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<p>Frontline providers battling COVID-19 in New York, where the outbreak may go down as the worst in the United States, share the latest updates and techniques that are paying dividends.</p>
Leveraging Hospital Incident Command to Battle COVID-19
June 1, 2020 9 minutes read
EXECUTIVE SUMMARY
Hospitals in New York state are leveraging hospital incident command centers to expand capacity and quickly respond to new challenges as COVID-19 sickens thousands of patients and poses new risks for staff.
At Stony Brook University Hospital in Stony Brook, NY, staff had treated 233 infected patients and monitored others under close investigation. This has put a strain on emergency department and intensive care unit (ICU) resources.
- To respond to the demand, Stony Brook opened field tents in the university parking lot to accommodate a forward-triage area for the ED and a COVID-19 testing area.
- Stony Brook also expanded its footprint beyond the hospital, with plans to take over ambulatory surgery and endoscopy spaces as well as several adjacent outpatient clinic areas.
- At Northwell Health, a 23-hospital system headquartered in Manhattan, staffing ratios have changed to accommodate a rapidly increasing demand for ICU care. The health system has cared for thousands of COVID-19 patients, more than one-quarter of whom had to be placed on ventilators.
- Northwell administrators advise that it is critical to maintain continuous communications with staff, particularly around scarce supplies such as personal protective equipment. They also encourage colleagues to look for ways to preserve key items in short supply. Frontline clinicians have been provided with breathable bags they can use to store their N95 respirators when not in use.
To optimally respond to the unfolding COVID-19 pandemic, Stony Brook University Hospital on Long Island in New York opened its hospital incident command center (HICC) just as March turned to April. Things escalated quickly from there.
“We see things that we could never have imagined in healthcare at our prestigious institutions as we watch droves of patients coming through our doors with cough, fevers, and shortness of breath with what feels like no end in sight,” explained Carol Gomes, the hospital’s chief executive officer and chief operating officer of the hospital. Gomes spoke at a briefing sponsored by the Patient-Centered Outcomes Research Institute (PCORI) that was broadcast on March 31.
Under orders from Gov. Andrew Cuomo, New York hospitals were asked to create a surge capacity plan to increase patient beds by an additional 50%. Soon, the target doubled; hospitals were directed to prepare for a 100% increase in capacity.
“Our plans include expanding inpatient footprints into our ambulatory surgery center space, our endoscopy space, our holding area spaces, and several of our outpatient clinic spaces that are adjacent to the hospital,” Gomes noted. In addition, Gomes said tents constructed in the Stony Brook University parking lot accommodate a COVID-19 testing site and a new patient care area.
As of April 28, Stony Brook University Hospital had handled 233 COVID-19-positive cases. There still were seven more persons under investigation (PUI), and the number of patients coming through the emergency department (ED) requiring intensive care unit (ICU) attention and intubation were continuing to escalate.
“The [HICC] is led by our chief medical officer, and it meets at least twice daily, following the usual HICC structure with updates that are provided regularly,” Gomes explained. “We do increase the frequency [of updates] depending on the circumstances.”
The updates concern everything from supply chain activities and staffing to progress developing the hospital’s surge capacity plan, Gomes said. Further, she noted leaders are apprised of various situational activities in the hospital’s external environment. This includes communications with local and state legislators, hospital associations, media updates, and other communications forums.
“There is a very strong communication arm [within the HICC structure] as it is extremely important to communicate as much information as possible to our staff and to our community. This includes statistics that we accumulate throughout the day,” Gomes said. “We host daily information segments on our intranet. I have ... written CEO blogs based upon COVID-19 updates that we push out regularly. We also push out daily email communications to our staff and our faculty to provide an overview of the day and any new resources or changes in policy that may be applicable.”
To increase capacity, hospital leaders have worked with staff to open a significant number of new ICU beds and med-surg spaces in nontraditional areas. Stony Brook University Hospital administrators worked with clinical leaders in the ED to create a forward-triage process to separate patients who were less ill into an alternate area. Initially, this forward-triage space was located in an ambulatory area. However, as the need for more inpatient space became apparent, it was later moved to a tent in the university parking lot.
“This has made a great difference in our capacity in the main ED. It allows us the ability to push over to another rotation some of that surge so that the main ED can handle patients who are sicker and more acutely ill,” Gomes said. She noted that on one recent day, the forward-triage space managed roughly 200 patients, “saving the day” for staff in the main ED, giving them the time and space to manage their sicker patient load.
The hospital has created twice-daily huddles from the HICC to focus on incoming patient flow, not only with a focus on current ED throughput, but also to anticipate demand in the next 24 to 48 hours, based on the hospital’s surge plan. Gomes noted these huddles include an interdisciplinary team of physicians, nurses, operational personnel, and administrative leaders who work closely with the hospital’s centralized throughput office to anticipate near-term demand.
Shortly after opening its HICC, Stony Brook worked with state and federal authorities to create a drive-through testing site for COVID-19 in the university’s parking lot adjacent to the forward-triage area.
“There is a New York State Department of Health phone number that the community can contact. Patients are triaged, and then they are scheduled, if appropriate, to have testing performed,” Gomes explained. “Then, they are assigned a date and a time for testing at the drive-through site.”
The pandemic has prompted considerable change in how labor resources are used, Gomes observed. “We have canceled elective surgeries, which has created a labor pool of individuals whose roles have shifted,” she said. “This also includes [people] working in the ambulatory environment where clinic visits have significantly declined ... we are pooling those labor resources to take care of patients in the hospital.”
To keep up with evolving guidance and other changes, hospital leaders have assembled several teams focused on specific areas. For instance, one team is charged with scouring all the literature for any new information regarding clinical guidelines or other best practices regarding COVID-19. This team includes representatives from pharmacy, the supply chain, and respiratory therapy. “We have also formed a team that is focused specifically on ventilator use, anesthesia machine use, and bypass planning,” Gomes explained. “This team is led by [the hospital’s] ICU physician leadership, respiratory therapy team, and anesthesiology.”
Yet another team is focused on ensuring the successful execution of the hospital’s surge plan as it is aligned with labor resources. All teams report to the HICC, Gomes said.
Northwell Health, a 23-hospital system headquartered in Manhattan, has taken many of the same steps as Stony Brook to keep up with the surge in COVID-19 patients. Northwell’s reach extends throughout the New York City metropolitan area, from Westchester to the end of Long Island, noted Mark Jarrett, MD, MBA, senior vice president, chief quality officer, and deputy chief medical officer at Northwell Health, who also spoke during the PCORI briefing.
As of April 23, Northwell had cared for 2,431 patients with COVID-19. Of these, 34% had been in ICUs, and 27% had been on respirators. “[These patients] can walk into the ED looking fine, and then their [oxygen level] drops. They may be intubated in two or three hours, though they are still very unstable,” Jarrett reported.
As the pandemic unfolded, the demand for care from these seriously ill patients quickly outstripped the health system’s typical supply of ICU coverage. Staffing ratios had to change because there are not enough ICU nurses or intensivists. “Even bringing on some of our anesthesiologists and our surgical critical care people online — we have not been able to cover all the extra ill patients. You need to think about developing staff ratios, which allow buddy systems where perhaps one critical care nurse is helped by two or three regular floor nurses,” Jarrett shared.
The hospital’s incident command structure, which Northwell refers to as its emergency operations center (EOC), opened around the beginning of March, although a small group had gathered to plan the health system’s response even before the EOC formally opened.
“It really paid to have a command structure because it really works well. It is the perfect thing to do,” Jarrett said. “You do not want people separated, especially in leadership, because these are the people who often have the knowledge base and the legacy base that can help ... when you are dealing with a large system.”
However, Northwell leaders quickly concluded that bringing all their senior people together in one room was not a good approach during an infectious disease crisis. Thus, all EOC meetings have been held virtually since early March.
In fact, Jarrett noted that a surprising number of employees throughout the health system continued working through telework arrangements. Northwell was somewhat prepared to leverage telework because it has used this approach during snowstorms. “It is amazing how many people don’t actually have to come into the office to work,” Jarrett said.
Jarrett’s advice to hospitals that are still waiting for the wave of COVID-19 patients to hit: Take steps to facilitate teleworking in advance. For instance, make sure there are enough laptops to go around, determine how to manage a large-scale telework arrangement for employees who can work from home, and establish the right security procedures.
Hospitals should make sure there is a good database in place to track all clinical and operational metrics. Further, it is vital to recognize that even if the demand for care slows, some numbers still will surge past normal levels, Jarrett noted. “The average length of stay for someone on a ventilator is four to five days, but [with COVID-19 patients], we are now talking two to four weeks,” he said.
Start thinking early about labor force needs and demand for alternative sites for care, Jarrett suggested. “At one of our institutions, we are now moving our postpartum patients over to an ambulatory surgery site on the same campus, but in a different building,” he explained. “That will open up another unit we can use now for our COVID-19 patients.”
It is critical to maintain continuous communications with staff, particularly around scarce supplies such as personal protective equipment.
Furthermore, Jarrett advises hospitals to consider methods for preserving N95 respirators in line with Centers for Disease Control and Prevention guidelines. “We actually gave our staff little bags that are breathable for when they are not wearing their N95 respirators,” Jarrett said. “Obviously, we replace [the N95 respirators] whenever there is a problem, but you would be surprised how much you can reuse a thing that you never thought about before.”
Also, think ahead about how to stretch ventilator supplies. “We have so many patients in the ICU that [securing enough] ventilators is becoming difficult ... some places have repurposed their anesthesia machines as ventilators,” Jarrett said. “Although it works ... you have to actually turn [the anesthesia machines] off for a period of time during the day, ideally. Otherwise, the machines won’t last. They are not designed to run 24/7 like a routine ventilator.”
Jarrett stressed an anesthesiologist often has to teach people how to properly use anesthesia machines or to help manage them. Considering this approach is not ideal, Jarrett advised hospitals to use the anesthesia machines only as a backup when ventilators are unavailable.
While many hospital systems, including Northwell, have canceled all elective surgeries to devote their resources to managing the pandemic, there is not always a clear line between what constitutes elective vs. an emergency or urgently needed procedure.
To make such decisions, Northwell has set up a central committee to determine which surgeries should and should not go forward, Jarrett reported.
Understandably, hospitals in hard-hit areas are trying to encourage people with mild symptoms to refrain from coming to the ED for care. That makes sense, given the need to protect people from exposure to COVID-19 while also effectively managing the surge of seriously ill patients. However, Jarrett noted it is important for hospitals to be careful in their messaging to the community.
“We have had instances where people [have gone] to urgent care centers with crushing chest pain and have acute MIs [myocardial infarctions] and really need to be in the hospital ... but they are afraid to go to the ED,” he explained. “It is really important that in your advertisements or your communications out to the public that you alert them that if they have symptoms of a stroke or symptoms of a heart attack, [they should] come to the hospital, and that you will do the right thing and protect them.”
Frontline providers battling COVID-19 in New York, where the outbreak may go down as the worst in the United States, share the latest updates and techniques that are paying dividends.
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