When patients are hospitalized, they may expect to receive daily visits and care in the hospital from their primary physician. But those doctors must continue to provide outpatient care at their clinics. They can’t be two places at once. That’s where hospitalists step in. Sansum Clinic hospitalists are board-certified internal medicine physicians who specialize in providing comprehensive medical care to patients in the hospital.
The formal Sansum Clinic Hospitalist Program began in 1999, mirroring a national trend at that time as primary care providers in the U.S. realized it was too difficult to focus on both acute care medicine and outpatient medicine. “If there is a sudden change in the condition of a hospitalized patient, it’s very difficult for primary care doctors to cancel outpatient appointments so they can rush to the hospital to care for someone who has urgent needs,” explains Jeffrey Yim, MD, a doctor with the Sansum Clinic Hospitalist Program. “Most physicians find it difficult to provide timely, effective, quality care in multiple environments.”
Sansum Clinic hospitalists work in teams to provide patient care 24 hours a day, 7 days a week at Cottage Hospital in Santa Barbara. “We are embedded in the hospital,” Dr. Yim continues. “Because our entire day is spent there, we can better focus on managing acute care patients on an hour-by-hour basis and be available for multiple visits when needed.”
Dr. Yim joined the Sansum Clinic staff in 1999 and was the first full-time hospitalist for Sansum Clinic. The program modernized the previous model that involved a panel of internal medicine doctors and family practitioner doctors who rotated through Cottage Hospital in limited shifts. Today, patients affiliated with Sansum Clinic who are admitted to Cottage Hospital for medical reasons are cared for by Sansum Clinic hospitalists. Cottage Hospital notifies primary care physicians about the patient’s admission, and the admitting hospitalist forwards a copy of a document termed a History and Physical. This document details the patient’s symptoms, the diagnostic plan, and the therapeutic plan. Sansum Clinic hospitalists also provide medical consultative services to surgical colleagues who care for Sansum patients. Cottage Hospital retains independent hospitalists for patients who are not affiliated with Sansum Clinic or do not have a primary care provider.
Hospitalists evaluate patients upon arrival, order diagnostic testing, and create a care plan. They collaborate with patients’ primary physicians to streamline the handoff and ensure continuity of care. “There is a formal process for transitioning care to us when a patient is admitted to the hospital and back to primary providers when a patient is released,” Dr. Yim explains. “We provide physicians with a discharge summary that has the relevant highlights about a patient’s stay in the hospital, including what medications we are sending them home with and information about conditions that need to be resolved. We inform primary care doctors about any disorders that may have been found incidentally while the patient was in the hospital that may require outpatient follow up. Medical assistants arrange timely follow up visits with patients’ primary care providers. This saves a considerable amount of time for our patients. We also communicate with patients’ families to discuss patient care.”
Dr. Yim describes Sansum Clinic’s hospitalists as generalists who are capable of treating a very broad range of conditions. He says the hospitalists care for adult patients on cases that can run the spectrum of virtually any organ system. They also assist oncologists with cancer patients and consult with proceduralists for the co-management of medical issues before and after surgery. They collaborate with medical specialists as needed and work closely with critical care providers including Bryan Garber, MD, MS, who specializes in pulmonary and critical care medicine for Sansum Clinic. “Dr. Garber is the quarterback overseeing critical care cases,” Dr. Yim says. “During the COVID-19 pandemic our collaboration with the critical care providers has intensified.”
Pandemic Places Hospitalists in a Vital Role
Sansum Clinic hospitalists have been busier than ever during the COVID-19 global health crisis. Dr. Yim says there was a lot of uncertainty in early 2020 about what was going to happen in the Santa Barbara area. “In February and March 2020 we were starting to get reports from places like New York about how chaotic it was to care for these patients,” he says. “We just didn’t know what we were going to be facing. We hadn’t had our first hospitalized case of COVID-19 in the Santa Barbara community yet. But anyone who was doing acute care medicine was very apprehensive about what we were about to encounter—from the emergency room physicians that treat urgent conditions to the hospitalists and the critical care doctors.”
Dr. Yim cites key national and local reactions to the situation. “An NBA athlete with the Utah Jazz tested positive for COVID-19 on March 11, 2020,” he recalls. “In response, Adam Silver, who is the commissioner for the NBA immediately suspended the competitive season. His actions set a national trend, and a lot of other major sports and other industries followed suit. To me, Silver is a hero for taking that initiative. On March 13, 2020, Santa Barbara Unified School District shut down our local schools, ahead of what the California state guidelines directed. Around that time, Sansum Clinic implemented a surge plan to rapidly add hospitalist providers should the need arise.”
Sansum Clinic hospitalists follow practices that Cottage Hospital implemented for the health crisis. “Cottage Hospital has done an amazing job with how they orchestrated care for COVID-19 patients,” Dr. Yim says. “Early in the course of the pandemic, they suspended all elective procedures because they were concerned about getting inundated with patients. They designated entire floors and nursing staffs exclusively to the care of COVID-19 patients. The Cottage Hospital staff— particularly nursing and therapy staffs including respiratory, physical, occupational, and speech therapists—were impressive as they completely reengineered their workflows.”
The exclusive floors at Cottage Hospital, known as COVID cohorts, utilize technology that creates negative pressure throughout. That means if a door is opened, air does not escape and circulate with the rest of the facility. Instead it is extracted through filters to avoid possible spread of the virus. “Initially the hospital had negative pressure rooms,” Dr. Yim explains. “Then entire floors were converted to negative pressure. When the new Cottage Hospital facility was built, it was designed to have that potential. That was incredible foresight.”
The day after Cottage Hospital opened its first COVID cohort, the Sansum Clinic Hospitalist Program implemented three key elements that helped with the care of COVID-19 and non-COVID patients. First, the hospitalists adopted the concept of dedicated COVID cohort providers. These individuals were imbedded within the COVID cohorts and cared for Sansum Clinic patients who were hospitalized with COVID-19. “Throughout the pandemic, this arrangement fostered a collaborative relationship between physicians and front-line care providers such as nurses, patient care technicians, respiratory, physical, speech and occupational therapists,” Dr. Yim explains. “That collaborative relationship continually enhanced and advanced the understanding of the care and treatment of COVID-19 patients.”
The second element was to implement a plan to account for surges in hospitalized COVID-19 or non-COVID patients. An on-call roster was created and updated daily, allowing for a rapid and efficient up-staffing of hospitalist providers as needed, based on the total number of hospitalized patients under the care of Sansum Clinic hospitalists. “This on-call system significantly decreased the possibility that the Sansum Clinic hospitalists would be overwhelmed with patients and ensured that there would be adequate physician staffing at all times,” Dr. Yim says.
Third, the Sansum Clinic Hospitalist Program began distributing a nightly email message to hospitalist staff and key Sansum Clinic administrative staff. The message contained essential information such as the total number of patients cared for by Sansum Clinic hospitalists and number of COVID-19 patients. Most importantly it documented current staffing assignments, including COVID cohort personnel and the on-call roster. “The nightly email messages provided an efficient mechanism to convey information to key personnel on the front line of COVID-19 care,” Dr. Yim explains. “The emails became a mechanism to exchange information and keep hospitalists up to date with the current diagnostic and treatment options as well as the evolution of procedures for the care of COVID-19 patients. This was particularly useful early in the pandemic when all aspects of the care of COVID-19 patients were continually changing and rapidly evolving.”
Hospitalists and Staff Become COVID-19 
Care Specialists
Dr. Yim explains that COVID-19 has hit the Santa Barbara area in three distinct waves over the past year. Each wave has enhanced the hospitalists’ understanding of the virus and helped them improve the care and treatment they administer.
The first wave hit our community in March and April 2020. It was the smallest in terms of the total number of COVID-19 patients. Dr. Yim says one of the biggest issues with the first wave was a lack of access to rapid-turnaround testing. It often took days to get results. “Because testing in Santa Barbara was very limited during the first wave, we placed anyone suspected of having the virus into the COVID cohort, based on their symptoms,” he explains. “The lack of test results made it extremely difficult to care for patients since we had to account for multiple potential diagnoses including COVID-19. Testing is very efficient now, utilizing multiple technologies and platforms that provide results in minutes to hours. Cottage Hospital tests everyone who gets admitted.”
There was a great deal of uncertainly early in the first wave. “Front-line providers had legitimate fears of being exposed to COVID-19, even with personal protective equipment,” Dr. Yim continues. “We were worried about our own health, and particularly concerned about infecting family members. Each provider faced a difficult decision: should I return home after each shift and risk exposing my family to the virus, or should I self-quarantine and be isolated from my family for days to weeks at a time?”
When treating COVID-19 patients, the hospitalists undertake a structured procedure called donning and doffing, which involves putting on and taking off their personal protective equipment in a specific order. The strict use of N95 masks, face shields, gloves, goggles, hair and shoe coverings, plastic gowns, and practices such as leaving personal items such as phones outside the cohort have proven to be very effective. As a result, the hospitalists have become much less fearful about contracting the virus as they care for COVID-19 patients.
“Our fears soon diminished to the point where we now feel safest when we are in the COVID cohort because of all the safety protocols” Dr. Yim says. “Sansum Clinic provides showers, lockers, scrubs, and a changing area for us. We change out of our street clothes and into scrubs before a shift, and then we shower and change after a shift. Both Cottage Hospital and Sansum Clinic do a phenomenal job of ensuring our safety and comfort.”
The second wave hit in mid-summer 2020. Dr. Yim estimates it was approximately twice the size of the first wave, with the census of inpatient COVID-19 cases in the care of Sansum Clinic hospitalists reaching the mid-teens at any one time and up to two hospitalists dedicated to the care of COVID-19 patients. “We were extraordinarily lucky in Santa Barbara that the first wave was relatively small, affording care providers time and capacity to understand how to better care for COVID-19 patients,” he says. “Through the first and second waves local doctors, nurses, respiratory therapists, and patient care technicians all evolved their COVID-19 care.”
Early on, providers such as critical care physicians, hospitalists, and respiratory therapists realized that it was often beneficial to reserve mechanical ventilation for only the very sickest patients. “Front-line care providers learned that the way COVID-19 affects the lungs is more of an oxygenation problem than a ventilation problem,” Dr. Yim explains. “A ventilator helps the lungs expand and contract, like a bellows. But the primary pathology with COVID pneumonia involves difficulty getting oxygen to diffuse across the air sacks of the lungs and into the blood. That causes inadequate oxygen levels in the blood. Once we recognized that, the care of critically ill COVID-19 patients evolved from a strategy of early intubation, which is the insertion of a tube into the airway, to delayed intubation and the use of high flow supplemental oxygen through nasal cannula technologies where a lightweight tube is placed in the nostrils. This doesn’t cure COVID-19, but allows the lungs time to heal.”
The third wave of COVID-19 illnesses hit Santa Barbara in late 2020 and early 2021 after the holidays and was twice the magnitude of the second wave, with more than thirty COVID-19 patients receiving care from Sansum Clinic hospitalists at any given time. The total COVID-19 census at Cottage Hospital was approximately 100 patients. Cottage Hospital had five floors dedicated to the care of COVID-19 patients. The total volume of COVID and non-COVID patients in the care of Sansum Clinic hospitalists necessitated the activation of hospitalist surge staffing, with the addition of two and occasionally three additional hospitalist providers from late November 2020 through late February 2021.
“We are at the tail end of the third wave now,” Dr. Yim says. “It was significant in terms of the number of admitted COVID-19 patients, severity of illness, morbidity, and mortality. A positive result of our involvement through these three waves is we have gained significant experience in the care of COVID-19 patients. Over time, the staff has learned more about how to determine what each individual patient needs and how to customize oxygen levels appropriately. The care of COVID-19 patients continues to evolve as the outcomes of clinical trials with new therapeutics become available for review.”
Advancing Medical Knowledge Builds Hope
Over time, practitioners developed a much better understanding of the natural history of COVID-19 pulmonary disease. Luckily, the majority of patients affected with COVID-19 do not develop significant pulmonary disease. Initial COVID-19 disease often presents with symptoms of fever, malaise, muscle aches, loss of taste and smell, nausea and diarrhea, and decreased appetite. While these symptoms can be extremely debilitating, patients usually do not require hospitalization. “Often it is during this phase of COVID-19 illness that patients get tested for COVID,” Dr. Yim explains. “As many of these initial symptoms start to wane, a subset of patients go on to develop pulmonary symptoms including cough and shortness of breath.”
Anywhere from days to weeks after the first symptoms occur, some patients seek further medical care for progressive shortness of breath and hypoxemia (low blood oxygen levels). These are the patients who are admitted to the hospital with COVID pneumonia. “The majority of patients spend days to weeks in the hospital where they are treated with moderate levels of oxygen, but go on to recover,” Dr. Yim continues. “However, there is an additional small subset of patients who develop severe COVID pneumonia requiring previously unfathomable amounts of oxygen for life support.”
Dr. Yim says there are three phases in patients admitted with the most severe COVID pneumonia. There is an initial active phase where the virus slowly and insidiously attacks the lungs. Over a period of days to weeks, COVID-19 causes progressive hypoxemia leading to increasing need for more oxygen through tubes in the nose or facemasks. “This phase is characterized by days or weeks of relatively stable lung function punctuated by episodes of sudden and acute decompensation in lung function requiring large increases in supplemental oxygen,” he says. “The episodes occur over a period of minutes to hours. These are the patients who are often transferred to the intensive care unit and sometimes placed on mechanical ventilation. These patients also experience an extremely high mortality rate.”
The second phase that occurs in patients with the most severe COVID pneumonia is a plateau phase. It is characterized by a prolonged period of time, often weeks to months, where patients are stable but require high levels of supplemental oxygen support that only acute care hospitals such as Santa Barbara Cottage Hospital can provide. “These patients often require forty or more liters per minute of oxygen delivered through specialized nasal cannula devices that were not often utilized prior to the pandemic,” Dr. Yim says. “Recovery during this phase is slow with minute decreases in needs for oxygen occurring over a period of many weeks.”
The third phase in severe COVID pneumonia is a recovery phase. During this period, patients experience a decrease in their need for high flow nasal cannula oxygen over a relatively rapid period of time, usually a week or so. During this phase, patients can eventually be transitioned to more traditional methods of delivery of oxygen so that they can be discharged to home or rehabilitation facilities.
Dr. Yim says one of the most challenging aspects to the care of COVID-19 patients is the isolation that patients experience due to the lack of visitation. “Seclusion presents a particular challenge to the care of our patients,” he says. “Physicians and nurses have had to change how we provide care and coordinate with families. The staff at Cottage Hospital has been phenomenal at trying to alleviate loneliness through supplying patients with tablet computers that enable frequent communication with families and loved ones.”
Sadly, terminally ill COVID-19 patients are typically isolated as they succumb to the disease. “One of the most difficult things for the staff is when patients end up passing away,” Dr. Yim says. “Our hearts go out to the patients who unfortunately must be separated from their families and friends during their final days. We offer our deepest condolences to the families who are dealing the loss of their loved ones.”
Medical experts now predict that a portion of patients will have prolonged effects from COVID-19. During their stay in the hospital and after their release, patients benefit from a team approach where specialists share their expertise. Nurses, patient care technicians, respiratory, speech, physical, and occupational therapists have risen to the task of helping to rehabilitate patients who have prolonged symptoms. They give patients the mechanisms to get their strength back and on the road to recovery and independence.
“A multi-disciplinary approach has been implemented,” Dr. Yim says. “These front-line care providers deserve a lot of recognition and credit for their roles in helping patients get through their illness. Nurses, therapists, ancillary staff, and pulmonary critical care doctors like Dr. Garber have been instrumental in helping us with COVID-19 patients. There is absolutely no way we could have done this without them.”
Sansum Clinic CEO and Chief Medical Officer Kurt Ransohoff, MD, FACP adds his support for the hospitalists and staff during the crisis. “It is impossible to fully capture the personal and emotional toll that comes with taking care of these patients when they become critically ill,” he says. “Even though arrangements are sometimes made for family members to visit when the end of life is near, for the most part patients go through their struggle separated from their families, with the doctors and nurses acting as intermediaries between family members who are overwhelmed with grief and fear and patients who are struggling to survive.”
Having to handle that difficult role while simultaneously managing severely ill patients has been a unique challenge for care providers during this pandemic. “Doctors and nurses are working in a strange world of their own isolation and removal from normalcy, worried about what they might bring home from their work shift,” Dr. Ransohoff continues. “We are all very grateful for the Sansum Clinic hospitalists and all the doctors, nurses, and staff who have stepped up and done the work during this crisis to care for these patients.”
As our community anticipates solutions to the pandemic, people can be confident that Sansum Clinic hospitalists are on duty to care for COVID-19 inpatients and those who require hospitalization for any illness. Dr. Yim concludes with a message of optimism. “As an acute care physician, I can attest to the fact that the hospitalized care of COVID-19 patients is evolving,” he says. “We are steadily gaining knowledge about this disease. As the vaccines roll out I think there will be light at the end of the tunnel regarding transmission of cases and hopefully decreased morbidity and mortality associated with COVID-19.
Meanwhile, preventative practices are helpful in slowing the spread. One of the most interesting effects of the combination of social distancing, sheltering in place, masking, and hygiene has been the virtual absence of patients hospitalized for non-COVID respiratory viruses such as influenza, metapneumovirus and rhinovirus, which implies that these measures can be effective in limiting the transmission of COVID-19 as well.”
Jeffrey Yim, MD is an internal medicine specialist and Sansum Clinic hospitalist. He graduated from University of Hawaii Medical School and is certified with the American Board of Internal Medicine. Dr. Yim joined Sansum Clinic in 1999. In 2000 he was Teacher of the Year in internal medicine at Cottage Hospital.
Kurt N. Ransohoff, MD, FACP is an internal medicine specialist. He has been CEO of Sansum Clinic since 2002 and Chief Medical Officer of Sansum Clinic since 2012. Dr. Ransohoff graduated from medical school at University of California, Los Angeles and is certified with the American Board of Internal Medicine. He joined Sansum Clinic in 1992.
Sansum Clinic Hospitalist Program; P.O. Box 1200 Santa Barbara, CA 93102-1200; (805) 898-3077