Prepare health systems and hospitals for future surges

Karen Frush, Alison Kerr and Quinn McKenna on preparing health systems and hospitals for future surges

In January 2020, as COVID-19 emerged as a global threat, Stanford Medicine leaders were already monitoring its impact overseas and beginning discussions about a response plan should an outbreak happen in the Bay Area. Stanford Health Care, together with Stanford Children’s Health, the Stanford School of Medicine and Stanford Health Care – ValleyCare, had a robust structure in place to ensure rapid dissemination of information to leadership and coordinated decision-making in emergency situations. The Office of Emergency Management had drafted plans for pandemics that had been used before; clinical leaders and administrators just needed to adjust them for the potential scenario. 

When Santa Clara County asked Stanford Medicine to be prepared for a possible surge of up to 200 COVID-19 patients, a committee of leaders mapped a solution for activating the beds in isolated units, with negative pressure rooms and proper ventilation support. At the same time, leaders were focused on employee safety, which included offering COVID-19 testing and ensuring an adequate supply of personal protective equipment. In just three days, Stanford Medicine established a clinic for employees that could provide evaluation and testing for up to 200 individuals a day.

“I’m proud that we’re caring for our health care workers and employees in order to care for patients and their families — and we’re providing care and support to address physical, emotional and psychological needs,” said Karen Frush, MD, chief quality officer at Stanford Health Care and associate dean for clinical affairs at the School of Medicine.

With the infrastructure in place, Stanford Medicine is prepared to handle future pandemic-related patient surges. Below, Frush; Alison Kerr, chief administrative officer of clinical operations at Stanford Health Care; and Quinn McKenna, Stanford Health Care’s chief operating officer, discuss the details of the planning process

What did Stanford Medicine do first, upon learning of a highly contagious virus overseas that could develop into a pandemic?

Kerr: Our Office of Emergency Management (OEM) is the group of people who are responsible for disaster planning and preparedness, including anything from an active shooter to an earthquake. We have plans for every scenario and a checklist of how we activate our resources, because if something happens, we have to make sure that we are keeping our patients safe and our employees safe. The OEM has an emerging infectious disease/biohazard subcommittee that includes epidemiologists, so we were tracking and trending what was happening in China. We knew the novel coronavirus was out there, and we were following it. We have pandemic plans, but “pandemic” can mean a lot of things. You have to adapt the plan. We used it for Ebola, swine flu and now COVID, too.

McKenna: As things progressed, and we started to see the first cases in Washington, Chicago and then in California, we brought together the adult hospital, the children’s hospital, the School of Medicine and ValleyCare. We very intentionally decided to run our hospital incident command structure through what was called COST, Clinical Oversight Steering Team, which was later changed to CORT, Clinical Oversight Resource Team. It was led by our medical directors, who really adjudicated the facts as we knew it. They helped coordinate communication with our county and our state, and took information from the Centers for Disease Control and Prevention to different internal groups, asking them to translate what it all meant to us.

Frush: COST was originally established to convene clinicians and content experts across Stanford Medicine for the purpose of discussing and addressing pertinent issues related to major clinical events and infectious outbreaks. The pivot to CORT helped to reinforce the tenets of a hospital incident command structure. We pivoted from debate to decisions about operationalizing key practices and policies. To me, that was one key element of our timely and continued response to COVID.

What were early concerns that needed to be addressed in order to be prepared for a possible surge of COVID-19 patients?

Kerr: We’re a Level I trauma center, so we always are prepared for mass casualty events. For those kinds of surges, we have rapid discharges, so any patient who can leave the hospital needs to leave the hospital, and we postpone all elective surgeries. But planning for this particular kind of surge was complicated because there were so many clinical nuances that we didn’t understand and because it was a novel virus, meaning we didn’t understand how virulent it was.

One key consideration was how to manage the availability and judicious conservation of personal protective equipment

We were asked by the county to be prepared to surge to 200 COVID-19 patients, which was double our usual capacity. And so we quickly mobilized. At the hospital command center, we said, “Tell me what you need to get 200 beds active. What are your equipment needs? Your oxygen? Your staffing?” Then our planning group developed plans to execute. In pandemic planning or surge care, you basically develop different models of care, triage models of care, that are outside of usual standards, but allow you to scope and scale expertise in a different way. It changes the fundamental one patient/one doctor relationship to one subspecialist overseeing care for a group of patients or even a unit.

We also ordered 100 more ventilators, knowing that those countries that experienced large intensive care unit surges were challenged with enough capacity. We were blessed in this organization to be able to get equipment, and our supply chain representatives were incredible partners.

McKenna: One key consideration was how to manage the availability and judicious conservation of personal protective equipment. Then there was bed capacity, in particular negative air pressure ICU units, to prevent airborne diseases from escaping the rooms. We needed to figure out how many units we could isolate and how we could provide the ventilation support that was needed for those patients. We also had to figure out how we actually bring patients in when we don’t know if they’re COVID-19 positive — the in-flow from the emergency department.

Overall, we had our leadership — physician leadership, administrative leadership, clinical leadership — in essence working seven days a week. And out of those CORT meetings, the word would come: We need an answer to these key questions today.

What steps did you take to support faculty and staff?

Frush: Occupational health was a huge focus upfront because COVID-19 was a threat to health care workers and other hospital employees, as well as to patients. Personal protective equipment (PPE) is a major part of that, but beyond physical safety there are also emotional concerns: fear, anxiety, panic. So, we collaborated across our traditional occupational health services, the quality department and primary care leadership in the department of medicine to create our Occupational Health COVID-19 response.

Over a three-day period, we stood up the occupational health respiratory evaluation clinic (OH-REC) and the occupational health call center (OH-TEC). We pulled providers and staff from across Stanford Medicine, who had worked in clinics and clinical areas that were temporarily shut down because we were seeing only emergent and urgent cases. The willingness, the flexibility, the camaraderie around forming a new team and doing this to take care of each other, was amazing to see. It was a hugely complicated process to establish a fast-moving clinic where our clinical teams could evaluate 150 or 200 people a day, get results to the right place, and provide confidential and compassionate care and communication.

This COVID-19 occupational health service has remained active. It’s now called HRT, which stands for Health Care Resource Team for the workforce. HRT services are provided under the direction of a medical director and operational leader, and full-time staff are being recruited to work in the clinic for the long term. It’s separate from Stanford Health Care’s regular Occupational Health Service, which continues to provide traditional health services to staff within the adult and children’s hospitals. I’m proud that we’re caring for our health care workers and employees in order to care for patients and their families — and we’re providing care and support to address physical, emotional and psychological needs.

How have you prepared for a future surge of COVID-19 patients?

Frush: We created surge models — we looked at potential numbers of patients and developed an escalation strategy. If we experience a large increase in the number of patients presenting to our hospitals, we’ll need to pull health care workers from their usual assignments to activate additional care teams. So, we’ve been considering various scenarios and planning how we would populate the team, where we would pull physicians and staff from, what number of patients would trigger the need for an incremental team. A comprehensive plan is now built out. We haven’t had to use it, but we have the model and are ready to deploy it if we need to.

McKenna: We have added more inpatient capacity than we had before. We’re prepared to flex as we go into flu season. If we experience a surge in cases, we can go up to 200 beds for COVID-19 patients. I don’t think we would need to shut down elective cases entirely; we’ll just be able to titrate within this 600-bed capacity.

We’ve got all the pieces on the table, including the pieces that will help us adjust and adapt if something new comes up through CORT. We’ve proved that we can come together, all of Stanford Medicine, get the right information and charge the right teams in a very quick and rapid process.

Could flu season bring a surge related to the pandemic?

Kerr: If people have flu-like symptoms, they’re going to be afraid that they have COVID-19. So, what we have been doing is very intentionally planning for flu season. We have a whole plan around managing telephone calls, getting more video visit capabilities and making sure people don’t run to the emergency department. We’re also strongly encouraging everyone to get a flu shot.

Influenza symptoms and COVID-19 symptoms are very similar, so we are going to have to treat every patient as having COVID-19. Until they get their COVID-19 test results, you have to assume that they are infected, so you’ve got to have your N95 mask on. You’ve got to have all your PPE.

How have you managed decision-making in an evolving situation with so many unknowns?

Frush: We agreed early on that we would make decisions for the next couple of days, but that we weren’t able to make decisions for the next six months or the next year. As we did all this, we were also evolving our own strategies for operating in a rapidly changing environment, literally day to day. It was basically rapid-cycle improvement the whole time.

McKenna: We could always point back to the fact that we’ve maintained safety of our employees, our physicians and our patients. When you look at the testing we’ve done of our employees, the asymptomatic infection rate is extremely low. At the end of the day, we felt comfortable saying you can trust the process.

Kerr: You have to be very comfortable making decisions without a full complement of information and in times of chaos. Stanford Medicine rallied around this particular challenge, developed a structure and a plan, and then executed well. We continue to adapt our plans as information changes over time.