Working with housestaff and APPs during COVID-19 will take thought and planning, and some new policies will need to be instituted. Different hospitals throughout the country appear to be managing this differently, and how housestaff are deployed may very well change as volume surges, hospitalist MDs and APPs become ill, and also as housestaff become ill and need to cover for one another to maintain minimum staffing levels in ICUs and other critical areas.
Programs vary considerably with respect to the percent of patients cared for by housestaff. A hospitalist service that operates with 75% of patients being cared for by housestaff will probably need to implement different protocols as compared to a program with <50% of patients on housestaff services. That said, some suggestions from user forums and other sources include the following:
- Where possible, assign COVID-19 positive patients to non-teaching teams without any APP.
- Consider assigning all viral respiratory infection patients to non-teaching teams.
- Given the mulitiple benefits of cohorting (discussed in a previous post), assign only hospitalists to those units, without any housestaff or APPs.
- For programs where housestaff and APPs will be caring for patients on precautions, establish a Single Examiner Policy. An example of such a policy would be for the attending physician and intern to round together, but only the attending performs the exam. This may limit the number of staff at risk for exposure while also preserving PPE (if the intern and resident remain 6-feet away, etc). DO NOT continue with the usual practice where your intern, resident, and attending all enter the patient room, donning full PPE, and where each team member examines the patient. Policies can also be drafted for APPs, but be sure to be familiar with state requirements and to keep up with emergency legislative actions which in many states have made APP supervision rules more lenient.
- Even for programs that try to limit exposure of housestaff to COVID and/or precaution patients, acknowledge that there will be times where an intern or resident directly care for and examine a patient on precautions (with or without COVID-19). Care should not be delayed to patients in order to try to keep with a Single Examiner policy (such as waiting for the attending to deal with a Rapid Response which requires an in-person re-evaluation including exam).
Do not forget to deal with social distancing with the housestaff and APPs. Housestaff and APPs in many places are used to working in relatively small workrooms. These are NOT suitable during this time when social distancing is required. For more information on social distancing in the workplace, see my post on precautions.