By Virginia Reid and Taylor Hurst
Montefiore Medical Center, an 11-hospital system headquartered in the Bronx, is at the epicenter of New York's Covid-19 surge. When reviewing early projections, leaders realized they would need to repurpose nearly every inch of their system into an ICU to care for the anticipated influx of critically ill Covid-19 patients. Knowing they wouldn't be able to physically expand their ICU quickly enough for the surge, they focused on scaling one of the most crucial elements: critical care expertise.
Your Covid-19 checklist to expand capacity
To do so, leaders from across Montefiore came together to stand up a critical care and pulmonary command center (from scratch) that provides virtual support to staff caring for critically ill Covid-19 patients across the system. And, they did it all in just two weeks.
To learn more, we spoke with the team who got the command center up and running. Below, see how they moved from their initial idea to a command center with a 1:50 critical care physician ratio—and their advice for other organizations that want to do the same.
The goal of the ICU command center is to provide on-demand critical care expertise and support to units across the Montefiore system. Any clinician working in the Montefiore system can call into the 24/7 command center for immediate advice on a Covid patient from a board certified critical care or pulmonary physician who sits at the main campus. In addition, critical care physicians in the command center conduct virtual rounds at remote ICUs with the clinicians at the bedside to ensure that acutely ill patients can benefit from the expertise of Montefiore’s team regardless of their location.
Beyond the ICU, hospitalists caring for patients on ventilators can consult with a command center pulmonologist on ventilator management from anywhere in the system, 24 hours a day. When a patient needs hands-on critical care support, the centralized command center dispatches a physician to provide in-person emergency assistance. The team recently layered in remote monitoring capabilities for patients who are waiting for staff to admit them to an ICU, and physicians in the command center can page staff on the ground in the event that a patient becomes high-risk.
To get the technology up and running, the team added functionality into their existing EHR and upgraded their servers so that physicians at the command center have a universal view of dozens of patients’ clinical data at once. Most recently, the bioengineering team linked the command center to a central monitoring system across all ICUs so that critical care physicians in the command center can see real-time vital signs, ultrasound results, and electrocardiograms of ICU patients to develop a plan of action. To access video and audio capabilities without the investment of installing mounted cameras, the team purchased and distributed iPads to ICU staff so they can connect with the command center over FaceTime.
In addition to centralizing critical care expertise in the virtual ICU command center, Montefiore proactively redeployed staff and shifted spaces to expand critical care capacity across the system.
The system started by repurposing staff with latent capacity to work in critical care units, where critical care attendings lead teams of internal medicine residents and fellows. At other sites, anesthesia and general surgery teams familiar with breathing management work with hospitalists and internal medicine physicians to care for Covid-19 patients. Respiratory therapists train anesthesia techs on ventilator management and maintenance. Other staff, including occupational therapists, physical therapists, and security officers, lend a hand with proning with the oversight of a clinician.
To create more physical space for Covid-19 patients, Montefiore repurposed PACUs, ambulatory surgery suites, step-down units, GI suites, and pediatric hematology beds to ICU beds.
The ICU command center has been up and running for over a week, and early feedback indicates that clinical staff feel more confident in treating critically ill Covid-19 patients knowing that they have access to in-the-moment assistance. In fact, Montefiore plans to retain many aspects of their command center beyond the Covid-19 epidemic to scale critical care expertise across their system.
Below, we round up four of the team's early insights—and their recommendations for others.
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