April 15, 2020

How Montefiore stood up an ICU command center for Covid-19—in just 2 weeks

Daily Briefing

    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. 

    Montefiore's ICU command center in action

    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.

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    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.

    Scaling critical care staffing and bed capacity

    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.

    4 early lessons from Montefiore's ICU command center launch

    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.

    • Start by building on the technology you already have available to expedite implementation and reduce the need for clinical training. Outside of purchasing iPads for virtual consults, Montefiore focused on upgrading its existing capabilities to get the command center up and running quickly. For example, the system added functionality into its existing EHR backbone and upgraded their servers so physicians in the command center can review patient data, waveforms, and ultrasounds remotely. The Montefiore team was able to move strategically to adapt their technology to meet their targeted goals by anticipating—and focusing on—the use-cases that they could leverage the command center to meet.
    • Publicly circulate phone numbers for each unit and detailed information about how to access virtual support. Make sure contact information is up-to-date, including unit phone numbers and staff Facetime IDs. Then, widely advertise how staff can reach the command center if they need in-the-moment support. Given the rapid pace of work, it can be easy to overlook where logistical hiccups can derail progress. If your organization is anticipating they’ll use a similar approach, start by updating contact information proactively so you can hit the ground running when you go live.
    • Be willing to make decisions more quickly than you’re comfortable with—and iterate on the backend. This crisis requires hospitals and health systems to make operational changes in weeks that would normally have taken months or years. While standing up an ICU command center would have taken months to perfect, Montefiore’s leadership team managed to stand up a feasible system within two weeks that they could continuously refine. In times like these, it's critical to make changes quickly and decisively in order to keep pace with patient demand.
    • Align around a clear purpose to fuel collaboration and progress. Although the ICU command center was a no-regrets investment from an operations perspective, its success hinged on the buy-in of critical partners. As Jeff Short, Montefiore’s VP of Staff and leader of their faculty practice group described, "The key to our success was a shared understanding that the rapidly approaching wave of Covid patients could overwhelm our clinical teams. So our IT, critical care, operations, and engineering teams quickly worked together to design and implement a solution to support a 300% increase in ICU beds." Make sure everyone understands the urgency of your initiative and identify a team of engaged partners who will dedicate the time you need to get things done. Because all team members at Montefiore bought in to the importance of the initiative, staff across the board said “yes” to critical ideas quickly—from repurposing their radiology suites for the command center to picking up iPads in bulk from Costco to eliminate shipping delays.
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