The Cough Cold and Fever Clinic: A Model for the Safe Management of Ambulatory Patients With Suspected COVID-19.

BACKGROUND AND OBJECTIVE: When the coronavirus disease-2019 (COVID-19) pandemic swept through New York City, hospital systems became quickly overwhelmed and ambulatory strategies were needed. We designed and implemented an innovative program called the Cough Cold and Fever (CCF) Clinic to safely triage, evaluate, treat, and follow up patients with symptoms concerning for COVID-19. METHODS: The CCF Clinic was launched on March 13, 2020, in the ambulatory internal medicine office of New York Presbyterian-Weill Cornell Medicine. Patients with symptoms suspicious for COVID-19 were first triaged via telemedicine to determine necessity of in-person evaluation. Clinic workspaces and workflows were fashioned to minimize risk of viral transmission and to conserve COVID-19 testing supplies and personal protective equipment. Protocols containing the most recent COVID-19 practice guidelines were created, updated regularly, and communicated through twice-daily huddles and as a shareable online document. Discharged patients were followed up for at least 7 days through telemedicine. Patient outcomes, including admission to the emergency department (ED), hospitalization, and death, were tracked to ensure clinical quality. RESULTS: We report on the first 620 patients seen at CCF between March 13, 2020, and June 19, 2020. Telemedicine follow-up was achieved for 500 (81%). We tested 347 (56%) patients for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), with 119 (34%) testing positive. Forty-seven (8%) patients were sent to the ED directly from the CCF Clinic and 42 (89%) of these were admitted. Of the patients discharged home from CCF, 15 (3%) were later admitted to a hospital. Twelve (2%) patients in total died. CONCLUSION: The vast majority of patients, over 90%, seen in CCF were discharged home, with only a small percentage (3%) later requiring admission to a hospital. Of the patients sent directly to the ED from CCF, close to 90% were admitted, verifying the accuracy of our triage. Overall mortality was low (2%), especially when compared with mortality rates in New York City during the pandemic peak. Telemedicine was effective in identifying patients in need of in-person evaluation and in tracking and follow-up. Workflows and protocols were adaptable to reflect rapidly changing resources and clinical guidelines. Frequent communication through a diversity of methods was critical. Through these strategies, we were able to create a safe and effective outpatient program for patients with potential COVID-19.

Implementation of Video Visits During COVID-19: Lessons Learned From a Primary Care Practice in New York City.

Background: During the height of the coronavirus (COVID-19) pandemic, there was an unprecedented demand for "virtual visits," or ambulatory visits conducted via video interface, in order to decrease the risk of transmission. Objective: To describe the implementation and evaluation of a video visit program at a large, academic primary care practice in New York, NY, the epicenter of the COVID-19 pandemic. Design and participants: We included consecutive adults (age > 18) scheduled for video visits from March 16, 2020 to April 17, 2020 for COVID-19 and non-COVID-19 related complaints. Intervention: New processes were established to prepare the practice and patients for video visits. Video visits were conducted by attendings, residents, and nurse practitioners. Main measures: Guided by the RE-AIM Framework, we evaluated the Reach, Effectiveness, Adoption, and Implementation of video visits. Key results: In the 4 weeks prior to the study period, 12 video visits were completed. During the 5-weeks study period, we completed a total of 1,030 video visits for 817 unique patients. Of the video visits completed, 42% were for COVID-19 related symptoms, and the remainder were for other acute or chronic conditions. Video visits were completed more often among younger adults, women, and those with commercial insurance, compared to those who completed in-person visits pre-COVID (all p < 0.0001). Patients who completed video visits reported high satisfaction (mean 4.6 on a 5-point scale [SD: 0.97]); 13.3% reported technical challenges during video visits. Conclusions: Video visits are feasible for the delivery of primary care for patients during the COVID-19 pandemic.

A Multidisciplinary Discharge Timeout Checklist Improves Patient Education and Captures Discharge Process Errors.

OBJECTIVE: To design and implement a discharge timeout checklist, and to assess its effects on patients' understanding as well as the potential impact on preventable medical errors surrounding hospital discharges to home. METHODS: Based on the structure successfully used for surgical procedures and using the Model for Improvement framework, we designed a discharge checklist to review and assess patients' understanding of discharge medications, catheters, home care plans, follow-up, symptoms, and who to call with problems after discharge. In parallel, we developed a process of integrating the checklist into the discharge process after routine discharge procedures were completed. We used the checklists to assess patients' level of understanding and need for additional education as well as changes in discharge documentation; we also noted whether good catches of significant errors in the discharge process occurred. RESULTS: Over 6 months of study, 190 discharge timeouts out of 429 eligible discharges were completed. Additional education was provided in 53 of 190 discharge timeouts (27.8%), with 62% of this education being related to medications. Twenty-one (11.1%) discharge timeouts resulted in at least one change to the discharge documentation or a good catch. CONCLUSIONS: A multidisciplinary discharge timeout directly involving the patient can be effective in targeting additional areas for patient education and in potentially reducing preventable adverse events.