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COVID Pro Tips from Hospitalists

A quarter century ago, hospitalists didn’t exist. Now, these specialists in hospital medicine are managing the care of countless North American patients with COVID-19. They’ve learned plenty over the past 10 months, and five from across the country shared pro tips with MedPage Today about providing optimal care.

Watch Out for Atypical Presentations

Physicians are taught that “common things are common” — simple diagnoses are usually correct, said Benji Mathews, MD, a HealthPartners physician and chief of hospital medicine at Regions Hospital in St. Paul, Minnesota. But COVID is different, he said.

“If you hear hoofbeats, you are more likely to see a horse, unless you are in an evolving COVID-19 pandemic. Then it may be a zebra,” said Mathews. “Try to think of COVID-19 manifestations in the differential for patients with atypical manifestations of common disease.”

Mathews highlighted a trio of atypical presentations of COVID. One is Multisystem Inflammatory Syndrome in Adults (MIS-A), the adult equivalent of the same syndrome in children (MIS-C). “We’ve seen a handful of 18- and 19-year-olds and young adults arrive with unusual cardiac presentations following initial COVID-19 infection — acute myocardial infarction, cardiomyopathy, and coronary thrombosis,” Mathews said.

So far, there’s been little discussion of MIS-A in the medical literature. A December report in the journal CHEST noted that “a lack of clear guidance regarding diagnosis highlights the need to establish MIS-A case definitions and testing algorithms.” The report also said there’s no ideal treatment for the syndrome, although “IV immunoglobulin, steroids, and other immunomodulatory agents have been used to treat suspected cases of MIS-A, with clinical improvement noted in some instances.”

Hematochezia — the passage of blood from the anus, often in or with stools — is another atypical initial clinical presentation of COVID-19 disease, Mathews said. Only a few case reports have highlighted gastrointestinal bleeding in connection to COVID-19, but Mathews believes they may not reflect the full extent of the problem. “Severe gastroenteritis seems to be underappreciated so far in the literature compared to practice,” he said.

He also urged colleagues to take note that “an impressive proportion of COVID-19 patients” have neurologic disease — neuropathic pain, peripheral neuropathies (Guillain-Barre-like syndromes), stroke, central nervous system vasculitis, and encephalopathy.

Don’t Be Misled by Oxygen Tubing

Many hospitals now allow more access to high-flow oxygen on floors outside the ICU. At a glance, it can be difficult to differentiate between high-flow oxygen delivery systems and a non-high-flow oxygen cannula because the tubing looks similar, cautioned hospitalist Grace Farris, MD, of the University of Texas and Dell Seton Medical Center in Austin, Texas.

As a result, she said, “a patient can seem very stable but actually require 10 or 20 times more oxygen than a nasal cannula delivers and be very close to needing intubation. Be wary of this, and always review what settings they are on. If they have been dialed up to FiO2 of 80%, that is getting pretty concerning.” (FiO2 stands for the fraction of inspired oxygen — the percentage of oxygen in a gas mixture. Room air has an FiO2 of 0.2, or 20%).

Farris has quite a bit of experience treating COVID. Prior to July 2020, she was chief of Hospital Medicine at Mount Sinai West hospital in New York City.

Don’t Force Proning

Some hospitals have enthusiastically embraced proning in patients with COVID-19 even when many staffers are needed to turn a patient over. Mathews believes proning has potential benefits – “it improves physiologic parameters and may or may not help prevent intubation” — and he tells patients that it’s fine to change position themselves. “But I tend to not force the issue, especially for patients unable to be on their stomach due to discomfort, pain, etc.”

Be on the Lookout for Delirium

Delirium is common in the hospital in the best of times, and hospitalists say they’re seeing it even more often in patients now. Isolation and COVID create a “perfect storm” for the development of delirium, said hospitalist Armond M. Esmaili, MD, of the University of California San Francisco. “You need to be on extra alert,” he said, and limit medications such as opioids and benzodiazepines that can trigger delirium.

In Texas, Farris conducts delirium screening via an “ultra-brief” bedside tool that requires medical professionals to ask just two questions: What day of the week is it? Can you say the months of the year backwards?

“If the patient has trouble with either or both of these questions, this is concerning for delirium,” she said. “This works better than using the phone to call the patient and do a longer mental status assessment since many patients have difficulty using the hospital phone due to hearing and vision impairments.”

The delirium tool, developed by Donna M. Frick, PhD, of Penn State College of Nursing, and colleagues, has a sensitivity of 93% (95% CI 81% to 99%) and specificity of 64% (95% CI 56% to 70%) at detecting delirium, according to a 2015 study in the Journal of Hospital Medicine.

As to delirium treatment, Esmaili said it can be helpful to bring familiar items into patient rooms to help orient them. But this may be difficult during the pandemic due to hospital restrictions.

A 2017 report in the New England Journal of Medicine suggested that “interventions to improve orientation and reduce sensory deprivation include clocks, calendars, and encouragement of patients to wear eyeglasses and hearing aids.” The report also noted that family visits can be helpful – but they’re typically not allowed during the pandemic unless they’re conducted virtually.

Understand the Connection Between Steroids and Delirium

Steroids are a very common treatment for COVID-19, but they can trigger psychosis, said hospitalist Charlie Wray, DO, of the University of California San Francisco. “It’s often a dose-dependent side effect, meaning the more you give, the greater chance you’ll see it. The problem is that steroid-induced psychosis can look a lot like hospital delirium, an extremely common entity we see in patients who are hospitalized and are very sick — where people become hyperactive, unable to sleep, and with altered mental status. Teasing these two phenomena out from one another can be difficult.”

One way to lower the risk of steroid-associated side effects is to shorten the standard COVID-19 course of the steroid dexamethasone (6 mg a day for up to 10 days) if patients are responding quickly, he said. “We also do small things like giving steroids in the morning so that they don’t interfere with sleep patterns too much.”

Beware of Parasitic ‘Hyperinfection’ in Foreign Patients

“We take care of many patients from diverse population groups and ethnicities. Patients who originate outside of the U.S., Australia, U.K., Canada, or Europe will need to be treated prophylactically for strongyloides, a parasitic infection that can emerge after corticosteroids are administered,” said Mathews. “The regimen is two doses of ivermectin, one day apart, with the first dose preferably given before steroids are administered.”

Strongyloides is caused by roundworms. Steroid use is linked to “hyperinfection” of pre-existing infestations.

Help Patients Cope with Fear of Death

“Don’t underestimate the fear patients have after they are admitted. Many are terrified that they are going to die,” said Mathews. “Calling out that fear, and reviewing how much better patients do now compared to earlier in the pandemic, has a hugely positive effect on the patients, their families, and our ability to care for them.”

But Mathews also urged colleagues to remain realistic when talking to patients about prognoses. “Uncertainty is ubiquitous with COVID-19, so acknowledging it is key: Say ‘I don’t know’ and ‘I will still be with you through this.’ Don’t emphasize certainty, and don’t acknowledge uncertainty without providing compassionate follow-through. Be truthful and transparent.”

Mathews highlighted the guidance from “Improving Diagnosis in Health Care,” a 2015 publication by the National Academies of Science, Engineering and Medicine that emphasizes the importance of sharing uncertainty with patients. The report says “the working diagnosis should be shared with the patient, including an explanation of the degree of uncertainty associated with a working diagnosis.”

Call the Patient Before You Enter the Room

Hospitalist Michelle Brooks, MD, of Virginia Commonwealth University Health in Richmond, has found a way to support her coworkers whenever she’s in PPE and about to go into a patient’s room. “Check with the patient virtually — by phone or FaceTime — whatever your institution is using — and with the nurse to see if you can bring anything in the room for the patient. This ensures that your team minimizes the amount of PPE used and helps your nursing colleagues if you can bring a pitcher of water.”

Embrace the Power of Human Touch

“I try to sit down in the room with the patient, spend some time with them, and lean forward,” Brooks said. “If the patient is open to it, I engage by touching their arm or hand during my interviews and exam. Even in a gown, gloves, mask, and face shield, patients still eagerly desire some form of human contact, and honestly, I do too. I believe this is safe with the proper PPE.”

Last Updated January 20, 2021

Source: MedicalNewsToday.com