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Tag Archives: Pharmacy

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Manufacturers poised to scale up production when COVID-19 vaccine arrives

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Drug manufacturers are under immense pressure to develop the COVID-19 vaccine. Now, they think that they can master a process that typically takes years by producing a vaccine in months.

These companies have already received millions of dollars in funding to scale up manufacturing capacity. But many in the medical community are worried about this type of guarantee.

Challenges ahead

While the news of early successes in vaccine trials has given us hope, COVID-19 vaccine developers face the biggest challenge of their lives. Developing the vaccine in record time and distributing it to the masses amidst quarantines and global travel restrictions will be tough.

Parameters like inventing new kinds of vials and syringes to administer billions of doses, avoiding hurdles in an untested supply chain, and managing extreme storage conditions have to be considered. But if companies can overcome these challenges, pharma manufacturers will be successful in pulling off the most significant medical manufacturing feat in history.

Some experts say that the first phase of production may vaccinate 60% of the world’s population.

Inherent risks

Since vaccines have never been developed at this scale before, filling capacity could be the main limiting factor. Companies and governments are scaling up their machinery to address these critical shortages. This unprecedented scale of manufacturing also means that scientists need to find out whether a vaccine works fast so that production in bulk can begin immediately.

There is also a risk that most coronavirus vaccines under development may fail. While stopping the spread of the COVID-19 virus is imperative, manufacturers are risking millions for a yet-untested vaccine. They are scrambling to get their hands on any available capacity and signing up with multiple manufacturing partners across the globe.

Efforts by the key players

  • Emergent is working on four vaccines in parallel. It is experimenting by making it easier to switch from one vaccine to another with single-use disposable bioreactor equipment that features plastic bags rather than stainless steel fermentation equipment.
  • Moderna is experimenting on new ways to mitigate the extreme cold storage demands of its vaccines.
  • SiO2 Materials Science is working on producing shatterproof vials that can resist super-cold temperatures.
  • Johnson & Johnson is dealing with travel restrictions to send its vaccine experts to oversee the launch of production sites.
  • Catalent is focusing on high-speed production of vial-filling and packaging services to handle millions of doses.
  • Pfizer and BioNTech plan to start Phase 3 testing so that they can produce up to 100 million doses by the end of 2020 and 1.2 billion doses by 2021 for global distribution.
  • Novavax‘s vaccine combines its proprietary Matrix-M adjuvant with an antigen generated from the virus’ spike protein. The early data results will help scientists determine the safety, immunity, and disease reduction to move on to the next phase.
  • AstraZeneca announced that it could produce up to 2 billion doses of AZD1222, the University of Oxford’s adenovirus-based COVID-19 shot. It also plans to provide 1 billion doses of the vaccine to low- and middle-income countries.

The U.S. government has invested billions into the Warp Speed initiative to kickstart active COVID-19 vaccine production. Multiple vaccine makers are working at getting legal and administrative approval and begin production with federal backing. The government hopes to make a selection and helps start the production within the next six weeks.

Cautiously optimistic

Vaccine manufacturing is an inherently risky venture. A manufacturing facility is set up only when the clinical data is proven to be safe and effective.

Despite the enormous financial risks stated by experts, finding a vaccine provides hope for the world.

If any of these efforts are successful, it will halt the spread of the deadly virus, which has killed over 650,000 people worldwide and sickened more than 16 million. Economies can reopen, and work and school can resume. Individuals concerned that this race to produce vaccines will upend the traditional drug development process have only to look at the rushing numbers again to see why we need this speedy process.

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New bill in the House aims to protect access to telehealth

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The changes to telehealth utilization and payment reform brought on as a response to the COVID-19 pandemic appear set for permanency as House Telehealth Caucus leaders introduced legislation on July 16 that would allow access to such services for Medicare patients.

The bipartisan bill, the Protecting Access to Post-COVID-19 Telehealth Act, would expand telehealth use by eliminating restrictions on its use in Medicare, which have been a thorn in the side of the technology’s advancement for decades.

Those patients enrolled in certain Medicare plans could benefit immediately because of the change in federal payment for services provided through the service, which likely would lead to private payers for individuals covered under private and employer-sponsored plans.

The passage of such a bill would be monumental for the telehealth movement. Bill co-sponsor Rep. Mike Thompson, D-Calif., said in a statement that it would provide a bridge for patients currently using the practices because of the coronavirus crisis and require a study on the use of telehealth during COVID-19.

Thompson, who is the founder and co-chair of the Congressional Telehealth Caucus, said the legislation would expand the use of telehealth for seniors and those on Medicare. “We know telehealth can be an essential bridge in delivering care, particularly during a crisis and today we are working to ensure telehealth continues in a post-Coronavirus world,” he said.

The bill also was introduced by caucus co-chairs Reps. Peter Welch, D-Vt.; Bill Johnson, R-Ohio; and David Schweikert, R-Ariz., and caucus member Rep. Doris Matsui, D-Calif.

The bill essentially authorizes the Secretary of Health and Human Services to waive or modify application of Medicare requirements with respect to telehealth services during any emergency period, and for other purposes. It also provides regulatory flexibilities that provider groups have long sought, including removing geographic restrictions on where a patient must be located to utilize telehealth services and enabling telehealth services provided to patients in their homes.

Additionally, the bill allows for federally qualified health centers and rural health centers to provide telehealth services and makes permanent the temporary waiver authority for the HHS secretary for future emergency periods and the 90 days after the rescinding of a public health emergency period.

Healthcare groups overwhelmingly cheered the legislative efforts to make telehealth a routine part of healthcare delivery.“HIMSS and PCHAlliance applaud the introduction of the telehealth bill sponsored by Representative Thompson and members of the House Telehealth Caucus, and call upon Congress to take swift action and make permanent the flexibilities that have supported the use of evidence-based connected care technologies to improve healthcare quality, access and value for all Americans during the COVID-19 pandemic,” said Hal Wolf, president and CEO of HIMSS, in a statement.

This legislation addresses many of the priorities HIMSS and more than 300 leading healthcare organizations identified for congressional leaders to make telehealth flexibilities created during the COVID-19 pandemic permanent.

“This unprecedented pandemic has proven that telehealth not only works, but that it’s essential,” said Welch in a statement. “These practical telehealth provisions have been successfully implemented and should be continued to ensure that everyone has access to quality healthcare no matter where they live or how mobile they are. This is a commonsense step to make sure our policies keep pace with our technology.”

“Prior to the coronavirus pandemic, there was still some question as to whether telehealth could be an effective alternative to going to the doctor’s office. The answer is now clear: unequivocally, yes,” said Johnson. “This bipartisan legislation will enable Medicare beneficiaries to continue using telehealth services when the current emergency declaration ends, and ensures that the enormous resources invested in making this technology work are not wasted. It’s time to expand high-quality telehealth services to all Americans, not roll back the progress we’ve made.”

“During the COVID-19 pandemic, telehealth has allowed our nation’s healthcare system to continue to effectively deliver needed care virtually, ensuring patients can safely access care when and where they need it. As the only organization exclusively dedicated to advancing telehealth, the ATA commends the House Telehealth Caucus for introducing this essential but commonsense legislation to ensure Medicare patients continue to have the choice to access telehealth after the current public health emergency,” said Ann Mond Johnson, CEO, of the American Telemedicine Association.

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How llama antibodies could help fight COVID-19

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Scientists around the globe are exploring ways to fight COVID-19 as we self-quarantine and wait. Though a potential treatment for COVID-19 may not be the first thought that comes to mind when you hear your kids watching episodes of “Llama Llama” on Netflix during your Monday morning conference call, llamas may be part of our ticket back to normalcy.

A New Study Finds Possible Therapeutic Uses for Llama Antibodies in Treatment of COVID-19

Perhaps it was serendipity?

Researchers from the University of Texas, in collaboration with Ghent University in Belgium, had been exploring how proteins from the viruses that caused MERS and SARS functioned using a llama named Winter when COVID-19 struck.

When COVID-19 hit, they decided to see if any of the nanobodies they harvested from Winter could stop SARS-CoV-2 from infecting cells. SARS-CoV-2 is the strain of coronavirus responsible for the current pandemic.

The team published their results in Cell last month.

Llama Nanobodies to the Rescue

The researchers injected a llama with prefusion-stabilized MERS-CoV and SARS-CoV-1 spikes. Spike proteins are the proteins on the surface of coronaviruses. They undergo a structural change after attaching to cells that allow the virus to fuse with the host cell, enter it, and copy itself to produce more viruses. Nanobodies harvested from llamas are a possible way to prevent the virus from entering cells because they bind to spike proteins.

The SARS VVH-72 nanobody was one of a handful of nanobodies harvested to target SARS and MERS, that also bound spike proteins on SARS-CoV-2, albeit not long enough to be effective.

The researchers fused two copies of SARS VVH-72 to improve its binding capacity. This engineered version prevented SARS-CoV-2 from entering cells.

SARS VVH-72 is among the first antibodies known to neutralize the strain of the virus responsible for COVID-19.

According to the authors of the study, its biophysical properties and robust neutralization capacity render it ideal for further testing in the development of COVID-19 treatments.

Implications for Humans

While a vaccine will likely come along in the next one to two years, there will still be a need for nonvaccine treatments, and that is where the results of this study come into play.

For example, vaccines will not help an infected person, but antibody injections could bolster the infected person’s immune response. Likewise, vaccines are not always enough. People who struggle to develop a sufficient immune response to vaccines would probably benefit from antibody therapy.

Llama antibodies may be a possible treatment for COVID-19, but not as a vaccine. Instead of injecting patients with something that produces an antibody response as is the case with vaccines, doctors and nurses would administer the actual antibodies directly to patients, possibly using an inhaler.

Either way, an antibody treatment is still at least a year off if all the research trials involved in developing this treatment are successful.

Why Llamas?

Llama antibodies are approximately one-quarter of the size of a typical human antibody and can be cloned with relative ease to form smaller antibodies known as nanobodies. Nanobodies are attractive because they are easy to mass-produce, and their properties make them effective weapons for boosting immune responses to specific pathogens.

Alpacas, camels, and sharks are also appealing to researchers for similar reasons.

No Harm to Llama

No harm came to Winter the Llama. Winter was injected with a noninfectious segment of the virus to generate an antibody response.

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New swine flu, unrelated to COVID-19, may be on its way from China

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As we continue to be overwhelmed by COVID-19, which originated in Wuhan, China, near the close of 2019, Chinese researchers have announced that they have identified a new strain of the swine flu that has the potential to become a pandemic.

The flu is carried by pigs and can infect humans. A study of the new virus was published in the Proceedings of the National Academy of Sciences.

So, while the world’s leaders in government and healthcare continue to battle the current pandemic, another may be simmering on the verge of an outbreak, again in China.

Researchers monitoring the virus say it may be possible to spread from person to person and trigger a global outbreak.

Like the COVID-19 outbreak, this new swine flu could be devastating to people across the globe as people likely have little to no immunity to it.

The new strain is being called G4 EA H1N1.

According to reports, the new strain has been found among people who work in Chinese slaughterhouses, and it can grow and multiply in the cells lining human airways.

Professor Kin-Chow Chang and his colleagues at Nottingham University say they are closely monitoring this new strain.

Kin-Chow told the BBC: “Right we are distracted with coronavirus, and rightly so. But we must not lose sight of potentially dangerous new viruses.”

Researchers think it may mutate further so that it can spread quickly from person to person and trigger a global outbreak.

The last pandemic flu the world encountered was in 2009. This new strain is similar to that virus, but with additional evolution.

Current flu vaccines do not appear to protect against it. The 2009 strain is now covered in flu vaccines.

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The new study on COVID-19 transmission that can help convince every patient to wear a mask

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As a healthcare professional, you know the critical importance of face masks in stopping the spread of COVID-19. You no doubt also know that some of your patient population is not in compliance with doing so, which is a very worrisome issue.

However, a brand-new study from researchers Renyi Zhang, Yixin Li, Annie L. Zhang, Yuan Wang, and Mario J. Molina, “Identifying airborne transmission as the dominant route for the spread of COVID-19,” can offer you the informational support your physicians and staff need to communicate the importance of mask-wearing to these patients.

The researchers report that face masks used in Italy reduced the number of infections by more than 78,000 from April 6 to May 9, and by over 66,000 in New York City from April 17 to May 9. Face masks were also a powerful tool against transmission in hard-hit China.

The researchers ultimately found that wearing a mask when you’re in public is the best and safest way to avoid getting COVID-19 or passing it to other people. Because many of your patients may not understand the specifics of why they need to wear a mask or have heard conflicting messages on the effectiveness of wearing one, informing them about the findings in this study can really clear up the confusion.

For even further clarification, the study also found concrete proof that wearing a mask does not just prevent COVID-19-infected cough droplets from infecting others but will also prevent your uninfected patients from breathing tiny virus particles in aerosol version that come from speaking. Those airborne particles can not only hang in the atmosphere, but can travel tens of feet.

Here’s the bottom line: whether it’s due to conflicting messages in the media, or simply a careless attitude, many people aren’t grasping the concept of the personal protection to themselves that wearing a mask can ensure. Your doctors, however, can do a tremendous amount to mitigate the issue.

How to make it happen? Use this up-to-date, essential info from the Centers for Disease Control to re-emphasize key points of COVID-19 prevention. You can never cover these recommendations too often or clearly enough. Posting it prominently on your website/social media platforms, in your facility, and making it available through email contact with your patients is a must.

Stress these important facts:

1. Everyone should observe the proper social distancing technique, which means staying at least six feet away (two arms’ length) from other people.

2. Wash your hands frequently for at least 20 seconds. When you can’t, clean your hands with a hand sanitizer that contains at least 60% alcohol.

3. Don’t touch your face (eyes, nose or mouth) with unwashed hands.

4. Disinfect commonly touch surfaces on a regular basis throughout your day. To do this correctly: first wipe down tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, and sinks with soap and water. Then, follow up by cleaning again with a household disinfectant, such as a wipe or spray.

In addition to communicating these highly effective techniques for stopping COVID-19 transmission, make sure that you and your physician teams also keep up with emerging information on the disease on an ongoing basis as well. You want to be able to pass along additional safeguards along promptly to your patients, always. A concentrated and focused effort will pay off and save lives.

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Study shows men receive preference for liver transplants

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Women in the U.S. are significantly more likely to die while waiting on a liver transplant. The results come from a large cohort study that looked at sex-based disparities among women and men who received liver donation from living and deceased donors.

“Our findings suggest that the MELD [model for end-stage liver disease] score does not accurately estimate disease severity in women and that the lack of consideration of candidate anthropomorphic and liver measurements in the current allocation system may have a greater association with the sex disparity in liver allocation than geographic factors,” the researchers wrote in their study in JAMA Surgery.

In short, using geographic data may not be enough to influence the disparity. To make the organ allocation more equitable, the way end-stage liver disease is interpreted between the genders needs to be considered.

“It has been known for more than a decade that women are disadvantaged on the liver transplant waiting list, with an increased risk of death and a decreased probability of deceased donor liver transplant compared with men,” wrote Dr. Elizabeth C. Verna of Columbia University Irving Medical Center in New York City and Dr. Jennifer C. Lai of the University of California San Francisco in an editorial, titled “Time for Action to Address the Persistent Sex-Based Disparity in Liver Transplant Access.” The piece appeared as a JAMA Viewpoint.

“Despite this knowledge, there has been no effective national push to implement evidence-based systematic changes and thus no improvement in waiting list outcomes for women,” they wrote.

The study used data from the Scientific Registry of Transplant Recipients. Some 81,300 adults who were waiting for liver transplants between June 2013 to March 2018.were reviewed.

Of these, roughly a third (36.1%) were women. Nearly 70% were men. Most were white and the median age was approximately 55. More women than men had previous abdominal surgeries and had fewer instances of hepatocellular carcinoma. Women also had lower anthropometric and liver measurements.

Some 8,800 of the 81,300 died while on a waiting list. Deaths were split roughly 60% and 40% between men and women, respectively. However, after adjustment, females were 8.6% more likely to die while on the wait list when compared with men.

The only other variable that varied significantly when it comes to increased gender disparity was the organization of organ procurement. Anthropometric and liver metrics and laboratory MELD scores had more statistically significant correlations than geographic differences.

“Thus, size mismatch between the donor and intended recipient and incorrect assessments of liver disease severity were more strongly associated with the observed sex disparity in wait-list mortality than local supply of organs,” the researchers wrote.

“We propose that a better course of action is to simultaneously address the attributes of the existing allocation system that were most strongly associated with increased sex disparities in wait list mortality and DDLT in our study: the MELD score and candidate anthropomorphic and liver measurements,” the investigators wrote. “Findings from our study support such process improvement in liver allocation.”

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How a new study can help doctors identify COVID-19 infections faster

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Outpatient presentations of COVID-19 remain a tricky management challenge for all healthcare professionals. When it comes to quickly triaging a patient, you need your evaluation to be as accurate as possible, especially when that patient’s symptoms may or may not traditionally fit testing criteria — or if your organization has testing kit shortages.

You also don’t want to undertest patients who need diagnostic confirmation and may need hospitalization right away. Good news: fresh research from Harvard Medical School may be able to help you determine which presenting patients need further COVID-19 workups and which patients may have another condition.

The new study by researchers Pieter A. Cohen, Lara Hall, Janice N. Johns, and Alison B. Rapoport, “The Early Natural History of SARS-CoV-2 Infection: Clinical Observations From an Urban, Ambulatory COVID-19 Clinic,” covers this gray area patient population in symptomatic depth.

Among the key new findings the researchers outline:

Body aches, especially very bad ones, can be a presenting COVID-19 symptom that shouldn’t be overlooked diagnostically.

Fever, contrary to popular belief, might not be present with COVID-19. If fever is present, it may be lower than your physicians are specifically looking for as part of a standard COVID-19 evaluation.

If a patient complains of serious exhaustion, that should be taken into consideration as a COVID-19 symptom.

Fever, cough and shortness of breath are considered to be hallmarks of COVID-19, but they don’t always appear in a constellation. Your doctors might not think to check for these kinds of less expected signs. However, it’s key to be on the lookout for cough without fever, sore throat, diarrhea, stomach pain, headache, body aches, back pain, dizziness, falling, and fatigue.

Nearly zero COVID-19 patients experience shortness of breath in the initial one to two days of becoming symptomatic. If shortness of breath occurs, it most likely will happen of day four or later in the progression time of the illness.

Once shortness of breath does begin, however, your team needs to swiftly step up patient monitoring. If outpatients are deemed not sick enough to be in the hospital and are quarantined at home, they need to be checked on frequently by telemedicine visits or in-person exams. Ongoing oxygen saturation level testing is crucial, as changes in condition can happen suddenly, and that testing can also be a valuable clue to a rapidly worsening condition.

Anxiety can mimic COVID-19 breathing issues as well. The researchers point out that shortness of breath due to COVID-19 shortness of breath will get worse if a patient is engaging in physical activity, unlike with anxiety. Also, patients dealing with anxiety won’t show a drop in their blood oxygen levels, but COVID-19 will indeed cause those levels to lower.

Your doctors should consult the study further, and then they can potentially use this information as part of a quick list of key clinical pearls. It’s also much better to err on the side of caution and hospitalize patients at high risk of serious COVID-19 outcomes as quickly as possible. This will focus your team squarely on the primary objective of setting your patients up on the care plan they need — or in the better-case scenario, searching quickly for other clues to illnesses that are not COVID-19.

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Some hospitals, surgery centers still aren’t performing cosmetic surgery

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Here in San Francisco, the city and health department issued a directive on May 15 allowing elective surgery. In the directive, it was very clear elective surgery, including cosmetic surgery and dental procedures, could move forward. For this reason, we began performing cosmetic surgery in our in-office AAAASF-accredited operating room the following Monday, May 18.

A full two months had passed after the last case in our office. Since that day, we’ve been busy going through our backlog of cases.

Based on previously scheduled cases and newly booked procedures, we’ll be operating at full capacity for the foreseeable future. While we have the luxury of performing cosmetic surgery in our own facility, not all facilities are proceeding with cosmetic surgery. Why not?

Facilities allowing elective cases but not performing cosmetic surgery

Based on a recent conference call with the leadership of one of the local hospitals, they explained they were deferring cosmetic surgery at their facilities for up to 6 months. The reason given was the need to clear their backlog of higher-tier cases. They of course were referring to this table developed by the Centers for Medicare and Medicaid. According to the table, cosmetic surgery is considered tier 1 and administrators should consider postponing.

However, there may be another underlying, unspoken reason facilities that generally handle insurance-based elective surgery are deferring cosmetic surgery for now.

Financial factors driving decision to defer performing cosmetic surgery?

According to a report from the American Hospital Association in this Becker’s Healthcare Review article, hospitals are estimated to lose $200 billion between March 1 and June 30. Of this, $161 billion is due to expected revenue losses from canceled services, including nonelective and elective surgery, and outpatient treatment.

But it’s worth noting that in the same article, Becker’s lists the top 10 specialties that generate the most revenue for a hospital through elective and non-elective procedures. Here’s the list based on the Merritt Hawkins 2019 Physician Inpatient/Outpatient Revenue Survey:

1. Cardiovascular surgery — Average revenue: $3.7 million

2. Cardiology (invasive) — Average revenue: $3.48 million

3. Neurosurgery — Average revenue: $3.44 million

4. Orthopedic surgery — Average revenue: $3.29 million

5. Gastroenterology — Average revenue: $2.97 million

6. Hematology/Oncology — Average revenue: $2.86 million

7. General surgery — Average revenue: $2.71 million

8. Internal medicine — Average revenue: $2.68 million

9. Pulmonology — Average revenue: $2.36 million

10. Cardiology (noninvasive) — Average revenue: $2.31 million

Notice which specialty is missing? Cosmetic plastic surgery is not a major driver of revenue for a hospital or hospital outpatient department (HOPD) such as hospital-owned surgery centers. Sure, cosmetic plastic surgery conjures images of expensive out-of-pocket, non-insurance-based breast augmentations, tummy tucks and mommy makeovers. But to a hospital, the facility fee paid by a cosmetic patient pales in comparison to the more lucrative facility fees paid by insurance companies for medically necessary hand surgery, hip or knee joint surgery, or minimally invasive cardiac procedures.

This is arguably the real reason hospitals across the U.S. will prioritize greater revenue-producing insurance-based procedures over cosmetic procedures. And while that’s certainly the hospital’s prerogative to make that financial decision, admitting it may avoid further uncomfortable and futile conference calls, like the one I was recently privy to.

Moving forward, surgeons, be they cosmetic plastic surgeons or other specialties where it’s feasible, should consider building their own accredited office-based operating room. Aside from better outcomes, a better experience for patient and doctor, it’s also nice being in charge of your destiny, professionally.

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Nurses: The professional progeny of Florence Nightingale

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Florence Nightingale, the founder and progenitor of the modern nursing profession, lit a spark several centuries ago that burns within millions of nurses to this day.

The lamp that she literally — or metaphorically — lit during the Crimean War continues to illuminate nurses’ paths forward, and her legacy is one that strengthens with age as her offspring continue to advance the profession. And in difficult times such as the current coronavirus pandemic, nurses fight the good fight around the clock.

The International Year of the Nurse and Midwife

May 2020 marks the 200th anniversary of Nightingale’s birth, and many around the world – nurses and non-nurses alike — celebrate this occasion. In its wisdom, the World Health Organization (WHO) chose in late 2019 to declare 2020 The International Year of the Nurse and Midwife, and this momentous passage is being recognized by myriad individuals and organizations. The WHO made its case eloquently and clearly:

“Nurses and midwives play a vital role in providing health services. These are the people who devote their lives to caring for mothers and children; giving lifesaving immunizations and health advice; looking after older people and generally meeting everyday essential health needs. They are often, the first and only point of care in their communities. The world needs 9 million more nurses and midwives if it is to achieve universal health coverage by 2030.

“That’s why the World Health Assembly has designated 2020 the International Year of the Nurse and the Midwife.

“Join WHO and partners including, the International Confederation of Midwives (ICM), International Council of Nurses (ICN), Nursing Now and the United Nations Population Fund (UNFPA) in a year-long effort to celebrate the work of nurses and midwives, highlight the challenging conditions they often face, and advocate for increased investments in the nursing and midwifery workforce.”

Who could not join in honoring nurses, the most trusted professionals in the United States year after year in the Gallup Poll? They are the very connective tissue of the healthcare system, and the Gallup organization reported the following in January 2020:

“For the 18th year in a row, Americans rate the honesty and ethics of nurses highest among a list of professions that Gallup asks U.S. adults to assess annually. Currently, 85% of Americans say nurses’ honesty and ethical standards are ‘very high’ or ‘high,’ essentially unchanged from the 84% who said the same in 2018. Alternatively, Americans hold car salespeople in the lowest esteem, with 9% saying individuals in this field have high levels of ethics and honesty, similar to the 8% who said the same in 2018.”

Florence Nightingale’s innovative work in hygiene, sanitation, infection control, the nursing process, and biostatistics continues to reverberate throughout the global community, and her initial spark never seems to diminish.

Are nurses valuable? The jury has indeed spoken multiple times, and the verdict is clear. And when we stop to witness the tremendous courage of nurses on the front lines of the COVID-19 pandemic, there can be no doubt as to their incalculable value.

Nightingale’s Progeny

Florence Nightingale’s progeny are clinicians who work in ICUs and ERs; ambulatory care centers; medical offices; schools, universities, and colleges; public health offices; homecare and hospice agencies; and myriad facilities housing the elderly, infirm, and disabled. They may be vocational/practical nurses; nurse practitioners and other advanced practice nurses (APRNs); nurses with ADNs or BSNs; or hold any number of master’s-level, Ph.D., or DNP designations.

Nonclinical nurses are just as crucial, and they can include researchers, educators, administrators, legal nurse consultants, expert witnesses, and other roles that often go unsung. Several even serve in Congress and state legislatures here in the United States.

A plethora of often unacknowledged nurse entrepreneurs also make their contributions, including inventors, writers, bloggers, podcasters, keynote speakers, coaches, and consultants.

Florence Nightingale would no doubt be exceedingly proud of the profession that nursing has become. She would be thrilled at the increased autonomy of nursing practice; and the depth and breadth of our individual and collective accomplishments. And if nurses can learn to use their voices and gain more personal agency and power as informed citizens and advocates, their power would be incalculable.

Nightingale’s original spark has gained significant fuel over the last two centuries, and it now burns as a beacon to all who see the profession for what it truly is. As Nurses Week 2020 comes and goes, we pause to celebrate the 200th anniversary of Nightingale’s birth and the yearlong celebration declared by the WHO.

The talented progeny of Nightingale are legion, and their central role in the maintenance of the health and well-being of most every citizen on this beautiful yet troubled planet of ours is irrefutable. Here’s to those trusted, courageous, and brilliant humans who always show up when duty calls, and always will.

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Telemedicine, webside manner, and barriers to care

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Telehealth and telemedicine have been gaining in popularity for a number of years, and medical providers’ ability to be effective in these very 21st-century roles has truly become a new expectation of practice.

In this time of the COVID-19 pandemic, the need for positive patient outcomes vis-à-vis telemedicine has never been so important, or so crucially put to the test. And when social and economic disparities loom large in terms of telemedicine reaching those most in need, we can experience a perfect storm of telehealth’s promises remaining largely unfulfilled.

Your Provider is Calling

When patients need medical counsel or symptom management during a situation like the novel coronavirus currently encircling the globe, the ability to provide such care over the phone or computer is paramount. In an effort to expose as few patients to potential infection as possible, telemedicine can mitigate risk while still accomplishing the goals of care.

While telehealth has been practiced in certain quarters for some time, it does appear that the Age of Telemedicine has indeed arrived. Smartphones and tablets are facilitating virtual visits between providers and patients, and a great deal can be accomplished when telemedicine is done well. But what challenges can stand in the way of success?

Providers Challenged by Telehealth

One particular challenge in telehealth is providers’ relative lack of training in conducting assessments, patient interviews, and therapeutic conversations that do not occur in person. Tuning into tone of voice, body language, and other aspects of patient visits can be less than optimal over phone or video, yet these cannot remain barriers when both patient health and provider liability are at stake.

In the age of COVID-19, patients are frequently frightened, confused, and often misinformed. Like people the world over, they may also be living with economic uncertainty, social isolation, and perhaps existential issues such as sick or dying loved ones, food insecurity, inability to access needed medications or treatments, or the threat of eviction or utility shut-offs.

In such dire circumstances, a physician, nurse practitioner, or other provider must have the means to dive deeper, perhaps providing supportive counseling, access to psychosocial and community resources, and taking the time for an empathic and reflective conversation. This can be a stretch for those unschooled in such conversations and may even pose challenges for those trained in mental health.

Yet another challenge is correctly assessing a patient’s physical status or symptoms via phone or video. Can edema or rales be properly identified over the phone? Can a patient’s report be trusted as altogether accurate? These are ongoing troubling questions.

Disparities Rear Their Ugly Head

It is all well and good when a relatively affluent patient accesses telehealth via a smart phone, tablet, or laptop. Such encounters are also more efficient and effective when patients have high-speed cable internet or reliable Wi-Fi.

For economically struggling communities in the inner city, suburbia, or rural areas, high-speed internet or Wi-Fi may simply be wishful thinking. For many patients, a tablet or smartphone may be completely out of reach, with many using basic “flip phones” of days gone by.

These types of economic and technological disparities pose even more insidious barriers to the delivery of effective telehealth visits, and the old nemesis of the “digital divide” rears its ugly head yet again when at-risk patients cannot receive care they clearly need.

Providers are hard-pressed to reach patients who lack adequate cellular service. And when a patient who cannot be assessed by video needs to be seen in person but lacks money for gas or will not come to the clinic for fear of infection with COVID-19, yet more barriers impede proper care.

Healthcare disparities are by nature borne by the poor, and consequently exacerbated by lack of access to the technologies that could benefit such at-risk communities. Herein lies a vexing conundrum of the 21st century.

Solutions Can Be Found

Webside manner and telehealth skill training should now be de rigeur in the education of all healthcare professionals. There is some promise in such training being integrated into medical education, and more will likely be coming online as COVID-19 continues to draw attention to such needs.

The art of listening, skills in motivational interviewing, and training in the development of empathy and compassion are not rocket science; perhaps one solution might be the consolidation of such training for mental health, medical, and nursing students through integrated curricula.

For underserved communities in both rural and urban environments, solutions must be found to mitigate technological barriers. In some cities, libraries and schools provide 24-hour high-speed public Wi-Fi that families and individuals can access from parking lots.

Meanwhile, in some localities, school buses are outfitted to serve as mobile Wi-Fi hotspots that can reach low-income communities so that students can participate in online learning, and, by default, parents may also access the internet for purposes such as telehealth. And if children from underserved communities could be outfitted with tablets or laptops and portable Wi-Fi devices, entire families would benefit in this manner, as well.

Some solutions may simply be tech band-aids, yet we must begin somewhere. If tech companies, healthcare institutions, government, philanthropic and grass-roots organizations, and schools training various healthcare professionals would coordinate efforts, many gains could be made.

In order to optimize the delivery of telehealth services, we need political will, public-private partnerships, and the societal desire to address disparities while shoring up the education and training of professionals who provide such services. With a more holistic approach to the maximization of telemedicine delivery and effectiveness, more patients will receive appropriate and safe care and providers will be more well-trained to meet those patients where they most need to be met.

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