key: cord-1043004-u43ayqro
authors: Lipworth, Adam D.; Collins, Elizabeth J.; Keitz, Sheri A.; Hesketh, Paul J.; Resnic, Frederic S.; Wozniak, Joanne M.; Mosenthal, Anne C.
title: Development of a Novel Communication Liaison Program to Support COVID-19 Patients and their Families
date: 2020-11-24
journal: J Pain Symptom Manage
DOI: 10.1016/j.jpainsymman.2020.11.016
sha: c4872ef2652f7a30258ba21d9be885b8b6203d1a
doc_id: 1043004
cord_uid: u43ayqro

In the Spring of 2020, our hospital faced a surge of critically ill COVID-19 patients, with intensive care unit (ICU) occupancy peaking at 204% of the baseline maximum capacity. In anticipation of this surge, we developed a Remote Communication Liaison Program (RCLP) to help the ICU and palliative care teams support families of critically ill patients. In just nine days from inception until implementation, we recruited and prepared ambulatory specialty providers to serve in this role effectively, despite minimal prior critical care experience. We report here the primary elements needed to reproduce and scale this program in other hospitals facing similar ICU surges, including a checklist for replication (Appendix A). Keys to success include strong logistical support, clinical reference material designed for rapid evolution, and a liaison team structure with peer coaching.

A defining tragedy of the COVID-19 pandemic has been the separation of families from their critically ill loved ones, especially at the last moments of life. Necessarily prohibitive hospital visitation policies exclude families from the bedside; at the same time, the need to deploy significant numbers of additional physicians and nurses to the ICU, some with little to no critical care experience, leaves few with the time or expertise to hold difficult conversations and to compassionately support families. Strategies to optimize palliative care team responses to COVID-19 patient influxes have been reported [2] [3] [4] , but during severe surges, the need for frequent, expert family communication can, and did, overwhelm even the largest palliative care teams' capacities.

At our institution, we faced this challenge by rapidly developing a Remote Communication Liaison Program (RCLP) to help the ICU and palliative care teams support families of critically ill patients. We report here the primary elements needed to reproduce and scale this program in other hospitals facing similar ICU surges.

In the spring of 2020, Massachusetts saw thousands of COVID-19 patients admitted to hospitals throughout the state. Facing an impending surge, our 335-bed tertiary care teaching hospital prepared to expand ICU capacity from 52 beds at baseline to at least 160 ventilator-ready beds.

The surge plan relied heavily on redeployment of physicians, advanced practitioners, nurses and medical assistants to care for patients in units repurposed as COVID-19 wards and ICUs.

ICU occupancy quickly surpassed historic capacity, peaking at 204% of the baseline ICU maximum, with 106 critical care patients on April 30, 2020.

By late March, well before the ICU census peaked, the volume of COVID-19 inpatients requiring daily family communication and support began to overwhelm frontline palliative care and ICU teams, causing great distress for providers and bedside nurses, who were often the only J o u r n a l P r e -p r o o f individuals present to comfort dying patients. Concurrently, many subspecialty providers who had not been deployed to the ICUs were eager to help and had excess capacity, since all elective surgeries and many ambulatory visits were suspended. Some of these providers had not been deployed because their age or health status imparted unacceptably high risk to onsite service. More commonly, however, these providers had not been selected for ICU service because they lacked the critical care experience to justify their presence, especially when critically low personal protective equipment supplies required thoughtful distribution to only those caregivers able to provide care most effectively. The challenge quickly became clear:

how to remotely provide family support and palliative care with a cadre of providers who were willing to provide this service, but who lacked the critical care skillset or formal training in palliative care.

In response, we developed the Remote Communication Liaison Program (RCLP) to support communication between ICU teams, the palliative care team, and families of ICU patients during the COVID-19 ICU surge. The RCLP was designed for a dual mission: (1) to support the families of critically ill COVID-19 patients, and (2) to support the ICU teams delivering care to those patients. To achieve these goals, Communication Liaisons needed to speak with families at least once a day, and to provide timely and accurate clinical updates, empathic guidance through difficult decisions, and consistent emotional support. Liaisons worked remotely, gathering information from chart reviews and discussions with critical care team members (Figure 1 ). Early each morning, liaisons reviewed their patients' electronic records to learn about overnight events and any changes in clinical status. Following these chart reviews, all liaisons and liaison-coaches assigned to a given unit would meet together virtually, to confirm or clarify their understanding of their chart reviews, and to discuss anticipated challenges in the planned phone calls for that day. Palliative care providers, who also divided themselves according to specific ICUs during the surge, joined these morning liaison team calls for their units whenever possible.

For patients whose chart review suggested overnight stability, liaisons would make the first of two planned daily calls to their family member, following the morning liaison-team meeting. In these calls, liaisons would inform a patient's family of the patient's stable status, remind them that the liaison would be in touch later in the day after speaking with the ICU team, and inquire whether the family member had any specific questions or concerns to relay to the ICU team. A primary purpose of these brief check-in calls was to reaffirm to family members that their loved ones had the attention of hospital caregivers; by calling and assuaging anxiety early in the day, liaisons pre-empted family members' calls into the ICU early in the day during rounds when it was difficult for the ICU tem members to meet their needs. When the chart review suggested a clinical status change, or raised questions the liaison could not answer from the chart alone, the morning check-in call was deferred until the liaison could speak to an on-site ICU team member for clarification. 

We present here a model for rapidly deploying a broad range of providers to support families of the critically ill and provide relief to ICU teams working through severe and taxing conditions. This model is feasible in a variety of settings (Appendix A), easily scalable, and can be successful J o u r n a l P r e -p r o o f in supporting over-stretched palliative care and critical care teams. Adapting our training paradigm, clinicians with even minimal prior exposure to critical care or palliative medicine can quickly learn to perform such a liaison service skillfully and to great benefit. Liaisons exhibited a high degree of engagement with the program, evidenced by the high (>80%) proportion of repeat volunteers and their magnanimous responses to scheduling disruptions, as well as by informal strongly positive feedback from many of the liaisons. Keys to success include strong logistical support, a team-based system with peer coaching, and "just-in-time" training with quick guides in wiki format to allow constant updates. As the nation faces new COVID-19related ICU surges, expanded communication support remains a critical need in this pandemic. Meeting conducted by telephone. The following people (names and relationships to the patient) participated in the meeting:

• @MECRED@, Critical Care Liaison Provider • ***

A Son's Story: Texts from my Father, in Elmhurst Hospital

Creating a Palliative Care Inpatient Response Plan for COVID-19-The UW Medicine Experience

The following clinical status update was provided to the televisit participants: {Blank single:19197::"As described under 'current status' above","***"} Markers of progress or setbacks and expected milestones (and what we might do if they are not achieved) {WERE / WERE NOT:19253} discussed: *** The patient's functional status, health characteristics, and/or social history prior to admission {WERE / WERE NOT:19253} discussed: *** What are the patient's goals as they relate to the current clinical status? {Goals:304000950}

SUMMARY, ASSESSMENT, PLAN, NEXT STEPS: *** @telehealthdocumentation@ @TD@ @NOW@ @mecred@ Symbol legend • "@" symbols flanking text indicates a "Smart Link" that will automatically bring information from the patient's chart into the note • Curly Brackets "{ }" indicate a "Smart List" that will present the note author with choices to select from. • A triple asterisk "***" indicates a "wildcard", a placeholder that must be replaced with free text or deleted. "assistance with clarification of goals of care" "assistance with withdrawal of life prolonging measures" "facilitation of Family Care Conference" "hospice referral or discussion" "non-pain symptoms" "pain" "psychosocial support" "spiritual support" *** WERE / WERE NOT:19253 "were" or "were not" Goals:304000950 "Recovery to baseline prior to this admission" "Recovery to rehabilitation/longer term assisted care (different than baseline prior to admission" "Comfort" "Unsure" *** HCP Activated:304009027 "Yes" "Not Indicated" "There is no healthcare proxy, consider pursuit of guardianship if indicated" *** Responses:304009028 "Yes, directive states: ***" "There is a copy in the patient's chart" "HCP has been asked to provide a copy" "No" Code Status:304000943 "Full" "DNR/DNI" "Partial" "Other:***" Confirmed With:304000944 "Patient" "Healthcare Proxy, Name: ***" "No Healthcare Proxy in place, next of kin: ***" "Not able to confirm code status at this time due to: ***" Blank single:19197Generic smart list for end-user to develop. Choices appear in note J o u r n a l P r e -p r o o f

Critical Care Wiki• Resource library: links to national and hospital-specific guidelines for COVID-19and ICU care • Critical Care "Chart Biopsy" Tips: how to rapidly extract key information from a patients electronic medical record • Vitals: Explanation of some common vital sign findings in COVID-19 ICU patients * These guides were constantly in flux throughout the program. Remote Communication Liaison Program participants were all encouraged to contribute to these reference guides by continually adding and editing, utilizing their experiences to refine the guides in real-time, so that all participants could benefit from newly acquired knowledge shared as quickly as possible.