Reflections on Geriatric Triage During the COVID-19 Surge
By Lynne O’Mara, PA-C, Brigham and Women’s Hospital
May 27, 2020
In mid-April, at the peak of the Brigham and Women’s Hospital (BWH) COVID-19 patient surge, my brother asked me: “Did you ever think you’d be doing something like this?” It was a legitimate question. One year ago, I was a general surgery/trauma physician assistant (PA) doing occasional shiftwork in geriatrics. Now, I found myself discussing goals of care and assessing the frailty of geriatric patients with COVID-19 in the Emergency Department (ED). But his question unexpectedly and poignantly describes the beauty of the PA profession. PAs have a unique ability to blur the linear – the lack of a required specialty allows for a flexible PA workforce and creates opportunity to bring experience across medical specialties and drive innovation.
When I was thirteen, my grandfather fell and broke his hip. Following his operation, he had a heart attack and ended up in the intensive care unit (ICU) on a ventilator. He was a 76-year-old WWII veteran and an avid gardener. After a long recovery, he eventually went to rehab and then back home. But he was never the same. He no longer gardened, he needed help around the house, and passed away within a year. During my six years as a trauma surgery PA, I saw my grandfather’s story repeated again and again. I hated watching it, but didn’t know how change it. I started talking with our trauma geriatrician, began working geriatric principles into my daily workflow, and eventually helped with the implementation of a standardized pathway of care for vulnerable older adult trauma patients. I began to pick up shifts with the Division of Aging and read geriatric literature. And when Zara Cooper – a trauma surgeon and Kessler Director for the Center for Surgery and Public Health – asked me to join her in the new Center for Geriatric Surgery, I was thrilled. Together with the Division of Aging and Rachelle Bernacki – a palliative care physician and geriatrician at Dana Farber Cancer Institute – we began expanding the trauma geriatric pathway and incorporating geriatric consults into surgical subspecialties.
When pandemic spread in Massachusetts was inevitable, my new role as a PA in the Center for Geriatric Surgery quickly transitioned to assisting with the geriatric COVID-19 response. Together with Palliative Care, the ED, and the Division of Aging, we developed a novel triage framework to virtually assess older adult COVID-19 ED patients using the clinical frailty scale (CFS) – a nine-point classification system used to evaluate a patient’s physiologic reserve and ability to tolerate stress. With surgical volume down in anticipation of the COVID-19 patient surge, I was re-deployed to cover call for this new triage service. We planned to have ED clinicians identify geriatric patients with COVID, page me to assess their CFS, and triage to usual care (CFS 1-3), geriatric co-management (CFS 4-6), or palliative care triage (CFS 7-9). But no pages came the first week. I then began to proactively track the ED patient list and within five minutes, had identified a patient. I called their health care proxy (HCP) – my first ever virtual call – and delivered the bad news that their family member had COVID-19. The HCP wept. I listened, reassured, and asked my CFS questions. It was heartbreaking. But at the end of the call, I was met with more “thank-you’s” than I had ever received.
In the coming weeks, I got into more of a rhythm. For patients with higher CFS scores, I joined the palliative care teams on patient calls and began to learn new communication skills such as responding to emotion, allowing for silence, and delivering a prognosis. I still heard sadness over the diagnosis, guilt for spreading it to their mom or dad or grandparent, and fear for what was to come, but I felt more confident in my conversations. Even in this new, virtual world, we were reaching the heart of patients and their families.
Then the pace picked up. At the peak of the surge, I was triaging 5-6 patients per day, but following up to 20 at a time; constantly monitoring, checking, refreshing. Patients began arriving clinically unstable, and I started requesting more urgent palliative care consults for goals of care discussions around intubation or ICU-level care. I was helping organize transfers to the intensive palliative care unit (IPCU) and helping avoid unnecessary testing at end of life. I was talking with COVID-unit providers about deliriogenic medications to avoid and ensuring everyone had a healthcare proxy. Then, the numbers declined and so did my calls. But that month left me forever changed.
I plan to integrate my new palliative care and communication skills into my patient visits moving forward, and I hope that more PAs will be utilized to fill gaps in health care to contribute to a holistic, patient-centered approach. So, while I never thought I would be doing “something like this,” this unique role that required a hybrid of old and new skills taught me that this is really what it means to be a PA. It taught me how invaluable flexibility and varied experience can be to innovation and to our patients. And it taught me that even in a time of crisis, there can also be great beauty.
Lynne O’Mara, PA-C, Brigham and Women’s Hospital