On April 10, 2020, a COVID-19 educational webinar hosted by Dr. Anna Loengard with Caravan Health featuring rural health leaders revealed a number of innovative strategies developed in response to the pandemic.
Below are summaries of those ideas.
- Leadership, Structure, and Administration
- Partnerships – Sharing Resources, Knowledge, and Patient Care
- Outpatient Screening and Testing
- ICU Staffing and Challenges
- PPE and Other Equipment
- Telehealth and Outpatient Services
- Community Outreach and Home Monitoring
- Optimizing Primary Care Downtime
Tim Putnam, DHA, MBA, FACHE, President and CEO, Margaret Mary Health, Indiana
Margaret Mary Health is a critical access hospital with 25 beds, traditionally with 80% outpatient and 20% inpatient services. Since their first COVID-19 case on March 13, the facility has converted to 20% outpatient and “250%”
inpatient services. Their surge plan allows for 68 beds. So far, they’ve had up to 30 patients admitted with COVID-19 symptoms with at least six patients on ventilators simultaneously, an atypical number for their facility. Patients have remained on ventilators for an average of 10-14 days.
Patrick Robert Anderson, MD, FACP, Medical Director, ACO & Medicare Advantage, Reid Health, Ohio
Reid Health is located in an Ohio hotspot. Leadership started a COVID 19 hotline on March 1, and within two weeks set up processes/policies for personal protection equipment (PPE) and employees returning to work after illness; instituted an emergency command structure; and fit staff for PPEs. Incident Command started a surge plan and began screening all visitors. On March 15, Reid had its first COVID 19 case in an outlying clinic, which left eight personnel exposed. That clinic had to close.
Reid repurposed some floors to a containment unit for patients with COVID-like illness. They didn’t wait for test results; if patients were negative for flu, they were COVID 19 until proven otherwise. Maximum capacity of the facility is 225 patients. Currently, there are 158 people in the hospital, one third are COVID 19 patients. Of those, eight are intubated and 10 patients are in the ICU. There have been 10 deaths to date.
Edwin Carmack, MD, Medical Director, Value-Based Care at Confluence Health, Central Washington
Confluence Health is a health care system located in north central Washington, approximately two hours east of Seattle. With Seattle as an early COVID-19 hotspot, Washington State shut down before other areas. This situation gave Confluence forewarning and early resources in terms of knowledge.
The hospital is licensed for close to 180 beds and typically runs a census in the 120-bed range. They staged a plan for floors and the ICU. The plan included sending medical patients to their smaller hospital about a mile away if the main hospital needed to transition to a COVID-19 facility. Provider and staffing models were included in the plan.
Initially, they tried to cohort COVID-19 patients on one hallway of one floor, but there wasn't a clear area designated for COVID-19. They transitioned to split the ICU to COVID and non-COVID, which preserves PPE and staff stays on one side or the other.
Leadership, Structure, and Administration
Putnam: As the volume and intensity of COVID-19 hits a facility, administrators need to ensure that hospital leaders are well-suited for what they are being asked to do. This crisis has been overwhelming for many people in health care and with so many professional and personal factors in play, it makes sense that some may take on the pressure better than others. Administrators might consider reorganizing roles, even if temporarily. Overall, staff are scared - not about giving care, but about taking it home to their families.
Anderson: From a risk management perspective, administrators need to keep track of decisions and document those decisions in print. Situations may arise where employees feel they weren’t protected. Or, someone in the community may decide to pursue legal action against a facility for issues, such as restricting visitors even as loved ones die. In addition, since situations can become challenging on the front line, leaders might consider having security at screening sites. Declaring emergency status early on is also necessary for risk management.
Carmack: Confluence leaders participate in the Washington State Medical Association’s weekly phone call, which includes ICU providers from across the state and the University of Washington. The group shares what they're doing; their practices; and how they approach different patients, such as the timing of tracheotomies. Confluence is also able to access research studies as they come online.
With workflow support from the State and Department of Health, their medical triage committee will lead the decision-making process if ventilator allocation becomes an issue. The surgery adjudication committee decides if a surgery is required or not for cases in the middle.
Partnerships - Sharing Resources, Knowledge, and Patient Care
Putnam: Early on, two of their four OB/GYNs went out on the same day. Margaret Mary found providers from other community hospitals willing to fill in. Within the past few weeks, those types of partnerships expanded to include several community hospitals and a formal organization. Their discussions: How do I help you through this? During the pandemic, there has been no sense of competition.
For Margaret Mary, the volume of patients exploded at one point, which was especially challenging since patients stay for a long period of time. They reached out to other facilities and were able to share the load. Each facility realized that surge times will vary, and they need to help each other when they can.
While there's no payment model for it, they all committed to doing what is best for patients. They developed an algorithm to determine when a patient was transferred and when to return. The focus is on the most critical patients who are about to be weaned on or off a vent.
This helps medical staff because many outpatient physicians feel better taking care of a patient who’s not on a vent and recovering than they do caring for a patient on a vent. This also allowed leadership to better plan the expansion to 70 beds, knowing the type of training physicians and nurses will need.
Outpatient Screening and Testing
Anderson: High wind made initial tents for testing and screening unusable. So, they developed a drive-through system and repurposed buildings at the same location. Patients do not require an appointment for screening/testing. One of the buildings serves as a respiratory clinic. If patients are deemed sick enough, they are sent to this clinic. Currently, patients are not given appointments in primary care offices. If they have respiratory problems, patients are sent through this screening process and then possibly into the respiratory clinic
ICU Staffing and Challenges
Anderson: There is a no visitor policy in the hospital right now. The sadness is overwhelming as people are dying without their family members. Reid Health is fairly advanced electronically and they do help patients FaceTime with family members. It cannot replace in-person presence, and this has a dramatic impact on patients, families, and staff.
Carmack: The challenge has been staffing in the ICU. Hospital floors are fairly slow since there are no elective procedures. The ICU is running a census around 18 and can go up to 20 beds. The stage plan could go up to 42 beds. Currently, it's not the number of patients in the ICU that is the challenge, but the intensity. Most patients in the ICU have COVID-19 and these patients typically stay on ventilators for 10 to 14 days.
The Confluence ICU typically has a hospitalist there all day and pulmonary critical care support in the morning. They now have two hospitalists and a pulmonary critical care physician all day. Their anesthesiology group provides additional support for turn teams, intubations, and other procedures.
A model was also developed for one ICU nurse to supervise two or three other nurses. This extends the ICU nurse’s abilities. There hasn’t been a need to fully implement that model yet but practicing ahead of time is important. Confluence increased staffing of all people that serve the ICU from the environmental services team to pharmacists.
Many COVID-19 patients are paralyzed and need to be placed in the prone position for part of each day. The process is staff intensive since they don’t have a rotating bed. It takes six to eight people to do this manually, and it’s done twice a day.
To avoid taking ICU nurses away from other patients, staff from outpatient departments that were not busy, such as ophthalmology, orthopedics, and urology, were asked if anyone would be willing to serve on the proning team. Those willing needed the ability to lift patients, not be high risk, and able to care for patients with COVID-19. The team was trained and fit tested. An anesthesiologist is part of the team to manage the airway. The team comes to the ICU for two hours, at set times, twice a day to turn patients from supine to prone positions.
Initially there is an anesthesiologist and a respiratory therapist on the team. Anesthesiologists are more often used to proning people in the operating room, but the approach is different for patients with Acute Respiratory Disease Syndrome (ARDS). Once the anesthesiologist is comfortable with this ICU role, the RT leaves the prone team and is free to work with other patients.
Community Outreach and Home Monitoring
Anderson: Reid Health reached out to jails and prisons in the area to communicate the importance of protecting guards and inmates since it cannot handle a deluge that could occur in confined situations.
They also expanded home monitoring with their home health partner. Since many patients don't want to be potentially exposed, Reid extended more home health care for their very elderly community. Case managers supervise home monitoring and help Reid prioritize patients who need telemonitoring.
Carmack: Confluence reached out to subacute patients and assisted living and independent living partners in the community to ensure care in those areas and avoid overwhelming the hospital. Efforts included sending oxygen concentrators, if people just need oxygen they can stay in their facility. Confluence also added extra providers to home health and hospice teams. If patients are diagnosed with COVID-19 and aren’t doing well, the team goes out to discuss goals of care. There were several patients who were transitioned to hospice without coming into the hospital, which helps them and the system.
PPE and Other Equipment
Anderson: Reid sees inventory management as a crucial part of this process. They were fortunate to receive federal funds after 9/11 and had a stockpile of N95 masks. They keep track of those on a daily basis. Plastics companies in their area have been making face shields for them. Inventory management also includes how many ventilators, beds, and negative airflow rooms are in use.
Reid declared an emergency early on and documented those steps in terms of hospital billing. They have a daily dashboard of testing done in outpatient, emergency room, and inpatient settings. They are in the process of trying to repurpose HVAC to create more negative airflow rooms.
Putnam: Team members were asked to store masks in bags with silica gels in case masks can be reprocessed. If they eventuality run out, they have those in reserve. The community was asked to sew homemade masks using a standard design that allows for a filter and nose piece. They now have hundreds of homemade masks. It made the community feel part of the solution, which is important in a small town. Dental and veterinarian offices also donated masks and gowns.
Carmack: The PPE supply has been okay, but they are somewhat concerned about the supply of surgical ear loop masks for droplet precautions. They are trying to save as much as possible and are investigating ways to sterilize in N95 masks to reuse. Confluence uses an outpatient and inpatient PPE committee since recommendations change and need to be communicated quickly.
Outpatient Services and Telehealth
Anderson: All patients who want to be seen are screened. Respiratory problems are referred to the respiratory clinic. Patients can still come into the office, but the process is different. Staff give patients a mask, take vitals, and proceed to telehealth services to see a provider. The provider does not meet in person with the patient but uses vitals and chart prep from support staff whenever possible. The goal is to serve patients while limiting exposure to providers and staff who are needed on the frontlines. Use of telehealth also helps to continue revenue streams.
Carmack: To address disruptions to outpatient services, they quickly ramped up telehealth services. Initially, they were doing more telephone visits, but within a week moved into using Epic My Chart as the basis for telehealth visits. There have been some struggles with that technology. As they work through that, they also use alternate approaches. There are challenges on the patient side as well, particularly with Medicare-age patients who struggle to use the technology on their end. This is being addressed and telehealth use continues to be high.
Optimizing Primary Care Downtime
Carmack: While facilities deal with addressing resource needs and challenges on the inpatient side, some outpatient services are not busy enough. They have asked providers to look at other issues with hope it pays off later. Before COVID-19, leaders were trying to get a problem list cleanup initiative off the ground. Now with time available, a tip sheet was sent to providers with guidance to clean problem lists. Their chief medical information officer also had one-on-one sessions to make providers in each department experts in problem list clean up. Those providers are teaching others in their departments. The hope is to get more HCCs onto the problem list that will then be captured later in the year.
Population health RNs in outpatient case management were redeployed to other areas, which hollowed out annual wellness visit processes. Providers were encouraged to do annual wellness visits via telehealth and used Caravan information to support the process.
Community Support and Challenges
Putnam: There has been an outpouring of support from the community, especially with sewing masks. However, fear and anger about testing for, and spreading, COVID-19 is a challenge. Visitor restrictions have created an especially stressful environment.
Anderson: There have been some negative experiences with patients, such as someone trying to take masks and posting threatening comment on social media. On a positive note, there has also been tremendous support. Early on, the entire regional EMS team, including police and firemen from about five counties, came to the hospital in their vehicles and set off their alarms, sirens, and lights as a show of support for hospital workers. Later, community members drove by and showed their support, including chalk designs on sidewalks outside the hospital with colorful signs of support.
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