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Even the most sophisticated trend analysis can only estimate how health care systems need to prepare for taking care of higher numbers of patients with COVID-19. Many across the globe are drawing on the best information available to date to guide preparations for an expected surge of patients in need of hospital-level care.
Northwell Health has been a major health care system at the epicenter of the US crisis. Its 23 hospitals and 800 outpatient centers are just north, south, and east of New York City, and are leading in the city’s efforts to learn together through the COVID-19 surge in their region.
It’s tempting to think that Northwell Health’s location, size, or resources have given them a “leg up” on many hospitals in terms of their COVID-19 preparedness response. It is, after all, a high-performing health care system that’s taken quality improvement seriously for many years, but Northwell, like every other health care system in the world, is facing unprecedented challenges because of COVID-19.
As Mark Jarrett, MD, MBA, Senior Vice President and Chief Quality Officer of Northwell Health, said when he joined the IHI Virtual Learning Hour on April 3 (Preparing for a Surge of Hospitalized Patients with COVID-19):
Those of you that are either very early in the game or don’t have much [more time before reaching your COVID-19 peak], I beg you to learn from our experience. We started meeting [around mid-February] to plan for COVID-19 surge preparedness and opened our formal emergency operations center [in late February]. At [the beginning of March], we had one case in one of our hospitals. [Very quickly], we had over 3,000 COVID-positive patients in our hospitals, with more than 600 on ventilators. Over 40 years of my professional career, this has been the hardest thing I’ve ever dealt with.
Jarrett shared Northwell’s learning to date about developing COVID-19 surge plans in the hope that other health systems could benefit from their experience. Here are eight key takeaways from the April 3 virtual discussion with Jarrett:
Establish an emergency management system. Utilizing a virtual emergency operations command, put the emergency management system and emergency operations command that handles your tornado, hurricane, or earthquake response in place. COVID-19 preparedness also includes financial planning. Despite losing revenue — from elective surgery and ambulatory care, for example — Northwell, like so many, is starting to plan for what comes next.PPEs, ventilators, and beds are the obvious supplies health systems know they will need. With so many ICU patients, critical care supplies and medications for sedation and comfort are increasingly difficult to acquire. As Jarrett said, "Whatever you think you’ll need, you’re going to need more."
Create a senior leadership coverage plan. With the high levels of COVID-19 community spread, Jarrett described Northwell’s efforts to avoid putting top leadership in the same room. Northwell Health leaders have all been working remotely from different sites, connecting virtually, and taking shifts being onsite with local teams.Every senior leader is encouraged to have a partner so the position is always covered. After months of COVID-19 response, Northwell senior leaders now try to take one day off to recharge each week. Their efforts reflect the importance of establishing a senior leadership succession plan, especially in this time of crisis.
Build capacity. A typical ICU patient is on a ventilator for four or five days on average. Northwell’s experience has been that COVID-positive patients who are extremely ill are on ventilators for around two to four weeks on average.To prepare for a COVID-19 surge, building bed capacity and building space has become necessary nationwide. By mid-April, Northwell had prepared 1,600 additional beds. Northwell, like it’s colleagues across New York, is providing little non-COVID care in the hospital; extra capacity in hospitals and alternate locations are necessary for patients with non-COVID issues.
Protect your staff. Clearly, personal protective equipment is critical. Northwell is working in coordination with other leaders to try to assure there are enough masks, gowns, and gloves. Jarrett talked about the problem of having to watch out for counterfeit and substandard supplies in recent bulk deliveries.There is growing evidence to guide systems on how best to decontaminate N95 masks so they can be used again. Northwell is following the Duke Health decontamination process. One issue to be aware of is the mask manufacturer’s guidelines to ensure the sterilization process does not degrade the mask. Another consideration is scaling up the mask decontamination process. The New York State Department of Health issued guidelines which include FDA emergency use authorizations for decontamination and IHI and Ariadne published a piece that summarizes common practices for PPE conservation.
Another vital component of the decontamination process is to ensure that each person gets back their own mask. At Northwell, for example, each staff person has been given a small breathable bag with their name on it in which to keep safe their N95 masks when not in use.
One process Northwell instituted early on is all staff who care for COVID-19 patients wear N95 masks and all other hospital employees wear procedure masks. The rationale was that this policy may cut transmission within the hospital.
Create a staffing plan. Around early March, Northwell developed 10 tiers of surge plans at all hospitals, including finding additional space or alternate care sites. One key was keeping alternate care sites on campus, or as nearby as possible, making it easier to move staff and supplies where they are needed.Staffing remains a significant issue. With a surge of ICU and very sick COVID-19 patients, the New York City facilities do not have enough intensivists or ICU nurses.
Northwell is tapping anesthesiologists to help with critical care needs and engaging its 1,800 residents and fellows. Third- and fourth-year medical and nursing students are graduating early and being assigned to non-COVID units. First- and second-year medical students are also volunteering in other ways, but again, not in COVID units. Retired nurses, doctors, and other health care professionals are also being called in.
Northwell has also engaged physicians and nurses without critical care training to care for very sick COVID-19 patients by instituting a buddy system — for instance, one intensivist may work with four hospitalists across a series of patients. The intensivist provides ICU expertise, while the hospitalists provide much of the routine care. This staffing model comes from previous surge plans created for SARS.
Like so many across the country, Northwell is also using telemedicine. For example, eICUs have been expanded by putting telemedicine carts with screens on non-ICU units caring for COVID-19 patients, which provides needed expertise and support for the COVID units.
Establish statewide coordination, shared learning, and standardization. Northwell Health leaders are on regular calls with health systems and others across the state to exchange ideas and attempt to standardize certain processes and policies. During the COVID-19 pandemic, increased coordination is playing out across a number of states and regions.Another example where coordination is helpful is in communicating to the public. During the pandemic, health systems are advising patients who are not that sick to go to an urgent care center, call their doctor, or stay at home. Health systems also play an important role in conveying the message that non-COVID diseases are still occurring and we don’t want someone experiencing a complication to avoid seeking care because they are afraid to go to the ED.
Communicate frequently with staff. It’s critical for health system leaders at all levels to communicate with staff. There are two things that hospitals leaders cannot communicate enough to their staff: 1) their efforts are deeply appreciated; and 2) what they’re doing and why. Leaders need to show that they understand this is a very difficult time. Staff are scared for their own health and scared for their families’ health. They need clear and consistent communication from all levels of leadership.
Support staff wellbeing. Staff are under tremendous stress. In an effort to address this, Northwell’s employee assistance program and chaplains are supporting staff who are mentally distressed by working so many hours and from seeing a lot of patient deaths. It’s critical for health systems to support all staff including nurses, physicians, advanced care practitioners, transporters, patient care assistants, social workers, and others. This must be a priority for the weeks, months, and even years ahead.It’s important for leaders to walk around the units and see what staff are facing. Northwell has held virtual town halls to communicate issues to staff. They are also trying to find ways to let staff take some time off because everybody’s been working at a fever pitch and, even in a crisis, everyone needs to recharge for the long road ahead.