Palliative Care Program Response to COVID-19: Mount Sinai Hospital

The palliative care program at the Mount Sinai Hospital, is one of several palliative care teams caring for patients in hospitals and community settings across Mount Sinai Health System (MSHS) in New York City.

This is a snapshot of the palliative care program's involvement in the Mount Sinai Hospital's COVID-19 response, based on an interview with Emily Chai, MD, System Chair, Palliative Medicine, Mount Sinai Palliative Medicine, on March 28, 2020. At the time of the interview, the entire Mount Sinai Health System was in the middle of the surge.

• New York City has the highest infection and death rates in the U.S.
• Hospital rapidly expanding its capacity by erecting tents in lobby areas, outdoors on the hospital campus, and in Central Park
• Community planning
  • Due to PPE shortage, patients often unable to go to hospice or home health
  • Long-term care facilities very cautious to take back non-COVID-19 patients upon hospital discharge
    • Temperature taken the day before and fifteen minutes before discharge to compare temperature
    • The EMT must witness the temperature at discharge

• Palliative care was a key stakeholder at the table for developing MSHS's system-wide response
  • Palliative care is seen as important system-wide to assist ED and intensivists in symptom management and advance care planning (ACP)
  • Because access to home health and hospice is challenging, palliative care is collaborating with pharmacy and procurement to create home comfort packs for patients and families being discharged, to provide medications and support once home, and providing a 24/7 telephone support line for patients and families
• Anticipating that the whole hospital will turn into a COVID-19 hospital, palliative care is helping by trying to move stable patients to hotels and student dorms rented by the hospital
• Focus on non-COVID-19 palliative care patients
  • Palliative care unit functioning as normal; question of whether it will become a COVID-19 unit
  • No longer able to staff with one attending, so brought on geriatric attending
• Helping with COVID-19-positive patients at end of life
• Social work and chaplaincy help with family contact

Clinical Partners

• Real-time consultants to fellow colleagues, with teams in the ICU
• Providing 24/7 telephonic assistance to fellow clinical colleagues, staffed by junior faculty
• Coaching front line clinicians for care and ACP conversations since they are overwhelmed
• Participating in virtual (video) team rounds

Become Educated About the Disease Trajectory

• Map the disease course and treatment

Change Clinical Practice to Reduce Exposure

• Move pumps and vent settings close to glass walls to allow monitoring from outside the room
• Use low-dose pumps to decrease the need to go in the room
• Do not remove ET tube for extubations
• Use internal or room cameras to see if patients are comfortable
• Patients can decline quickly, so be proactive in care

Visitor Policy

• Consider implementing a strict policy on visitation early on to avoid nurses having the additional stress of enforcing the policy

Preparation

• Embed palliative care team in different places
• Review current patients and clear the hospital of stable patients to get ready for COVID-19 patients

Teamwork

• Promote teamwork
• Provide support to palliative care team
• Provide support to clinicians on the frontlines, critical care nurses and physicians and hospitalists who are being exposed to such trauma

This snapshot was consolidated, edited, and condensed by Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN, Consultant, Center to Advance Palliative Care.