Girding for the surge: How one system got ready for expected COVID-19 influx
IN THE NEXT FEW DAYS, Erie County in upstate New York is projected to see its peak number of coronavirus cases. The county, home to Buffalo-based Catholic Health, has already been hit hard by the virus, but more patients are expected to fall ill.
As of April 17, more than 2,020 residents had tested positive and 115 had died from the novel coronavirus, according to the Erie County Health Department. Projections indicate that the county will experience its apex of COVID-19 patients on April 22.
While that prospect is daunting, Catholic Health leaders are confident they can handle the surge because of strategic decisions made over the last seven weeks. Since the five-hospital system saw its first COVID-19 patient in late February, operations have dramatically changed to prepare for an influx of cases.
In just a few weeks, Catholic Health set up an incident command center, created a real-time dashboard to track vital supplies such as N95 masks and, perhaps most unique, ceased all operations at one of its community hospitals and transformed it into a treatment center for COVID-19 patients.
“We are trying to take a proactive approach to the COVID-19 crisis,” system CEO Mark Sullivan said.
Catholic Health is among many U.S. systems closely following projections of when their community can expect a COVID-19 patient surge and transforming business in preparation. Healthcare planning consultants say that in this pandemic, preparing for patients—in big or small ways depending on resources—makes sense for any provider organization, or else they risk putting patients and staff further in harm’s way.
“You can’t assume you are never going to see one of these patients,” said Dr. Chuck Peck, a partner at consultancy Guidehouse. While Catholic Health is making large investments, Peck said not all organizations can or should. “There are things that they can do to prepare that will cost some money but won’t necessarily break the bank,” he said.
Also, providers expecting a surge can benefit from lessons learned in cities where one has already taken hold, such as New York and Chicago. “This is hitting the whole country, but it’s not spiking everywhere at the same time, which allows for some great planning options in terms of supplies, equipment or staffing,” said Teri Oelrich, partner at architectural firm NBBJ.
Designing units specifically for COVID-19 patients has become common, but Catholic Health saw an opportunity to go a step further given the low daily census at one of its community hospitals. In a week, the emergency department at St. Joseph Campus was closed and all its space transformed with new units, walls and doors. The St. Joseph COVID-19 Treatment Facility opened March 27.
Designating an entire facility for infected patients allows Catholic Health to deploy relevant supplies and staff to that area as well as prevents its four other hospitals from being overwhelmed, Sullivan said.
When patients who test positive for COVID-19 present at one of Catholic Health’s hospitals, they are transferred to St. Joseph. Those who are too sick to be transferred safely are treated at the hospital where they initially arrived, said Martin Boryszak, senior vice president of acute care at Catholic Health.
While the four other hospitals are experiencing lower volumes due to postponed elective procedures, their EDs are seeing more patients with respiratory illnesses and patients with chronic conditions who waited too long to seek care such as those with diabetes, Sullivan said. After the pandemic recedes, the system
expects a secondary surge of other patients who put off routine care.
St. Joseph now has three zones: green, yellow and red. The structure emulates that of operating rooms, which have designated areas for certain events and where certain personal equipment is worn, said Alyssa Mulhollem, a nurse manager who helps lead infection-control oversight at St. Joseph.
The green area is designed to be a space for clinicians to unwind during or before shifts, with comfortable chairs, food, coloring books and stress balls. No PPE is required because no patients are nearby. Chaplains are also available. “Hopefully by paying attention to these things” levels of burnout can be mitigated, said Rebecca McCormick-Boyle, chief integration officer at Catholic Health.
The green area is also where the staff put on their PPE. Trained members of the OR team observe them to ensure the equipment is put on safely. The system provides staff with scrubs to wear before their shifts as well so staff can easily change back into their street clothes after shifts, Mulhollem said.
The red zones are where the COVID-19 patients are located. There is both a 90-bed intensive-care unit as well as an 80-bed medical surgical unit for less severe COVID-19 cases.
Because all COVID-19 patients are in the same zone, caregivers don’t need to change gowns, gloves and masks as often, Boryszak said. Staffers are practicing extended use, which means they wear their N95 masks throughout their shift.
The yellow zone is designed for transitioning patients from the entrance to the red zone.
Although Catholic Health has established a core team of critical-care specialists, about 1,300 clinicians across the system have volunteered to work in the center. Because some don’t have extensive critical-care experience, a sameday training program has been created that involves how to ventilate a patient, put them in the prone position and other techniques. More than 500 nurses have been trained so far, Boryszak said.
“Even the most experienced nurses sometimes haven’t seen that level of sickness over such a broad population,” he said. “When you get to 35, 40 patients on a ventilator, it becomes daunting.”
Last week, Catholic Health also opened a recovery center for COVID-19 patients healthy enough to be discharged. The system leased a recently vacated long-term care facility and quickly equipped it with supplies and staff.
Sullivan said the recovery center addresses the complicated continuum of care for COVID-19 positive patients. Unlike other patients who can be discharged home or to skilled-nursing facilities right away after a hospital stay, coronavirus patients are likely still contagious and therefore must stay away from others for some time, elongating hospital stays unnecessarily. At Catholic Health, patients now have a specific place to go when they are ready for discharge, which frees up hospital beds.
“We have built a COVID-19 continuum,” Sullivan said. Finding a safe place for COVID-19 patients to go when they are ready for discharge is an issue nationally, Peck said. “They are being kept in the hospital a lot longer—it’s harder to find a place for them to go,” he said.
Field hospitals created in response to the pandemic could potentially serve as an alternative place for COVID-19 patients to go post-discharge, Peck added.
But there are limits to how prepared health systems can be during this pandemic. Some issues are beyond providers’ control like short supplies of PPE nationally.
For instance, testing is a challenge. Catholic Health received about 600 test kits that offer results in about an hour, but the supply will eventually run out. Then the system will be forced to use tests that give results much more slowly. That poses a barrier to the goal of only having COVID-19 positive patients transferred to St. Joseph.
Another concern is the financial toll on Catholic Health. Sullivan said the system “spared no expense” preparing St. Joseph as a COVID-19 treatment center, and it’s spending millions weekly as a result. But he said the investments were necessary, adding, “Our community relies on us to be there, unconditionally, and that is what we are doing.”
But investments preparing for COVID-19 surges are something of a gamble. Much of the country is social distancing, so projections of expected cases might be much lower. “There is certainly some amount of risk” in how much health systems prepare, Peck said.
In fact, Sullivan said, Catholic Health isn’t expecting as many patients as initially anticipated during its peak, likely due to social-distancing efforts.
Some fiscal relief to hospitals will be available through the CARES Act. Hospitals can be reimbursed for COVID-19 investments, and that should help shield them from devastating losses, Peck said.
“The one thing that hospitals should be doing is making sure they are filling out the paperwork for the preparedness relief from FEMA,” Oelrich added. ●