• Despite several previous surges, many centers reported a feeling of disorganization and last-minute planning with this current surge. The number of patients with COVID-19 increased very quickly at many sites.
• In the current surge, many more staff have been out of work due to infection or need for testing due to exposure. Similarly, risk of workplace transmission is higher, and it has been harder to keep physical workplaces safe.
• Employee health/hotlines are overwhelmed with the need for employee testing, which makes it hard for those services to give clear feedback to staff regarding current policies, which are also rapidly changing.

• Many centers' census levels have never returned to pre-COVID levels, and now with the Omicron surge, the total medicine census is higher than ever at most sites.
• Patients are generally lower acuity, with fewer ICU patients, but hospitals noted more challenges related to discharging patients (with or without COVID) into the community or facilities, which has translated into longer length of stay. Both challenges predominantly affect HM services.

• Fewer closures of non-essential services (e.g., surgeries) than during the first surge at many sites means less additional staff are available to assist.
• When non-hospitalists cover shifts (via deployment or volunteerism) and request to work with resident teams, it places additional restrictions on the teaching time that hospitalists have with trainees (i.e., hospitalists are moved to solo direct care services).
• Many sites are having issues with rapid testing for staff, getting them back to work quickly.
• Less volunteerism (e.g., due to burnout), and with increased spread in the community due to Omicron, even those who would have volunteered before are reluctant to sign up for shifts.
• Locums and non-HM providers are less familiar with systems (sign-out, etc.); need time to on-board, train, supervise, and help them. There is also the financial impact of locums providers who cannot bill because they are not fully credentialed.
• Severe staffing shortages, not just MDs and APPs but nurses, respiratory therapists, housekeeping, etc. Creates challenges with clinical care, also difficult to manage financial aspects of how to pay providers (e.g., having to pay for traveling nurses due to nursing shortage, etc. pulls money from physician moonlighting pool).
• Many centers are less able to utilize residents this time (i.e., not able to invoke emergency ACGME rules).

• Staff are exhausted, with little opportunity to boost morale given inability to gather for community-building events, which has led to more loneliness, disconnectedness, and burnout among inpatient providers.

• Bring HM attendings back from other non-HM services (consult services, pre-op, etc.).
• Identify tasks that can be done remotely (triage pager, transfer pager, chart round on patients cared for by non-medicine attendings, etc.) and provide payment for providers to do that off-site to offload active (on-site) clinical staff.
• Many centers are trying to avoid locums given high cost and challenges related to transfers of care among locums providers who may be unfamiliar with local structures, workflows, signout practices, etc.
• Allow residents and APPs to pick up admitting shifts and move hospitalist attendings to daytime shifts and/or staffing admissions. Some centers have created policies where APPs can independently see patients (e.g., long-stay patients awaiting placement, more stable patients, etc. — best if choose which patients to see this way).
• Many sites are pulling hospitalists off teaching services (which are now filled by non-HM faculty) to work on direct care services.
• Create a dedicated patient liaison to facilitate communication with patients and families during times of increased visitation restrictions to alleviate pressure on teams to call families.
• Some sites have created an operations role to help with patient progression (e.g., getting MRI done, working with pharmacy on medication reconciliation), which can sometimes be done remotely and by non-medicine faculty.

• Sources of additional help currently include PCPs, medicine specialists, non-medicine providers, moonlighting/per diem, locums, APPs, residents, and fellows (inside and outside of medicine), depending on the site.
• As with previous surges, many sites utilizing several layers of contingency planning, to be invoked as needed depending on the census.
• Recognition of need to "staff to a buffer," for centers that are financially able. If not possible to staff to a buffer, then add additional lines of jeopardy/backup coverage.
• Provide incentives for signing up for a larger number of additional shifts and for signing up for shifts far in advance (as opposed to raising moonlighting rates at the last minute for an uncovered shift, which incentivizes waiting until the last minute). Some innovative models, such as a tiered payment system where shifts are "worth" more depending on the number of available shifts (i.e., higher pay if more coverage is needed).
• Expand moonlighting ability for residents and APPs. Some centers are also able to provide "retainer" pay for jeopardy (pay a smaller sum like $250 for signing up for the shift, regardless of whether the person is called in).
• Some sites have created an internal locums pool: recruiting physicians from other hospitals in their health system as needed.
• Increased pay rates for moonlighting/surge coverage where able (depending on local financial ability), compared to pre-COVID.
• Avoid forced redeployment when possible (although sometimes necessary), ensure fair payment for clinical work when possible. If groups are redeployed, many centers maintain the "dyad" (resident/attending) pair that they are used to based on their service of origin. Other hospitals purposely pair seasoned HM faculty with non-HM residents/APPs or vice versa to spread COVID experience.
• Less emphasis on geographic cohorting of COVID-19 patients to allow for more flexibility when admitting patients.
• To try to address logistical challenges (like patients who can go home except for needing dialysis), some centers have developed programs to discharge patients home with a supportive service (like Hospital-at-Home) and bring those patients back into the hospital to be dialyzed while still COVID-positive. Others set up a "COVID hotel" in hospital for patients ready for discharge without a place to go or place to isolate.

• Allow other service lines (surgery, neurology, etc.) to remain "intact" and keep their normal team structures, but care for patients who would otherwise be on HM teams (e.g., altered mental status for neurology, cellulitis for surgery, etc). Rationale: without this approach would require other service lines to redeploy to medicine.
• Utilize Hospital-at-Home (for centers that are able).
• Emergency department can take over observation unit duties from HM.
• Some hospitals are allowing patients with mild-to-moderate COVID without active medical comorbidities to be admitted to non-medicine teams (e.g., neurology, surgery) with an automatic medicine consultation on day 1 and then as needed, and with clear criteria for transfer to medicine or ICU.

• Pair experienced resident/APP with inexperienced faculty, or vice versa.
• 1 day of hands-on training (e.g., paired with HM PA).
• Formal rounds with experienced provider daily or BID, interim chart review.
• Leadership chart review of patients to make sure clinical issues aren't missed.
• Informal or formal consultation as needed.
• Some sites using seasoned medical students to orient off-service/locums staff, help them navigate the system.

• Some centers have created provider-specific rapid testing workflows to reduce time out related to testing/waiting for results.
• Utilize 5-day return to work, if without symptoms (some also require staff to have negative antigen testing on day 5).
• Utilize tip sheets for clear communication on current policies related to staff testing, infections, isolation, etc.
• Some sites utilize absent staff to do remote work which was described previously.

• A few centers have placed high-quality air filters in shared offices (which were privately bought by leadership as opposed to funding from the hospital).
• Many sites have taken over administrative spaces (and told all non-clinical staff to work remotely).
• Grab-and-go meals, discourage clinicians from eating together.

• Regular, clear communication.
• Email-based caregiver celebrations with verbal read-outs and sharing.
• Encourage stepping away from the hospital when possible.

1. Compared to prior surges, there is less use of redeployed services and less interruption of non-HM services, as well as lower rates of volunteerism. Successful strategies include providing financial compensation that incentivizes early sign-up for shifts and continuity of care, and avoiding locums when able.
2. Many centers are offloading patients who could be cared for by other teams (neurology, surgery) to those services to allow other service lines to stay intact.
3. Some centers are increasing capacity by allowing APPs to see more patients independently, identifying tasks that can be done remotely (triage/transfer pager, chart rounding, patient communication, patient progression).
4. Combating burnout, maintaining morale and staff health remains a challenge and a priority.
5. Overall focus on creating solutions without requiring disruptions in clinical experience of trainees, as this is not as feasible compared to earlier surges.
6. Mechanisms for rapid testing of staff (and reporting of results) and for providing safe staff workspaces are essential to maintaining stable staffing.

• $500/year honorarium for being a community partner (paid after registration) plus $200 per patient enrolled.
• Option to participate in clinical roundtables with COPD thought leaders.
• Contribute topic ideas for future grant proposals or publications related to hospitalist care.
• Community Partners will not be investigators / authors, but will be acknowledged in the RELIANCE publication.