April 9, 2020

'Preparing for a disaster': How Dignity Health is navigating the Covid-19 epidemic

Daily Briefing

    Richard Carvolth— Chief Physician Executive of Dignity Health, a six-hospital health system in California—recently spoke with Taylor Hurst, a Senior Consultant at Advisory Board, about how Dignity is enacting disaster preparedness strategies to protect its workforce and deploying their expanded testing capabilities.

    New: Covid-19 emergency preparedness planning guides

    Question: Thank you for taking the time to speak to us today, Dr. Carvolth. Let's start with planning—as you saw the epidemic unfolding elsewhere, what did you proactively do at Dignity to prepare for a surge of patients?

    Richard Carvolth: While we didn't see our first confirmed Covid-19 patient until about three weeks ago, we've been closely monitoring the epidemic since January. We've been approaching the epidemic as a disaster, but have modified our standard disaster preparedness approach to meet this particular circumstance.

    One of the first actions we took was about six weeks ago, when we stood up a command structure at each of our hospitals in addition to a centralized division-level command center. We developed template surge plans that were tailored to each hospital's unique needs and community. Now we're in the process of amalgamating those plans at the system level. We also perform daily, system-wide updates on the number of Covid-19 positives, persons under investigation (PUIs), and available ventilators and ICU beds.

    Q: It sounds like Dignity decided to look locally first then work your way up to the system level. Are you taking a similar approach to staffing preparedness in the event of a surge?

    Carvolth: Yes, that's right. We're anticipating staffing to be a critical factor if we see a surge that stretches capacity. We are doing basic ventilator training for a lot of our physicians and nurses who are trained in internal medicine and have taken care of ventilated patients but haven't actually run a ventilator themselves.

    We're also looking to deploy team-based care across the hospitals in med-surg and the ICU. While a typical ICU doctor can take care of about 15 patients, we can dramatically expand that number by adopting a team-based approach. In the event that we need more staffing flexibility, we're categorizing the skills and competencies of each of our ambulatory providers who are seeing lower patient volumes right now.

    The key to all of this is adequate training. We've had a number of training sessions at our facilities to bring doctors and nurses up to speed to treat Covid-19 patients. And we've been able to make great use of our state-of-the-art simulation lab, which we just stood up this year, to complete a lot of the training.

    Q: I know testing has been a hurdle for many health systems. How has Dignity approached testing over time?

    Carvolth: We have been at this for about three weeks and we've seen testing speed evolve. Initially, we struggled with testing because we were relying on different local health departments and the transit times were very long. But now we have good testing capabilities through our work with Abbott and Cepheid, and we're able to turn tests around in just minutes in some case.

    Q: A lot of hospitals are eager to gain access to the Abbott tests because of the quick turnaround time. Who would qualify for that rapid tier of testing?

    Carvolth: We're prioritizing our highest-risk patients for the Abbott five-minute test. Those include admitted inpatients, ED patients pending admission, active labor patients, trauma patients, stroke patients, and other patients who can't provide an adequate history for us to assess their risk level.

    We're continuing to use the standard testing method for patients who exhibit Covid symptoms but don't have other risk factors.

    Q: And are you including clinical staff into the group that is eligible for rapid testing?

    Carvolth: Physicians, advanced practice providers, and other providers that are in a critical staffing areas would fall into the Abbott testing category.

    For everyone else we're using the Cepheid system, which has a turnaround time of a few hours. That encompasses non-critical care staff and employees who have had Covid-19 exposure, particularly those who could potentially come back to work. We also group some patients into this testing tier, such as patients who are ready for discharge.

    Q: So let's take a step back and revisit staff. You've been in various planning stages for several months now, and actively treating patients for about three weeks. How are staff holding up? Are there any specific supports that you all are putting in place for staff to bolster resilience?

    Carvolth: I think preparing the workforce is especially important. There's a lot of fear among staff, so managing their anxiety, giving them support, and making sure they understand the science and methodology behind everything we’re doing is essential. In this type of disaster, you need to be doing more than just the logistical management—there's also the human element that leaders need to account for. 

    One big lesson learned for us was in managing staff anxiety around PPE. We didn't like the concept of cloth masks at first, but eventually with shortages we didn't have any other option. We've put systems in place that allow staff to safely bring in PPE from home—but in hindsight, I think our response there was too slow. Getting ahead of that curve is critically important, otherwise your staff might jump to the conclusion that you don't care about them and their safety.

    Having mental and behavioral health support services is also critical. We recently set up a home health service connection for our physician providers. We have a couple of physicians who tested positive for Covid-19, and a lot of our physicians take care of themselves instead of having their own doctor. To help them access appropriate care, we've set up a home health outreach program that we can scale if we end up with more Covid-positive physicians.

    Q: Based on your experience, what should organizations do now to prepare for the Covid-19 surge?

    Carvolth: First, if you have the luxury of time, you should prepare. This is a disaster, which means all elements—from supply chains to staffing to care coordination—will be impacted. Once cases start to appear, it's too late.

    The second piece is determining how you will manage canceled surgeries and the impact that will have down the line. The effect of canceled procedures on the independent physician community is huge, and many of our independent doctors are struggling to maintain their overhead. So we're just now starting to look at what Covid-19 recovery would look like for them and assessing how we can help sustain our physician community through that process.

    Finally, don't forget to learn from the experience of others, because none of us have been through this before. We've learned a lot from organizations in the northwest, and will continue to share our lessons learned with others.

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