key: cord-0706915-24ffip0s authors: Vahia, Amit; Chaudhry, Zohra S; Kaljee, Linda; Parraga-Acosta, Tommy; Gudipati, Smitha; Maki, Gina; Tariq, Zain; Shallal, Anita; Nauriyal, Varidhi; Williams, Jonathan D; Suleyman, Geehan; Abreu-Lanfranco, Odaliz; Chen, Anne; Yared, Nicholas; Herc, Erica; McKinnon, John E; Brar, Indira; Bhargava, Pallavi; Zervos, Marcus; Ramesh, Mayur; Alangaden, George title: Rapid Reorganization of an Academic Infectious Diseases Program During the COVID-19 Pandemic in Detroit: A Novel Unit-Based Group Rounding Model date: 2020-07-01 journal: Clin Infect Dis DOI: 10.1093/cid/ciaa903 sha: 2f4055bf29127105c8f3d84a2d3a4bf8e308db29 doc_id: 706915 cord_uid: 24ffip0s The surge of coronavirus disease 2019 (COVID-19) hospitalizations at our 877-bed quaternary care hospital in Detroit led to an emergent demand for Infectious Diseases (ID) consultations. The traditional one-on-one consultation model was untenable. Therefore, we rapidly restructured our ID division to provide effective consultative services. We implemented a novel unit-based group rounds model that focused on delivering key updates to teams and providing unit-wide consultations simultaneously to all team members. Effectiveness of the program was studied using Likert-scale survey data. The survey captured data from the first month of the Detroit COVID-19 pandemic. During this period there were approximately 950 patients hospitalized for treatment of COVID-19. The survey of trainees and faculty reported an overall 95% positive response to delivery of information, new knowledge acquisition, and provider confidence in the care of COVID-19 patients. This showed that the unit-based consult model is a sustainable effort to provide care during epidemics. On March 10, 2020, Michigan reported the first case of coronavirus disease 2019 caused by the novel Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2). As of April 27, over 38,000 cases had been reported with the majority in the greater Detroit area (1) . The first case of COVID-19 in Michigan was hospitalized at Henry Ford Hospital (HFH) on March 10, and within one week over 30 Infectious Diseases (ID) consultations were requested daily for the management of confirmed or suspected COVID-19 infection. The rapid increase in the volume and complexity of COVID-19 patients made the traditional one-on-one consultation unsustainable. We emergently restructured the ID division consultation service to address this unprecedented demand by developing dedicated COVID-19 teams as an effective way to manage a hospital-wide crisis. We describe in detail the rationale for the COVID-19 teams, the composition of the team, its scope of work, the mechanics of its deployment, and the effectiveness of this strategy on the management of COVID-19 as reported by our frontline care providers. This descriptive study was done at HFH, an 877-bed quaternary care teaching hospital located in Detroit and is part of a 5-hospital Health System that serves southeast Michigan. All inpatient ID services at HFH are provided by the Division of ID comprising of 15 faculty, 8 fellows and 2 advanced practitioners. During the early days of the outbreak, two faculty were assigned infection control leadership roles, while three other faculty were assigned to one of our four satellite hospitals to assist with the volume of consults seen outside of downtown Detroit. The consult teams of students, residents, fellows and faculty, provide consultations for the general hospital population as A c c e p t e d M a n u s c r i p t 4 well as cancer, transplant patients and HIV infected patients. The faculty also supervise residents on a 24-bed inpatient ID unit that houses patients with complicated infections and is also the special pathogens unit. The reasons for the development of the COVID-19 consult teams and new unit-based rounds model were a combination of administrative, provider and hospital-related factors ( Table 1 ). The primary driver was the sudden surge of hospitalizations of COVID-19 patients ( Figure 1 ) at HFH that resulted in a rapid increase in ID consultations that was unsustainable. In addition, the executive decision to minimize exposures and conserve use of personal protective equipment (PPE) restricted non-procedure consultative services such as ID from performing face-to-face encounters with COVID-19 patients. Another consideration was the rapidly evolving institutional clinical management and Infection Prevention guidelines for COVID-19, and the limited avenues for rapid communication of updated information to the frontline teams with the implementation of Accreditation Council for Graduate Medical Education (ACGME) Pandemic Emergency Status Guidance (2). The primary objectives and scope of the ID COVID-19 consult teams was to optimize outcomes of COVID-19 patients by providing education, advice on clinical management, and rapid dissemination of updated information to physicians and nurses delivering patient care. The physician-leads of the ID COVID-19 consult team included the ID fellows and the supervising ID faculty. These providers were assigned to manage all COVID-19 consultations throughout the hospital. The COVID-19 consult team began as a single team, but quickly expanded A c c e p t e d M a n u s c r i p t 5 to three teams which included one team to round with the intensive care units (ICU), one team to round with the general practice units (GPU) and Emergency Department (ED), and a "float team" to handle overflow COVID-19 cases and non-COVID-19 ID consults. The ICU and GPU teams were assigned to alternate in assisting the emergency department with consultative services and troubleshooting management issues. The COVID-19 team fellows and faculty were available anytime throughout the day for assistance via a hot-line. Supporting the COVID-19 consult teams was a multidisciplinary team that met daily via video conference, referred to as the noon huddle. The composition and responsibilities of the COVID-19 team members are summarized in Table 2 . The primary responsibility of this team was to develop and update management guidelines related to antiviral and adjunctive therapies for COVID-19 based on the available literature. The updated institutional treatment guidelines were posted on the hospital's intranet and disseminated in paper copy by COVID-19 consult teams. A copy of updated guidelines is available in the supplemental material (Appendix Figure 1 ).  Provide education simultaneously to all house-staff within a unit to provide consistent messaging.  Answer questions with all team members present to address common clinical problems.  Distribute updated educational materials and institutional guidelines in hard copy format.  Provide opportunities to address concerns about guidelines and practice patterns directly to the ID team. These were eventually communicated during the following daily noon huddle for discussion.  Improve the house-staff and care-teams' confidence in diagnosing and managing COVID-19 patients and thereby minimize need for frequent ID consultations. The study reports the period from March 10, 2020, when the first patient with COVID-19 was hospitalized, to April 10, 2020 when a survey was administered to assess the effectiveness of the consult teams. The majority of respondents were residents (59%) and faculty (20%) (Appendix Figure 2a ). Sixty-eight percent of the respondents were primary medical or medical subspecialty providers, and 26% were surgical and critical care providers (Appendix Figure 2b) . Overall, 95% of the respondents agreed or strongly agreed with the survey questions related to delivery of information, new knowledge acquisition, provider confidence in applying the knowledge and perception of outcomes related to management of COVID-19. Figure 4 shows the questionnaire responses. Provider confidence in discharging COVID-19 patients was the only element that 14% of the respondents disagreed with. The positive responses of the trainees and faculty were comparable (Appendix Figure 2c ). Overall, the COVID-19 consult team at Henry Ford Hospital was a well-received, effective, and scalable initiative undertaken by the division of ID to meet the rapidly increasing demand for consultative services during the COVID-19 outbreak in Detroit, Michigan. The use of daily, unit-wide education and group rounds led to an overall increase in knowledge, expertise, and confidence amongst the front-line house-staff and faculty in taking care of COVID-19 patients. Additionally, the ID faculty and fellows invested time in one-on-one interactions with ED providers regularly to help address workflow concerns. This was a critical step in ensuring our treatment protocols were being disseminated quickly to front-line staff. From the ID team's perspective, the use of the unit-based group rounds was a novel idea that proved beneficial in disseminating first-hand practical knowledge and up-to-date guidelines to A c c e p t e d M a n u s c r i p t 9 the teams immediately. This bolstered the primary teams' knowledge of the pathophysiology, natural history, diagnosis, treatment, and management of COVID-19 patients. Additionally, this model complied with physical distancing requirements to reduce healthcare workers (HCW) exposure to COVID-19 patients. The outbreak led to repurposing of non-medical ICU units for COVID-19 care. Non-internal medicine residents were redeployed to new COVID-19 units in ICU and GPU and were overseen by internal medicine faculty physicians. By spending an appropriate amount of face-to-face time with clinicians otherwise inexperienced in the care of complicated infectious diseases, including residents in disciplines such as orthopedics, vascular surgery, ophthalmology, dermatology, endocrinology, and others quickly became confident managing COVID-19 patients. The satisfaction of the primary services with the ID team is reflected in the strongly positive responses on survey, affirming the COVID-19 team's utility during the outbreak (Figure 4) . It is notable that the responses were comparable among multiple disciplines and by both trainees and faculty alike. The effectiveness of this approach is demonstrated by the fact that the number of ID consults stayed relatively consistent despite the surging rate of COVID-19 admissions. 14% of survey respondents did not feel comfortable discharging COVID patients early in the epidemic. The time to discharge from the hospital improved over the course of the epidemic. The initial lack of confidence by survey responders was primarily due to evolving Institutional and State Health department guidelines for the discharge of patients safely back to the community. Moreover, the increasing confidence in discharging COVID-19 patients over time validates the unit based ID consult model. ( Figure 1 ). The clinical efficacy of the reorganization was reflected in improved COVID-19 mortality rates. The average all-cause in-hospital 28-day mortality decreased from 32.4% for the period March 10th-25th to 15.4% for the period March 26th -April 10th. This improvement was likely multifactorial including the implementation of the dedicated ID COVID-19 teams. There are scant reports of similar reorganization of the delivery of care during the COVID-19 pandemic. Two reports describe the restructuring strategies of a surgical department and a A c c e p t e d M a n u s c r i p t 10 gynecological and obstetrics department to triage surgeries during the COVID-19 pandemic (4, 5) . Another report describes the approach to maintaining neurosurgery resident education and safety during the COVID-19 pandemic (6) . A report from Seattle described the restructuring of surgical care teams during the COVID-19 outbreak to comply with physical distancing requirements, decrease resident exposure to direct patient contact, optimize work-force well-being and provide resident reserves (7) . Finally, the electronic survey was distributed as a blast email to the all departments and hence it was not possible to determine percentage of COVID-19 providers that responded to the survey. However the 111 responses received was representative of multiple disciplines and job categories that manned the COVID-19 units. While it is possible that dissatisfied HCW may not have responded, we tried to mitigate this by ensuring that all of responses were anonymous. In conclusion, our novel unit-based group rounds model of delivering ID consultative service was effective in responding to an unprecedented demand during the COVID-19 surge at our hospital PhD for rapidly developing reliable diagnostic testing which was critical for patient management. Lastly, we would like to extend our heartfelt gratitude towards all front-line healthcare workers at Henry Ford Health System including all residents, fellows, faculty, nurses, and other allied health professionals who are key to providing lifesaving care daily. Conflicts of Interest: None of the authors have any financial or institutional conflicts of interest related to this manuscript preparation or related academic work. A c c e p t e d M a n u s c r i p t Stage 2: Increased Clinical Demands Guidance Clinical Characteristics of Coronavirus Disease 2019 in China Rapid Response of an Academic Surgical Department to the COVID-19 Pandemic: Implications for Patients, Surgeons, and the Community COVID-19 Pandemic: Staged Management of Surgical Services for Gynecology and Obstetrics Letter: Maintaining Neurosurgical Resident Education and Safety During the COVID-19 Pandemic Emergency Restructuring of a General Surgery Residency Program During the Coronavirus Disease