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Covid in children primary care perspective
- 1. COVID in Pediatric Primary Care Sabrina Braham MD FAAP Menlo Medical Clinic, Dept of Pediatrics Adjunct Clinical Instructor, Stanford Children’s Hospital Twitter @BabyDrBraham
- 6. Making decisions when you don’t have all the facts ❏ Communication ❏ Collaboration ❏ Clarification of values
- 7. Barriers to efficient response 1. IPC Protocols 2. Knowledge of pathogen 3. Diagnostic testing 4. PPE 5. Administrative hurdles
- 8. ● Assimilation of new data ● Risk stratification protocol ○ Triage workflow ○ Patient workflows ● Ventilation review ● PPE rational use protocol ● PPE budgeting ● Testing protocol ● Results reporting protocol ● Access/Capacity ● Continuity/Well care ● HCW/Childcare issues ● HR/psychosocial issues
- 10. COVID in Pediatric Primary Care What have we learned?
- 12. Communication and Collaboration ● Patient-centered ○ Leverage digital health ■ Information dissemination ■ Uninterrupted patient care ■ Business continuity and revenue ● Regional response teams ○ Ambulatory ○ Inpatient ○ Academic ○ Regulatory ● Nimble internal communication framework ○ Review communication structures and tools ○ Team-based approach vs silos ○ Front line surveillance/response system
- 14. Clarification of Values ● Staff safety ○ IPC protocols ○ PPE supply chain, fit-testing provisions ● Continuity of care ○ Rigorous pandemic response plans ■ Vetted approach based on primary mode of transmission ■ Capacity for surges ■ Preservation of access to routine care ● Community Leadership and Advocacy ○ Eg Vera Cloud Testing
- 15. “We must recognise that medical care exists on an ever-changing continuum between the inpatient and outpatient settings and stay flexible enough to enhance the care in one setting without abandoning the other. We must preserve the spirit of innovation, the collaboration across silos and the sense of urgency and model this for our trainees.”
Editor's Notes
- 1 of 13 pediatricians in a large mainly adult multispecialty clinic Insured population, “in-network” for Stanford Hospital employees so play key role in caring for the Stanford community and healthcare workers specifically
- Important to remember: COVID-19 arrived in the US in the middle of flu season Not remarkable overall
- Particularly bad season for children, worst in a decade, based on hospitalizations
- Behind the hospitalization data are the ambulatory visit data for influenza-like illnesses Large volume for ILI coincided with first reported COVID cases locally As you know, children don’t drive themselves to the doctor so adding parent and possible siblings, we can have near 500 bodies in and out of our space daily in flu season. Learning about COVID-19 presenting with ILI, but asx spread also possible
- Faced with a very real and immediate operational crisis, but also a very real threat to the health and safety of our physicians and staff Our task: serve our sick patients while staying safe ourselves Scratched out this triage after a phone call with Roshni (cell phone number), for implementation the next day Complete overhaul of nursing and MD workflows implemented within 24 hours
- What happened can best be described as building the plane as you are flying Making critical decisions with limited information Not typically how medicine works (17 yrs for research to become practice AND outpatient providers accustomed to waiting for evidence-based guidelines to inform decision making )
- Story: testing rolled out but not informed, no info about testing children Story: PPE shortages, reuse was common, but then donation and supply chain didn’t take into account fit testing
- Eg GI sx in kids, aerosolization from nebs Story: ultimately have run RCC without nursing staff to preserve PPE and limit staff exposure Story: high staff/square foot ratio posed unique IPC problems, symptom screening of staff, space staff out without impacting work product, masks for staff etc
- IDSA COVID guidelines in late April - validated our approach Operating since March without a single occupational exposure Now focused on prep for winter/flu season surges and transitioning from crisis to longer term sustainable operations
- Engage ambulatory care in front line surveillance and response Create 2-way comm structures to leverage each group input toward common effort Pull together as a team
- Retrospective EMR data analysis Amb visits for ILI sx in 15 states Jan-Mar 2020 (compared to 2 prior years) Increased ILI/+flu ratio not present in prior years Lots of non-flu ILI in Feb and March Could use ACC visits for ILI sx as surveillance or early warning system for spikes in COVID or future pandemics
- Bolster IPC training - provides rubric for any outbreak (airborn, droplet, contact) Comm leadership - Lisa Chamberlain (food insecurity) and Vera Cloud Testing Platform (low cost scalable COVID testing to underserved) What about childcare programs, schools - childcare crisis. What about other community organizations (churches, synagogues etc) providing critical support?
- We must recognise that medical care exists on an ever-changing continuum between the inpatient and outpatient settings and stay flexible enough to enhance the care in one setting without abandoning the other. We must preserve the spirit of innovation, the collaboration across silos and the sense of urgency and model this for our trainees.