log, and report tests, a patient must first go through a registration process. Furthermore, in a time of shortages of testing materials, testing needs to be limited to only those people who really need to be tested and not asymptomatic people who are anxious about the pandemic.

Our process was to establish a COVID-19 call center. Patients with symptoms contact their physician who then transfers or directs the patient to the call center. Volunteers in the call center ask the patients scripted questions to determine who requires testing and who does not require testing. Patients meeting testing criteria are registered in the electronic medical record and an order is entered for the test. That order is routed to the patient’s physician, or if the person does not have a physician, it gets routed to a designated physician in our health system – as the medical director our hospital, that often means me.

Patients are told to drive to a specific location and look for innocuous colored signs with arrows labeled with non-specific wording so as to not attract people who just show up without being screened and registered over the phone. They pull their car up to the testing station and a nurse with proper personal protective equipment comes to their window, confirms their identity, performs a nasopharyngeal swab, and the patient drives off. Patients who appear ill are directed to go to the emergency department; others return to their homes.

At our hospital, we chose a side entrance with a covered entryway that in past years led to the emergency department entrance but now is used as a drive-up/drop-off area for ambulances to bring hospital transfer patients to our hospital. We set up a second swabbing station in a parking lot on the University campus that was vacated with University classes all being converted to on-line during the outbreak. This second swabbing station was created using a portable enclosed tent with the ability of several cars to pull up simultaneously on either side of the tent.

The process is that once the patient is registered into the electronic medical record and the order is placed by the call center staff, the patients drive into the swabbing station and call the swabbing station phone number. Staff in the interior of the hospital entrance then print up patient labels for the specimens, pre-label the specimen tubes and then pass those tubes out to the nurse wearing personal protective equipment. That nurse goes to the car window and obtains the nasopharyngeal swab. The patient drives away and the nurse comes into the building and deposits the tube containing the swab into a plastic isolation bag held by another hospital staff member wearing PPE. Another staff member then takes the specimen to the lab for the test to be sent out to a commercial lab (we are currently doing tests on inpatients and employees with our internal hospital test and sending out the outpatient tests to a commercial lab).

I called one of the patients who tested positive over the weekend. She and her husband had returned from a trip overseas the week before. Her husband had mild cough and low grade fever that had since resolved. She had a bit more cough and fever to 101. Because the test takes a few days for the commercial lab to run, by the time her test came back, she was already recovering and no longer had fever or cough. She commented on how smooth and efficient the process went and how upbeat and encouraging the swabbing nurses were.

In Central Ohio, we are still early in the outbreak and the virus is not as prevalent as other parts of the world. Thus far, we have performed 3,000 tests, 1,146 of which have which have been completed. Of these completed tests, we have had 50 positive tests meaning that 4% of tests are positive and 96% are negative. We expect this to change in the next 2 weeks.

March 24, 2020

Categories
Physician Finances

Retirement Planning In The Time Of COVID-19

I’m taking a break from rounding in the ICU this afternoon while waiting for 3 of my patients’ COVID-19 test results to come back. And I was trying to think of anything good that has come from the financial melt-down that has occurred over the past month. There is at least one small opportunity that the sudden drop in value of the stock market presents, namely, the opportunity to convert your traditional IRA into a Roth IRA with less negative tax implications.

Physicians are generally not able to contribute directly to a Roth IRA because they have too high of income. However, physicians (or anyone) can contribute to a traditional IRA with after-tax dollars. In a previous post, I outlined why I believe that traditional IRAs are an unwise investment option for most physicians. However, many physicians (and other people) have traditional IRAs that they have accumulated when rolling over a pension plan into an IRA. This often happens when changing employment and leaving one employer’s pension plan to join another plan.

I have been a long-standing proponent of annually contributing to a traditional IRA and then shortly thereafter, moving the money in that traditional IRA into a Roth IRA, a process called a Roth conversion. This is also called the “backdoor Roth”. In the past, the only mechanism for contributing to a Roth IRA was by people who have annual incomes less than $124,000 ($196,000 if filing jointly in 2020) contributing directly to the Roth with pre-tax dollars. However, several years ago, a law governing Roth contributions expired, allowing anyone (regardless of income) to “convert” a traditional IRA into a Roth IRA. This now allows a person making more than $124,000 to contribute to a traditional IRA with post-tax dollars then convert that traditional IRA into a Roth IRA.

The advantage of the Roth IRA is that it grows in value tax-free and then when you take the money out, you don’t have to pay any taxes on it. I believe that the Roth IRA is an important component of a diversified portfolio of retirement investments.

One consequence of converting a traditional IRA into a Roth IRA is that you have to pay regular income tax on increase in value of the traditional IRA at the time of conversion. So, if you originally contributed $2,000 to a traditional IRA and it increases in value to $3,000, then when you convert it to a Roth IRA, you have to pay regular income tax on the appreciation value of $1,000. Other than doing an annual “back door Roth” conversion, there are two times that it is smart to convert a traditional IRA into a Roth IRA: (1) when your income tax rate is low and (2) when the stock market crashes.

As I have stated in previous posts, my philosophy to retirement planning is to be able to have enough retirement savings that when you retire, you can withdraw enough out of your retirement funds to equal your current income. If you are successful with that, then you are not going to be in a lower tax bracket when you retire so option (1) for traditional IRA to Roth IRA conversions will not be possible. The COVID-19 outbreak and its effect on the world’s stock markets makes option (2) now very appealing.

When we changed our physician practice corporation in the early 2000’s, I rolled my former corporation’s pension plan into a traditional IRA. In 2009, the stock market dropped precipitously and I used that as an opportunity to convert about half of my traditional IRA into a Roth, thus minimizing the amount of income tax that I had to pay at the time of conversion. Over the next several years, the stock market regained all of its losses and then continued to grow in value so when I retire and take money out of my Roth IRA, I won’t have to pay any taxes on all of that increase in IRA value.

Over the past month, the stock market has fallen by about a third of its value. Consequently, most people’s traditional IRAs have fallen to their lowest value in many years. As a physician, I know that epidemics eventually pass and COVID-19 will eventually go the way of all other previous human epidemics. When that happens, the economy will get back into gear and the stock market will rise again. Therefore, this may be one of the best times in years to convert a traditional IRA into a Roth since you will pay considerably less in income tax on the conversion now than you would pay on withdrawals from the IRA in retirement.

One small silver lining an a sky otherwise full of dark gray COVID-19 clouds

March 21, 2020

Categories
Intensive Care Unit

The Management Of Respiratory Failure In COVID-19 Patients

Every hospital in the United States is bracing for a potential deluge of patents with COVID-19 infection and many of these patients will require admission to our country’s intensive care units. There are not enough critical care physicians to manage all of these patients so it may be necessary for doctors and nurses who do not normally manage critically ill patients to step in. Although we hope that the seemingly draconian measures our countries leaders are taking will “flatten the curve” of the prevalence of COVID-19 in the United States and minimize the demand on our hospitals, it remains possible that the critical care crisis that has occurred in Northern Italy will happen here.

The Ohio State University Medical Center is taking a multi-faceted approach to the COVID-19 outbreak and one of the tasks that I was assigned was to create a webcast that could be used by physicians around the world who need to know how to manage COVID-19 patients in the intensive care unit. Rather than repeat everything from that webcast in this post, I’m giving you a link to the 1-hour webcast by my colleague, Dr. Rachel Quaney and myself. I’m hoping that this presentation will give physicians, nurses, and respiratory therapists the tools that they will need to improve the survival of these patients who are in our ICUs. Click this link to access the webcast.

March 20, 2020