April 14, 2020

How University Hospitals is managing Covid-19 'micro-surges'—and planning for what's next

Daily Briefing

    Daniel Simon, MD,  President of University Hospital Cleveland Medical Center and UH Chief Clinical and Scientific Officer, recently spoke with Steven Berkow, Advisory Board's VP of Provider Research, to discuss the Cleveland, Ohio-based system's emergency planning for the new coronavirus epidemic and the steps needed to begin re-opening their health system to non-Covid patients.

    Your Covid-19 checklist to expand capacity

    Question: Thank you so much for joining me. I'd like to start off by getting a sense of where you are in the curve today. How many patients are sitting in your beds?

    Dan Simon: At our peak, we had just over 110 Covid-19 cases in all of our beds. That's now down into the seventies. We're actually in very good shape on bed capacity at this point, some might even argue too good. Across our 12-hospital system, we've got about 1,700 beds. With the deferral of elective care, especially non-essential surgeries and procedures, our occupancy rate right has fallen to 50% to 55%, for both inpatient and ICU beds.

    Of course, there's variation throughout the system. Some of our community hospitals have lower occupancy rates, but they are also managing local flare-ups. At one point, one of our community hospitals in a high international travel zone had 10 intubated patients and more Covid-19 patients than our academic medical center. More recently, we had to care for a spike in Covid patients at the federal prison in Columbiana County. I'm also very concerned about flare-ups in our nursing homes and a large Amish population we serve in another county, who continue to gather to a certain degree.

    But overall, we're not seeing the mass influx of patients that hot spots like New York are experiencing. We're in a different crisis management phase. Statewide, we have no bed shortage, including ICU beds, and overall adequate ventilators. Our challenge is to guard against micro-surges and make sure we have the needed resources wherever they pop up.

    Question: That's a pretty striking contrast to stories coming out of Michigan, your neighbor right next door. What's accounting for the difference?

    Simon: I can't speak to Michigan; every state is facing different factors. What I do know is that Gov. Mike DeWine's quick calls for social distancing and canceling elective surgeries and procedures really helped flatten the curve here in Ohio. UH Medical Center actually had the first three cases in the state back in March. I remember this vividly. I was sitting at a press conference at the Mayor's office on March 9 when I got the call confirming the first three cases at our hospital. DeWine declared a state of emergency for Ohio that same day.

    The governor's order established four criteria for essential surgeries and procedures that we're still working within: life-threatening, organ- or limb-threatening, risk of cancer upstaging or metastasis, or time-sensitive progression of disease and symptoms. The Medical Center was at 95% capacity in early March. Almost immediately, we saw a 60 to 65% degradation in total surgeries across the system.

    The impact of the governor's order has been dramatic on flattening the curve here. Between March 10 and 15, our daily case growth rate was 30 to 40%. That's now down to 8 to 10%.  

    Question: Let's continue our focus on UH's responsive—and preemptive—actions in early March. At what point did you launch your own emergency preparedness plans? And what did those look like?

    Simon: I actually started co-leading a multi-disciplinary coronavirus preparedness team back in February, so before we had our three confirmed cases and the governor's declaration. We're not a hurricane city. We're not a flood city. We've never had a pandemic before. So we didn't have a plan sitting on the shelf. The team included everyone, from operations to logistics to planning, supply chain, finance, marketing, PR, and more. And by early March, we had our plans in place.

    We officially flipped the switch from preparedness planning to a system-level hospital incident command structure (HICS) led by Eric Beck, DO, UH Chief Operating Officer, right after the governor's order on March 9. But we were already on the cusp of this decision based on our own analysis of how fast things could possibly move. The order was more final straw, than catalyst.

    The change in how we function is sizeable. The system-level command group meets twice a day, every day, and everything is carefully coordinated in a top-down manner right now according to HICS practices. For example, the operational lead has about six people reporting up to her, including ambulatory, academic medical center, east community medical center region, and west community medical center region community. The next level down in the reporting structure is the hospital presidents.

    Question: How is this different structure helping at the frontline? Are you shifting resources real-time to deal with micro-surges? Or better ensuring you have sufficient resources spread across the system farther out in advance?

    Simon: Both. Our incident command team includes very experienced disaster team leaders. Under their direction, we've created plans to surge to 100%, 200%, and 300% capacity, and tabletop tested each of them in about 14 days. These plans provide for movement across the system of ventilators, PPE, acute care teams, and other assets for all three scenarios—whatever our individual facilities need.

    For example, we've got a system-wide nursing pool of 1,200 to 1,400 and, in the last few weeks, we cross-trained 700 nurses who were doing elective surgery and other procedures to staff inpatient medical units, ICUs, and our EDs. We can mobilize these team members wherever needed.

    We also have contingency plans to add beds through field hospitals in different areas. For example, we can get an additional 250 beds by standing up a field hospital at the indoor track of Case Western University, and then we'd look to the Division 3 men's and women's basketball arena. But right now these are just ready-to-go plans. Based on the numbers we're tracking, I'd estimate there's a less than 5% likelihood of our needing field hospitals, unless there's an unforeseen disaster.

    How are hospitals handling a PPE shortage?

    Berkow: We've talked about your ability to flex staff and it sounds like you're well positioned on beds and vents. What about PPE?

    Simon: That's a critical question. PPE, and particularly masks, is where we're stressed. We have three levels of PPE use: conventional, contingency, and crisis. Even with roughly half our beds empty, we are in contingency. We'd love to be masking every caregiver and patient in the system with surgical masks, and giving frontline staff N95s. But that would be 200,000 masks a week, and we just can't do that right now.

    We just started distributing DIY masks sewn by amazing community supporters for non-frontline caregivers. We are asking our staff to wear face shields and reuse their mask unless visibly contaminated. Again, we just don't have a big enough supply to change masks after each patient encounter. Fortunately, we are standing up an in-house N95 re-sterilization capability in collaboration with Steris.

    Our UH Ventures innovation team has been leading an "Alternatives Task Force" that has started sourcing 3D printed PPE such as eye protection and non-health care sourcing via industry partnerships with local homemade PPE manufacturers, and accelerating new technologies to support our frontline effort.

    Covid-19 emergency preparedness planning guides

    Question: So with the exception of masks, it sounds like your system is feeling relatively good on emergency preparedness. Looking ahead, when might you relax incident command mode? Have you started to think through how to re-open your doors to patients who have deferred care?

    Simon: We actually just started our recovery and reactivation planning a week ago. It's still in the early stages, but we're going to rely on the same incident command structure to lead us through recovery. The reason for that is two-fold: first because of how certain funding streams work under FEMA and second because of accepted best practice for disaster recovery.

    So that team is starting to think through various questions like: Which patients get to come back first? Do we need to operate seven days a week? Should we go from 10-hour days to 12- to 14-hour days? If so, how do we staff for this? And should we have Covid and non-Covid facilities moving forward given anticipated resurgent cases?

    It's not just about how fast we can safely ramp back up. You also need to consider the patient perspective. While many patients are no doubt eager to resume their care, others may be hesitant to come back in. We've seen a number of patients, who I believe met the criteria for essential care, nonetheless postpone surgeries out of fear of potential exposure. We're going to have to figure out what's needed to make our high-risk, non-Covid patients feel safe.

    We've already started doing this for our cancer patients. Until recently, we isolated our freestanding cancer hospital to keep treating non-Covid cancer patients aggressively. But we now have a few cancer patients who tested positive for Covid-19 overdue for infusion therapy. So across the past couple of weeks we created a separate, negative pressure infusion therapy room just for these patients.

    But the gateway for all of this is Governor DeWine lifting those restrictions on non-essential care, and I'd be surprised if that order comes before mid-May to June 1. All non-essential care will remain on hold until the governor feels we have sufficient capacity to cover any microbursts of Covid-19 and do elective procedures. In many ways, this all comes back to PPE. We're struggling with PPE shortages at 50% capacity. We're going to need additional sources of PPE to fully open our doors for elective surgeries and procedures.

    Question: I know we're getting close on time here. With the benefit of hindsight, is there anything you would have done differently across the past several weeks?

    Simon: In hindsight, I would have built up a pandemic supply of PPE—and that's something I think you'll see more of in a post-Covid-19 world. Testing is another area where we would have benefited from a jumpstart. We're currently completing 400 tests per day, up from 100 when we started, but it's not enough. For instance, we're still not testing patients at home with say a fever or cough but no risk factors. We want to be testing everybody. Hopefully we'll also be ready to quickly scale antibody tests once we have a good one.

    Question: Do you have any final lessons or observations you'd like to share with peer executives across the country? What has shocked or impressed you the most during this crisis?

    Simon: Honestly, our staff and peers in the medical community have been amazing. While unimaginable 6 months ago, this has been an incredibly inspiring time to be a leader here. All of our staff have stepped up. Staff in areas that we've shut down have been eager to retrain or find a way to work and support the system. We've tried to meet this energy by neither cutting salaries nor furloughing anybody, and I think a lot of our staff appreciate this.

    More broadly, it's amazing how much we're learning from others in the medical field right now, including our peers in Asia and Europe who had a head start confronting the disease. That's the beauty of medicine, clinicians solve problems by learning from each other.

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