COVID-19 Proactive Disease Management Using COVID Virtual Hospital in a Rural Community.

Purpose: A community teaching hospital serving a rural population established an intensive "hospital at home" program for patients with COVID-19 utilizing disease risk stratification and pulse oximeter readings to dictate nurse and clinician contact. Herein, we report patient outcomes and provider experiences resulting from this "virtual" approach to triaging pandemic care. Methods: COVID-19-positive patients appropriate for outpatient management were enrolled in our COVID Virtual Hospital (CVH). Patients received pulse oximeters and instructions for home monitoring of vital signs. CVH nurses contacted the patient within 12-48 hours. The primary care provider was alerted of the patient's diagnosis and held a virtual visit with patient within 2-3 days. Nurses completed a triage form during each patient call; the resulting risk score determined timing of subsequent calls. CVH-relevant patient outcomes included emergency department (ED) visits, mortality, and disease-related hospitalization. Additionally, a survey of providers was conducted to assess CVH experience. Results: From April 22, 2020, to December 21, 2020, 1916 patients were enrolled in the CVH, of which 195 (10.2%) had subsequent visits to the ED. Among those 195 ED visits, 102 (52.3%) were nurse-directed while 93 (47.7%) were patient self-directed; 88 (86.3%) nurse-directed ED visits were subsequently admitted to inpatient care and 14 were discharged home. Of the 93 self-directed ED visits, 3 (3.2%) were admitted. A total of 91 CVH patients (4.7%) were ultimately admitted to inpatient care. Seven deaths occurred among CVH patients, 5 of whom had been admitted for inpatient care. Among 71 providers (23%) who responded to the survey, 94% and 93% agreed that the CVH was beneficial to providers and patients, respectively. Conclusions: Proactive in-home triage of patients with COVID-19 utilizing a virtual hospital model minimized unnecessary presentations to ED and likely prevented our rural hospital from becoming overwhelmed during year one of the pandemic.

You Have Been Hacked!

On October 31, 2021, I learned the electronic health record in my independent, solo practice had been attacked by a Russian syndicate who was holding our data and our practice management system for "ransom." An encryption key could be given to our cloud provider once $5,100,000 was delivered in bitcoin to the hacking entity. After 3 long months of negotiations, with us going back to a completely paper-based system in the interim, our cloud provider paid the Russian syndicate and access was restored. There were many lessons to be learned from our experience. We were fortunate, and through the help of many of our business associates we were able to survive and live to see another day.

Improving use of narcotics for nonmalignant chronic pain: a lesson from Community Care of North Carolina.

OBJECTIVE: To describe the development, implementation, and effects of collaborative effort to reduce diversion of prescription drugs in Caldwell County, NC. DESIGN: Development and implementation of practice guideline, statewide opioid registry, and survey of all primary care providers. SETTING: Rural Caldwell County, NC, has a population of 83,029, of which 89 percent are non-Hispanic White; 2009 median household income of $35,489. PATIENTS, PARTICIPANTS: All primary care clinicians in the county (N = 35). INTERVENTIONS: A task force developed and implemented a practice guideline that encouraged the following: 1) signing of pain contracts; 2) requiring patients to undergo random urine drug testing; and 3) requiring random pill counts. North Carolina implemented a statewide registry in 2007 that contained information on virtually all opioid prescriptions filled by pharmacies. MAIN OUTCOME MEASURE(S): Opioid pill confiscations by the Caldwell County Narcotics Division 24 months prior to implementation of the guidelines, the first 12 months during guideline implementation, and 12 months after the guideline was fully implemented. RESULTS: From 2005 to 2007, opioid pill confiscations decreased by 300 percent. Of the 35 physicians who were sent surveys, 27 responded (77 percent response rate). Ninety percent of respondents who prescribe opioids use the chronic pain guidelines. Sixty percent report an improvement in the overall management of patients with chronic pain; 65 percent reported having more confidence in treating patients with chronic pain; and 60 percent reported using the opioid registry. CONCLUSIONS: This county wide medical initiative appears to have resulted in a significant improvement in the abuse and diversion of medically derived opioids.