The Silver Linings Playbook for COVID-19

In the film Silver Linings Playbook, the protagonist Pat struggles to control his bipolar disorder, which triggers violent outbursts leading to hospitalization in a locked psychiatric unit. Upon discharge, Pat commits to a new outlook on life, embodied by the Latin word “Excelsior”—”ever upward.” Emboldened by this new mantra, he endeavors to reframe crises as opportunities … or silver linings. His psychiatrist cautions that attitude alone is an incomplete solution: “You need a strategy for when you get these feelings…otherwise you will be sent back.”

Amid the 2020 global spread of SARS-CoV2 and our own lock-downs, the worldwide medical community came together in crisis. Leaders and frontline health care workers quickly re-engineered care delivery processes to support the triad of protecting patients, limiting exposures for health care workers, and preserving the supply of personal protective equipment (PPE).

Outpatient care rapidly shifted to delivery via “virtual visits” by videoconference, aided by waivers of CMS reimbursement restrictions and HIPAA regulations.

Health systems quickly erected “drive-through” testing sites, allowing access to needed testing while minimizing opportunities for coronavirus transmission.

Hospitals re-engineered their workflows with similar goals. Guidance on inpatient care proliferated, stressing mindful care delivery practices such as an escalation of inpatient telemedicine use, reduction of unnecessary blood draws, thoughtful restraint in imaging, reduction of vital sign checks in stable patients, and shifting to medications with less frequent dosing intervals. At teaching hospitals, where visits by large groups of trainees throughout the day were commonplace, excessive bedside contacts were restricted.

For champions of high-value care, these ideas were familiar. Over the past decade, clinician-led initiatives like Costs of Care and Choosing Wisely, as well as campaigns backed by professional societies like the American College of Physicians, Society of Hospital Medicine, and High Value Practice Academic Alliance have advocated for broader implementation of best practices to promote value and evidence-based care. Increasingly, scholarly articles outlining “Things We Do for No Reason,” “Choosing Wisely: Next Steps,” and “Less is More,” encourage clinicians to reduce wasteful practices without sacrificing high-quality care. Comparable curricula and mentorship programs targeting trainees (such as Dell Medical School’s “Discovering Value-Based Health Care” and Choosing Wisely Stars) are now well-established. Progress, however, has been slower than expected.

Initiatives to reduce overutilization are not new. The Choosing Wisely campaign has advocated against the use of routine daily labs since 2013. Similarly, the American College of Radiology piloted a more rational approach to diagnostic imaging, and pioneered the development of clinical practice guidelines to better align study orders with specific clinical questions, thus improving efficiency and reducing waste.

Reflexive over-monitoring with telemetry and vital signs harms hospitalized patients by increasing alarm fatigue and reducing sleep quality without improving outcomes. Bundled interventions exist to reduce superfluous nighttime interruptions by fostering nursing unit sleep culture and promoting “sleep-friendly orders,” such as reduced overnight vital signs and minimizing nighttime med dosing, but implementation has lagged.

Like our protagonist Pat, we need a strategy after COVID-19 to ensure we carry forward key lessons once normalcy is restored. Thoughtful integration of telemedicine in the hospital could decrease equipment waste for patients in isolation, reduce unnecessary exposures, and increase efficiency and timeliness of consultation for appropriate specialists while still maintaining physician-patient rapport. With new flexibility in regulatory requirements creating opportunities for innovative care delivery, a restructuring of the interplay between documentation and billing that emphasizes clinical decision-making over a regimented physical exam and rote review of systems could meaningfully enhance patient encounters. U.S. hospitals currently produce over 5.9 million tons of medical waste each year; moving forward, overuse of PPE should be scrutinized in the same fashion as unnecessary phlebotomy, imaging, and procedures. For trainees returning to learn at the bedside, what will be best practices?

Fear of contracting COVID-19 has accelerated hand hygiene and disinfection practices and even threatened the sanitizer supply chain. Improved attention to handwashing is overdue, given average compliance rates of around 40 percent. With no vaccine in sight, and the possibility of reinfection after recovery, COVID-19 may threaten hospitals for years. We should seize the opportunity to leverage renewed motivation for hand hygiene to entrench habits and standards of behavior for the long term.

The practices we now embrace were valuable before COVID-19 and will remain so afterward. For too long, we have accepted cautious and incremental change. Our creative, urgent, and massive system overhaul in response to the pandemic should rejuvenate improvement efforts and embolden us to elevate our expectations. As we have leveraged our own fear of serious harm to transform care, we should not lose sight of the fact that mistakes kill > 250,000 patients each year, making medical errors the third leading cause of death in the U.S. For our patients, there has always been an urgent need for improvement; now, we have an unprecedented opportunity to accelerate change and abandon inertial low-value practices.

We must prioritize the health and comfort of our hospitalized patients and devote systematic attention to the mindful stewardship of resources to ensure meaningful progress. For example:

  • Limit diagnostic testing to that which would meaningfully advance the care plan
  • Batch blood testing to minimize needlesticks and sleep disruptions
  • Consolidate visits by treatment teams to balance competing patient needs for rest and diagnostic workup
  • Limit overnight interruptions in stable patients
  • Integrate inpatient virtual visits when clinically appropriate
  • Maintain fastidious attention to hand hygiene
  • Explore new models of care delivery fostered by current waivers
  • Reform stringent E&M documentation requirements

The coronavirus pandemic offers a unique opportunity to improve our health care system and study the rapid implementation of best practices. A focus on urgent health care transformation — executing the COVID-19 “silver linings playbook”— should be our new gold standard.

Gregory B. Seymann, Arkady Komsoukaniants, Daniel Bouland, and Ian Jenkins are internal medicine physicians.

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