Managing the dual threat of flu and COVID-19 with level of care guidance

Co-workers wearing surgical mask with arms crossed in dental clinic

With the flu season upon us and the COVID-19 pandemic continuing to surge, healthcare organizations now face an unprecedented challenge. As medical resources are stretched to capacity, the ability to quickly identify the appropriate level of care and safely, but efficiently, move patients through the system, is of critical importance. Frontline workers need the guidance to successfully evaluate patients and transition them to post-acute levels of care in order to avoid occupancy challenges many have faced throughout the pandemic. 

The importance of Acute Viral Illness care guidelines

From the outset of the pandemic, MCG Health has sought to provide clinicians with evidence-based tools and care guidelines to help them make timely and informed decisions. What we came up with was a new set of care guidelines for Acute Viral Illness (including COVID-19 and influenza) that cover adult inpatient, pediatric inpatient, and Observation Care. We made these guidelines available at no cost for any hospital, government agency, or health plan. They are developed to meet the highest standard possible for evidence-based care and still have utility for those on the frontlines of the current pandemic.

To help guide successful transitions to post-acute levels of care, MCG also published guidelines for Recovery Facility Care and Home Care. These new guidelines are designed for patients with an acute viral infection that is pulmonary or systemic in nature—not primarily gastrointestinal (e.g., gastroenteritis) neurological (e.g. meningitis), or dermatologic (e.g. herpes zoster). 

Looking beyond COVID-19

When developing these guidelines, we knew we had to think bigger than the current pandemic. That’s why these guidelines were written for “Acute Viral Illness” rather than COVID-19 specifically. The pandemic may have been the catalyst, but acute viral illnesses will always be with us— whether COVID-19, influenza, or something else. The decision to broaden the scope increases the general utility of the guidelines. They are written with COVID-19 in mind but are able to cover other common and important viral illnesses. Clinicians need the tools to not only address the current crisis, but other health risks to follow.  

Determining Level of Care and Length of Stay

The inpatient Acute Viral Illness guidelines assist in determining the appropriate level of care by laying out the evidence-based indications for inpatient admission. In this way, they provide a guide that supports clear clinician documentation of the admission decision. But with every new set of guidelines there will always be questions:

Should these guidelines drive all decisions?

Guidelines should not dictate care. Ultimately, healthcare professionals should always feel empowered to use their professional judgment to make the best decisions for their patients. As with all MCG care guidelines, clinical content was written to serve as a platform upon which to evaluate patients, aid decision-making, reduce unexplained variation, and guide efficient documentation.

How do these guidelines integrate with my EHR

Our first priority when developing these guidelines was to make them available to as many healthcare professionals as possible to support them through the COVID-19 pandemic. But while anyone can reference this guidance, there are added benefits to embedding them within your EHR, such as MCG’s integration with MEDITECH’s Case Management solution. Based on your license, this integration enables care providers to access these guidelines within their natural workflow and incorporate them into their review notes, with no separate sign on required.

How do I ensure I am using the best content?

Having too much content can overburden providers. Keeping with the same standard of all MCG care guidelines, appropriate use of published research and evidence was paramount. Through careful review of the rapidly expanding evidence-base, MCG editors winnowed down the explosion of new literature so only the most relevant and valid publications were cited. In this way, MCG’s work would allow clinicians to spend less time finding the information they need and more time absorbing and acting upon it.

But what if my patient is already admitted?

MCG’s Acute Viral Illness guidelines also include helpful tools for tracking a hospitalized patient’s day-to-day progression to help determine when discharge is safe. There are clinical recovery milestones for each day against which to measure patient progress towards discharge readiness. The last day’s recovery milestones constitute the discharge criteria. 

What if criteria are not met?

Equally important to determining readiness for discharge, these recovery milestones can be used to help efficiently document why the patient needs to stay in the hospital if they are not met. 

Other key considerations

There is rarely a cookie cutter approach to guidance. If you choose to take advantage of MCG’s Acute Viral Illness guidelines, here are some of the factors to consider:

  • Observation Care is a finite period of time. Patients whose need for inpatient care is unclear can be treated and evaluated. By the end of this finite period of time, if the patient meets MCG Observation Care discharge criteria, then they can be discharged. If they fail to meet the Observation Care discharge criteria, they meet criteria for inpatient admission. 
  • Payer rules or payer provider contractual agreements often drive the duration of the finite period of Observation Care (e.g., the CMS Two-Midnight Rule). 
  • The indications for inpatient admission come in two general types. The first are indications concerning a severity of illness, such that inpatient care is justified without need for Observation Care (e.g., new-onset hypoxemia). The second type indicates a lesser degree of severity, such that the need for inpatient care will depend upon patient response to Observation Care (e.g., dehydration).
  • For viral illnesses other than COVID-19, there is sufficient data to approximate length of hospitalization. For COVID-19, such data is only now emerging. As is true for all patients, whatever the expected length of stay, discharge readiness is a clinical determination which can be greatly aided through use of MCG discharge criteria.

Forging ahead

Regardless of your current COVID-19 volumes, it’s important to stay two steps ahead to prepare your frontline workers for what’s to come. If or when you encounter another surge of patients —whether for COVID-19, influenza, or both— having a solid plan for correctly and efficiently making and documenting decisions around level of care and discharge readiness can make all the difference. 

To learn more about MCG care guidelines and other resources to meet the challenges of COVID-19, visit this page, where you can sign up to receive access to these guidelines and educational resources and listen to our podcast recorded in April 2020.


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Topics: EHR, Care Coordination, Coronavirus

Written by Bill Rifkin, MD, FACP, Managing Editor, MCG Health

Dr. Rifkin oversees research, guideline writing, and other content development focused on acute inpatient care. Before joining MCG in 2009, he was an Associate Professor of Clinical Medicine and the Director of the Internal Medicine Residency Program at Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, New York. Prior to that, he was an academic hospitalist and Associate Residency Program Director at two other New York hospitals and at the Yale Primary Care Internal Medicine Residency Program in New Haven, Connecticut. He has published research in the areas of hospital medicine and quality of clinical care. He graduated from the State University of New York Stony Brook School of Medicine, completed his internal medicine training at Lenox Hill Hospital in New York, and is board-certified in internal medicine.

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