On March 14th, Michael Wagner, Chief Physician Officer at Wellforce, published an article urging health systems to proactively cancel elective surgeries amid the new coronavirus outbreak, “COVID-19: Should hospitals proactively cancel cases before they see an influx of COVID-19 patients?” Wellforce is a multi-hospital health system, including Tufts Medical Center, which serves Eastern Massachusetts. Wagner recently spoke with Steven Berkow, Advisory Board Vice President of Provider Research, about how Wellforce is re-purposing capacity created by surgery cancellations and other health system strategies to meet the demands of COVID-19.
Question: Michael, thank you for taking my call with all the pressures on your time. You've been out in front on the cancellation of elective surgeries to free up capacity. Can you walk me through Wellforce's decision here?
Wagner: Absolutely! There were two key factors that led us to proactively cancel any surgeries that could be safely deferred. First was the preservation of PPE (personal protective equipment). We are starting to go through what looked like a month's supply of PPE in a matter of days. By canceling elective surgeries, we have conserved PPE, though not a huge amount—but every bit counts right now. Second was conservation of bed capacity and ICU capacity in particular. We wanted to minimize any patients in beds for prolonged care associated with elective or deferrable surgeries—and we wanted to do it fast. You also have to remember that a typical large medical center has a high degree of foot traffic and may, in a typical year, have well over one million visitors. Cancelling surgeries and cases assists in social distancing and protects staff you will need when the surge hits.
Q: What's your gameplan for re-purposing capacity freed up by cancelled surgeries?
Wagner: Right now we’re focused on how best to re-purpose our PACU (post-anesthesia care unit), ORs, procedural space, short stay units and any other units appropriately outfitted with gases and other basics. But you've got to plan beyond the physical beds and anticipate your needs for ventilators, replacement staffing, and other equipment. And even if you free up all of your traditional inpatient locations, you then must look beyond your traditional locations to large spaces outside your organization, including large auditoriums, gyms and spaces that can be used as makeshift hospitals..
Q: Let's go back to the first factor you mentioned: PPE. We're hearing more and more stories about the speed at which hospitals are going through PPE. Where's the crunch hitting you first?
Wagner: It started with anticipated shortages of N95 respirators, the fitted masks that stop respiratory pathogens. But now that regulations have been relaxed to allow use of surgical masks that prevent transmission from droplets, we are anticipating shortages in those as well. This is a huge stressor for our frontline staff. They see our mask supplies being conserved and know that we may not be able to replace them from our suppliers.
But there has been one bright spot here. We've reached out to our larger community for available masks and gotten helpful donations from local biotech companies, construction companies, and testing labs. I encourage health systems to let area businesses know what supplies they need. We get stories every day of some company dropping off a box of 1,000 masks they realized they were just sitting on.
Q: That's heart-warming to hear. When you reflect on the last week, what other recommendations would you offer your peers in areas a bit behind Massachusetts in community spread, clinical executives in states like Montana or West Virginia, about what they should be doing right now to prepare?
Wagner: One recommendation is to shore up your supply chains for PPE and try to conserve whatever you currently have; it will go fast when you get COVID patients. Also, do whatever you can to source ventilators. In terms of additional ICU capacity, have beds set aside and ready to go—assume your ICU volumes may need to double, if not triple, during this surge period. After social distancing and flattening the curve, ICU capacity will be the single most important determinate for ensuring patients survive the acute illness.
The other big thing is telemedicine. If you haven't got your telehealth up-and-running, get it up-and-running because you're going to have a major disruption in your ambulatory and physician practices, as soon as this starts to unfold. We were able to quickly use our online platform "online connect" with American Well. In seven days, we have trained and are now on pace to have 1,000 providers ready to use the platform for providing care. We have completed around 250 tele-visits and anticipate that number will skyrocket in the coming weeks.
Q: Let's shift to staffing. Massachusetts has been in the forefront of thinking about things like loosening up credentialing and licensing requirements. Have you had a moment to take action on these changes, to build up a network of on-call nurses and doctors?
Wagner: Currently, all of our hospitals have plans in place in terms of the allocation of physicians, including where they work and credential changes. We're starting to put together lists of physicians and nurses who recently retired, or stopped working but are still in the community, and ready ourselves to rapidly reactivate them. For some, you may need to quickly fill knowledge gaps. One of our physicians just reached out to the Society of Critical Care Medicine, which has excellent modules on ICU medicine and has been generous in opening up their resources to help get doctors and nurses back up to speed.
Q: One last question—your system includes multiple hospitals and other care sites. How are you thinking about combatting COVID-19 across the region? Have you done anything to break down the facility-based silos that still plague us in health care to do things like quickly shift PPE and other resources from one site to another?
Wagner: That was one of the first things our system CEO asked me when planning ramped up about two weeks ago. Soon after, the CEO of Tufts Medical Center, our AMC, was asked to take charge of the incident command structure for the entire three hospital system. This past Monday, we activated a system-level incident command; we meet every day and have already built out a number of key sub-groups from this daily meeting. We've brought together the infectious disease epidemiology folks to standardize our policies and procedures on our PPE and separation of COVID-19 patients. We've put together and implemented a series of HR polices at the system level because this is going to challenge us from a HR perspective.
So this is really advancing our system development, and we've leaned into that opportunity. All our leaders recognize that our separate parts must do things in a common way to efficiently respond to the pandemic at hand—and that we've got to get on one page right now. We have a moral obligation to our patients to figure out the right way to get where we need to go, and make that happen.
And I'd push that the concept of systemness be taken to the next level. There's a compelling argument that we need a consolidated regional incident command structure that brings together all area systems. In particular, I worry about the vulnerable and underserved populations in our community. If we don't come together with a more organized incident command structure at a regional level, we will miss the opportunity to respond in the right way to make sure everyone has the best access to care and to get through all of this.