The coronavirus playbook: How 12 health systems are responding to the pandemic

In early January, a smattering of news reports detailed a mysterious pneumonia outbreak sickening about three dozen people in Wuhan, China. Researchers identified the source of the outbreak as a novel coronavirus strain later named SARS-CoV-2, which rapidly spread across Asia before reaching Europe and the Americas, causing the disease COVID-19.

The World Health Organization on March 11 declared the COVID-19 outbreak a pandemic, further solidifying the importance for U.S. healthcare organizations to adequately prepare for the virus' continued spread.

Becker's spoke with a dozen infection control and clinical leaders overseeing response efforts at hospitals and health systems nationwide. Here's how their institutions are responding to the pandemic, organized into seven main categories: leadership, screening, triage, communication, education and training, supply chain, and telehealth.

Leadership

"You need to ensure there is a group or someone in the organization who is responsible for planning response activities. This is typically a collaboration with emergency management and infection prevention, among others."
— Richard Martinello, MD, medical director of infection prevention at Yale New Haven Health

The first step to ensure outbreak preparedness is simple: Identify who is in charge of response efforts. 

Chicago-based CommonSpirit Health created a system-level, multidisciplinary task force as soon as it heard about China's outbreak in January. The group includes stakeholders across all channels, including risk management, communications, supply chain, human resources and infection control. Once formed, the group immediately got to work creating tools and resources in anticipation of the virus spreading to the U.S. 

Los Angeles-based Keck Medicine of USC's task force also consists of a cross-functional team that represents 13 distinct workstreams. The group of physicians, administrators and operators meets three times a week to assess current priorities with regard to the pandemic.

These task forces are responsible for developing an emergency response plan, communicating information with staff members and allocating necessary resources, among other duties. They must ensure every affiliated hospital, physician group and outpatient facility within their organizations is properly equipped to treat a potential influx of patients with COVID-19.

This leadership approach ensures that organizations are well prepared across all clinical, financial and operational domains. It also ensures that patients and employees across the system receive clear, standardized communication and instructions regarding the pandemic.

Screening

"We're screening at the point of first contact, so we can get a mask on [patients] and funnel them away from others."
— Judd Hollander, MD, senior vice president for healthcare delivery innovation at Jefferson Health 

The next priority healthcare organizations should address is the development and implementation of protocols to quickly identify, isolate and inform relevant stakeholders of COVID-19 patients, per CDC guidelines. These protocols should be enacted not just at emergency departments, but across a system's inpatient and outpatient facilities.

"We are asking questions about travel history and exposure very early on to make sure we can identify patients who may be at risk of infection as soon as possible," said Richard Martinello, MD, medical director of infection prevention at Yale New Haven (Conn.) Health. 

Organizations will likely need to reorient these screening questions and processes as the virus evolves and spreads to other countries.

Patients with a fever or respiratory symptoms should immediately get a surgical mask as a form of "source control" to prevent them from spreading the virus throughout the healthcare environment, according to Michael Phillips, MD, chief epidemiologist at NYU Langone Health in New York City. 

"This is such an important intervention, probably sometimes more important than getting protective equipment on a healthcare worker," he said. "If you have a mask on a patient in a crowded room, you're protecting everyone in that room."

Health organizations like CommonSpirit Health are implementing EHR triggers to promote the early identification and isolation of suspected COVID-19 patients. The electronic trigger uses algorithms to identify any at-risk patient based on the CDC's definition, walking users through screening questions related to travel and symptoms. If the algorithm detects a patient may be at risk of having COVID-19, the EHR directs caregivers to immediately place a mask on the patient, transport him or her to a negative airflow room, and inform all relevant stakeholders, including physicians, infection control leaders and local public health officials. 

Some health systems are designating specific entrances or isolated waiting areas to prevent patients with COVID-19 from infecting others. For example, Philadelphia-based Jefferson Health's biocontainment unit, built in response to the 2014 Ebola outbreak, contains a separate backdoor entrance where at-risk patients can enter for screening.

Other organizations are working to prevent patients from coming to their facilities altogether by emphasizing phone screenings and virtual care services such as online chatbots and telemedicine consultations. Based on these virtual screenings, providers can then direct patients to the proper care setting, if necessary, and already have isolation precautions in place. 

Communication

"Communication to employees and healthcare workers is key. As the news develops and civilians and individuals, including healthcare workers, get concerned of what they are hearing — concerns and anxieties lead to potential errors and mistakes. So controlling that by constant communication and education is absolutely necessary." 
— Roy Boukidjian, MSN, system vice president of infection prevention at CommonSpirit Health

Information about COVID-19 is spreading rapidly across news sites, social media channels and text messaging groups. Communicating quickly and effectively with healthcare workers, who are also exposed to information outside the health system, is of the utmost importance. Anxieties among healthcare workers about the pandemic could adversely affect patient care if health systems don't combat the rising concerns. Organizations must ensure employees have access to accurate information and know the health system's plans to combat an outbreak in their community, along with how the organization plans to keep them safe.

Dr. Martinello of Yale New Haven Health said it is essential to keep staff up to date with the latest information regarding COVID-19. The system is creating an internal process to review data and guidance from the World Health Organization and CDC. For example, the health system is working on updating its list of "countries of concern," so staff who are asking travel screening questions have the most up-to-date information. 

"To operationalize [the preparedness] effort, they have to have very clear guidance on what countries and what areas we are worried about. So we are just getting that process into place now, about how we update that list," said Dr. Martinello. 

San Diego-based Scripps Health has a command center staffed with employees on call after hours and on weekends. The team closely monitors information released by the CDC and worldwide agencies about COVID-19 and helps coordinate efforts across the system. 

Other healthcare organizations are relying on technology to make sure staff is on the same page as the outbreak situation evolves. 

Indianapolis-based Indiana University Health has an intranet, which employees can access via a portal to obtain information resources and action plans. The health system is also in the process of scheduling educational webinars for staff and recently held a Facebook Live session where infection control leaders and infectious disease experts were interviewed about the pandemic, according to Douglas Webb, MD, medical director of infection control at IU Health. 

"I know we had several thousand views within the first couple of days," he said. "There's a real need to get information out to the healthcare workers to allay some anxiety and [let them] know we've got a plan."

At Keck Medicine of USC, the communications team has created an internal communications link that houses all documents and workflows, creating one information repository, said Neha Nanda, MD, the system's medical director of infection prevention and antimicrobial stewardship. 

Healthcare organizations are also communicating with each other on a state and national level. Dr. Webb of IU Health said healthcare organizations across Indiana are sharing resources and information, which is likely occurring in every state. Indiana's health commissioner is also convening an advisory group of hospital leaders to discuss state preparedness and how to optimize resources and equipment they currently have on hand.

Roy Boukidjian, MSN, system vice president of infection prevention at CommonSpirit Health, said there is an email group of about 200 system-level infection prevention leaders across the U.S., who have been sharing resources and action plans with one another.

Triage

"In theory, we're prepared. We know what we need to do. But depending on the extent and seriousness of the outbreak, knowing what to do and being able to do it are two different things. The one thing I know with 100 percent certainty: If we think we're fully prepared, people will find a way to make sure we're not."
— Judd Hollander, MD, senior vice president for healthcare delivery innovation at Jefferson Health

All health systems had at least one commonality when discussing triage tactics, and that was the need to develop, revise and perfect surge plans. 

A predicted 70 million to 150 million Americans will contract COVID-19, Brian Monahan, MD, the attending physician of Congress and the U.S. Supreme Court, said March 11. The need to safely screen, triage and isolate such a large quantity of infectious patients could pose an operational challenge for many organizations, especially since flu season is already driving large amounts of patients to the ED.

To help prevent this overcrowding, NYU Langone Health is updating its ambulatory processes to try to shift non-COVID-19 patients who may be seeking care in EDs to more appropriate care settings. 

"Early data from China showed rapid transmission of the disease, so we feel like this is something we've been preparing for all along," said Dr. Phillips of NYU Langone Health.

Boston-based Massachusetts General Hospital has increased signage to direct at-risk patients to proper care locations, said Paul Biddinger, MD, chief of the division of emergency preparedness and director of the MGH Center for Disaster Medicine. Mass General is also working to identify overflow locations to diagnose and treat mild cases, reserving its limited amount of negative pressure areas for severe COVID-19 patients.

To help prevent ED overcrowding, many healthcare organizations like Yale New Haven Health are using telehealth consultation to direct some patients seeking care in the ED to more appropriate care levels in ambulatory settings, said Dr. Martinello.

As a CDC-certified Ebola Assessment Center, IU Health has a negative pressure unit but, as of early March, the health system has elected not to use it for COVID-19 cases. The decentralized approach aims to reduce dependence on a singular hospital. "We may see many cases in the U.S. — all hospitals in one system should be ready," said Dr. Webb.

Mr. Boukidjian of CommonSpirit said it's crucial for health systems to ensure all facilities are aware of surge capacity policies, implement visitor protocols and conduct live drills to identify any shortcomings before actual surges of COVID-19 patients.

At the time of speaking with Becker's, Jefferson Health had not treated any patients with COVID-19 and was still able to conduct screenings one-by-one in its biocontainment unit. Judd Hollander, MD, system's senior vice president for healthcare delivery innovation, acknowledged that space may become an obstacle if their patient volumes increase. 

"One thing we can't do is build a negative pressure room or biocontainment unit overnight," he said. "If we do start seeing a real pandemic, the answer is just going to be doing the best we can."

Education and training

"Hospitals should absolutely make sure that they have confidence in their training for clinical staff who might be expected to care for patients with COVID-19, whether in an emergency department, an urgent care setting or in the inpatient setting."
— Paul Biddinger, MD, chief of the division of emergency preparedness at Massachusetts General Hospital and director of the MGH Center for Disaster Medicine

Continuous education and training is a cornerstone of ensuring high-quality patient care at any given time, but particularly during times of crisis. When outbreaks threaten public health and hospitals are preparing for sudden upticks in patient volume, it is important that staff are at the top of their game and have received training that will help them effectively provide care. 

As hospitals prepare for a swell in COVID-19 patients, they are turning to well-documented strategies to educate staff.  

Massachusetts General Hospital activated its hospital operations emergency plan Jan. 26, according to Dr. Biddinger. The health system initially focused on implementing the CDC's "Identify, Isolate, Inform" guidance with respect to COVID-19. The guidance was first created as a response to the 2014 Ebola outbreak. As part of this effort, the system has increased signage and made sure all front-line and patient-facing staff were trained and given the resources they needed to identify suspected cases of COVID-19. 

Massachusetts General is also focused on implementing well-defined checklists and protocols for how to care for COVID-19 patients. Though COVID-19 and Ebola are very different diseases, the response to the Ebola epidemic taught clinicians that checklists and tools help, as they ensure staff don't forget crucial steps, said Dr. Biddinger. 

CommonSpirit Health developed electronic learning modules for staff, which is an interactive, education-based module that takes about 15-20 minutes to complete, according to Mr. Boukidjian.

"It goes over the background overview of coronavirus, how to identify, isolate and inform," he said. "The education module will ask the individual [questions] to assess their comprehension of what we are relaying. There is an integrated video in that module that shows them how to don and doff personal protective equipment."

Certain departments were required to take the module, such as the emergency department and critical care department, but it was also available for anyone in the organization to take, including those in the dietary and environmental services divisions. 

CommonSpirit Health also made posters for patients and staff that explain the nuances of COVID-19 and how it differs from the flu.

Other healthcare organizations, including Boston-based Brigham and Women's Hospital and Baltimore-based Johns Hopkins Medicine, are ramping up drills and exercises to ensure their staff are poised to respond quickly and effectively to the crisis.

The biocontainment unit at Johns Hopkins Hospital is also conducting a variety of drills, including ones that focus on sharpening even simple tasks. Drills include calling up staff at 6 a.m. and asking them to come in to time how long it takes them to get to the hospital, said Neysa Ernst, MSN, RN, nurse manager of the biocontainment unit.

Brigham and Women's has rolled out a new training program on the proper use of personal protective equipment. It is also continuing to conduct drills on the identification, transport and rooming of patients with COVID-19. 

Supply chain

"Hospitals need to immediately evaluate their supplies to ensure they have appropriate inventories and assess what contingencies [are] available to ensure supplies will not be diminished." 
— Roy Boukidjian, MSN, system vice president of infection prevention at CommonSpirit Health

Shortages of personal protective equipment, including N95 respirators, pose a major concern for health officials and providers working to prevent the novel coronavirus' spread.

In early February, WHO Director-General Tedros Adhanom Ghebreyesus, PhD, said that demand for personal protective equipment was 100 times higher than normal, according to AHA News. By the end of the month, some U.S. hospitals reported only having a one- to two-week supply of N95 respirators left. 

The risk of PPE shortages has also been exacerbated by fearful Americans purchasing large quantities of masks from drugstores and online retailers, which depletes the amount available for hospitals.

Federal agencies are taking proactive steps to help ensure adequate mask and respirator supplies amid these supply chain threats. CMS updated its guidelines March 10, allowing healthcare workers to use face masks instead of respirators as a temporary alternative amid shortages. The FDA is also permitting healthcare staff to use respirators past their shelf life or to use face masks regulated by the National Institute for Occupational Safety and Health during the outbreak.

Mr. Boukidjian of CommonSpirit Health said healthcare organizations must immediately evaluate their PPE supplies and develop contingency plans as needed. Contingencies could include assessing current PPE allocation by contracted vendors or communicating with local public health entities who may be able to provide additional supplies from their own emergency stockpiles.

"It is sort of a matrix response to ensure there is always PPE available," he said.

Other items hospital supply chain teams should keep a close eye on are gloves, gowns, alcohols, face rub and Clorox wipes, according to Dr. Nanda of Keck Medicine of USC

"When each supply item reaches a certain level, our supply chain and materials management team is alerted to proactively place orders for replacements," she said, which allows for a more proactive, rather than reactive, approach. 

Leaders at Scripps Health are closely monitoring N95 and surgical mask supplies by performing daily inventory counts, the health system said in a memo shared with Becker's. Scripps also removed all masks from general care areas to help conserve its supply. Instead, front-line staff and patient service representatives are instructed to offer a mask to any patient displaying respiratory symptoms.

Daniel Uslan, MD,chief infection prevention officer at UCLA Health, echoed the need to limit PPE access from both patients and healthcare workers.

"Start thinking of ways to restrict access to PPE so that it is only used when needed in the hospital," he said. "Staff may take PPE home or use it outside the hospital as a result of worry and anxiety."

Scripps Health also ordered powered air-purifying respirators as part of its advance preparations for COVID-19. The PAPRs serve as a substitute for N95 masks and can be cleaned and reused. 

"We placed an early order for PAPRs and will receive them this week," Scripps Health said in the first week of March. "While these are above and beyond CDC guidelines, PAPRs offer the greatest level of protection for doctors and staff."

Telehealth

"Nothing in the world is easy, but our system of providers involved in our telehealth program has made [our coronavirus response] much easier." 
— Judd Hollander, MD, senior vice president for healthcare delivery innovation at Jefferson Health

Many health systems are relying on telemedicine to both screen and treat patients with COVID-19 to help limit the virus' spread. The technology can also be an effective way for quarantined physicians or other hospital employees to aid in response efforts.

The federal government has also recognized the benefits of this strategy. On March 6, President Donald Trump signed an $8.3 billion emergency funding package to combat the pandemic, including a provision to waive telehealth restrictions for Medicare beneficiaries.

At present, the most common use of telemedicine revolves around screening and triaging potential COVID-19 patients. Many organizations, like IU Health, are offering virtual COVID-19 screenings at no cost to those with symptoms. The goal is to promote social distancing, prevent ED overcrowding and limit the infection's spread by ensuring infected individuals come to the hospital for treatment only when it is absolutely necessary. 

For example, patients at Jefferson Health can video call the system's emergency physicians, along with over 1,000 primary care specialists. If physicians identify an at-risk patient, they connect with Jefferson Health's infection control team, which works closely with the state's department of health to conduct COVID-19 testing in patients' homes. 

Some healthcare organizations, like Keck Medicine of USC, are still working to equip all of their physicians with telehealth capabilities. Having a telehealth program with thousands of providers already involved has helped Jefferson Health tremendously amid the pandemic, Dr. Hollander said, noting the importance of developing a full-fledged telemedicine system before a major public health emergency occurs.

Health systems are also using telemedicine to treat COVID-19 patients in isolation. For example, Lebanon, N.H.-based Dartmouth-Hitchcock delivers telehealth services to numerous health systems, including Bennington-based Southwestern Vermont Medical Center, where an inpatient case of COVID-19 is currently being treated. 

Where we are today

Nationally, 1,701 COVID-19 cases have been confirmed, with 40 related deaths as of 9:30 a.m., March 13. Worldwide, 137,066 cases have been reported, along with 5,069 deaths. Globally, 69,643 people have recovered from the illness.

More articles on infection control:
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14-day quarantine for coronavirus is appropriate, study suggests

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