How WellSpan repurposed their IRF to treat med-surg patients
To manage potential inpatient surges during the Covid-19 pandemic, WellSpan prepared their combined rehabilitation and surgery hospital, WSRH, to treat med-surg patients. This approach allowed WellSpan to expand inpatient capacity with fewer resources and time than other organizations who have repurposed non-healthcare facilities to manage the surge. WSRH was chosen for the conversion because of its already low census due to cancelled elective surgeries. Additionally, as a clinical site of care, it was already set up and staffed to care for patients; WellSpan just needed to modify WSRH to manage different, higher acuity patients than usual. This document focuses on the four components that made this initiative successful.
1. Equip and redesign the unit for acute care patients
In order to expand surge capacity and take care of higher acuity patients than the WellSpan Surgery and Rehabilitation Hospital was initially designed for, the WellSpan team had to clear out their current patients, expand bed capacity, equip the space with additional supplies, and prepare for Covid-19 isolation spaces.
Clearing out existing WSRH patients
First, WSRH had to discharge their existing rehabilitation and surgery patients from the hospital. To do this, they stopped taking new admissions two weeks prior to completing the conversion. At the end of the two weeks, patients were discharged home with enhanced home health. The enhanced home health model was developed by WellSpan’s hospitals, IRF, and WellSpan VNA Home Care. The model adds advanced practice providers and two physicians to the home health staff to care for more complex patients.
Expanding WSRH bed capacity
Second, WSRH had to expand their own bed capacity. The facility had 73 rehab beds, and various peri-operative spaces, such as post-anesthesia care units, pre-operative rooms, and post-operative rooms. They repurposed their peri-operative spaces into an additional 43 beds, creating 116 beds total.
Equipping the IRF
WellSpan equipped their units with supplies from two of their closed ambulatory surgery centers.
Preparing for potential Covid-positive patients
Lastly, although WellSpan planned to take non-Covid med-surg patients, they recognized they could unknowingly admit an asymptomatic Covid-19 patient. To prepare for this possibility, WellSpan identified a space within the hospital where they could cohort patients if necessary. They decided on their brain injury unit because it was already separated from the rest of the facility.
2. Designate admission criteria in accordance with legal requirements
WellSpan used the Federal 1135 Blanket Waivers to convert their IRF into a med-surg unit. The waivers allow hospitals to treat patients outside of their traditional settings, including post-acute facilities and non-clinical buildings. To ensure proper reimbursement under these waivers, WSRH trained their billing and documentation staff on new documentation procedures. Additionally, WSRH consulted with WellSpan Health Quality and Patient Safety professionals throughout the conversion.
Determining admission criteria
After deciding the IRF would be used to treat excess med-surg patients, WellSpan had to determine which types of med-surg patients they could treat. The WellSpan team settled on non-Covid, stable, acute care patients, and generated a list of admission criteria and capabilities, sampled below. For the full list of criteria, see page 13.
The admission process for incoming patients is the same as if WSRH were a typical med-surg unit in WellSpan York Hospital. Available beds in this unit and the admission criteria are part of WellSpan’s central patient logistics center which informs all admission decisions. When a referral is made, it is sent electronically to WSRH.
3. Prepare staff to treat new patient types
To treat a larger volume of high acuity patients in WSRH, WellSpan recognized they would need to make changes to their current staffing model. This included bringing in additional staff, creating schedules based on each staff member’s experience and competencies, and training staff. Additionally, they had to consider changes to their food delivery staffing model.
Bringing in additional staff
To augment WSRH’s current staff, WellSpan redeployed 55 RNs and CRNAs from one of their closed ambulatory surgery centers.
Understanding staff capabilities
To prepare to care for med-surg patients, WSRH did a competency inventory of all clinical staff members. The competency inventory involved individually speaking with each clinician to learn about their past experience, including prior experience working in an acute care setting and which procedures or activities they felt comfortable performing.
From this competency inventory, WSRH learned that only the nurses from their surgery unit routinely inserted IVs. Using this knowledge, they designated the surgery nurses as the IV team.
Additionally, WellSpan used the competency inventory to create staff schedules, matching up more senior nurses who have experience in the acute setting with less experienced nurses. Based on this information, WSRH created a temporary organizational chart to clarify who staff were reporting to under the new system.
To provide additional training for staff, WSRH’s clinical educators went to WellSpan York Hospital, WellSpan’s largest acute care hospital, to observe how care is delivered there. Based on this visit, they created a short curriculum with a combination of didactic and hands-on modules.
All WSRH nurses (RNs and CRNAs) and physicians (hospitalists and physiatrists) took part in the training. After shadowing at the WellSpan York Hospital med-surg unit for a few hours, staff were able to return to WSRH to complete additional online learning modules and to practice the skills they learned using mannequins from WellSpan’s centralized simulation lab.
Non-clinical staffing considerations
To lower the risk of infection spread, WSRH closed their dining room and decided to serve all meals directly in patients’ rooms. To do so, WSRH also needed to bring in additional food service staff. Because staff in many of their outpatient clinics were out of work, WellSpan was able to pull in the food service staff they needed from a centralized list of staff who were looking to be redeployed. Food service at WSRH was listed as one of the work assignments that these staff were offered.
4. Provide on-demand advanced clinical support
In addition to the staffing and training initiatives, WellSpan recognized that to safely treat acute care patients, they would need on-demand access to advanced practitioners.
Non-emergency advanced clinical support
WellSpan decided to take advantage of telehealth coverage expansions and provide access to WellSpan York Hospital physicians 24/7 via telehealth. The physicians can view patients’ status and any updates through WellSpan’s EMR.
Telehealth technology was set up in patient rooms to facilitate regular virtual visits between physicians and patients in a number of areas, including cardiology, pulmonary, infectious disease, gastroenterology, and general surgery. To set up the telehealth units, WSRH created a new profile in their EMR for every clinician, and trained staff to document telehealth interactions.
Emergency advanced clinical support
In addition, WSRH stood up a rapid response team made up of WSRH’s anesthesiologists to provide 24/7 escalation support. When a patient is escalating, the team will be alerted via Ascom wireless phone. This team is expected to intervene in cases such as a patient requiring intubation, or experiencing a rapid decrease in blood pressure. The rapid response team is equipped with a code cart and medications. To prepare to serve this role, the anesthesiologists completed training using the simulation lab in one of WellSpan’s hospitals.
Ready for the worst, hoping for the best
WellSpan was able to successfully prepare their surgery and rehabilitation hospital to treat 116 med-surg patients.
The predicted surge in the areas near WSRH have lowered as social distancing measures flattened the curve. Because of this lowered surge, WellSpan has not had to use the WSRH to treat overflow med-surg patients. However, they are now well-equipped to do so if the need does arise.
Currently, WSRH is currently back to 100% census as an operational rehabilitation hospital. They’ve actually noticed an increase in volumes due to other hospitals in the area shutting down to new admissions.
Even though WellSpan didn’t need to use WSRH for additional med-surg capacity, the preparation did spur several innovations that will benefit the hospital well beyond the current Covid-19 pandemic. This includes setting up the structure for telehealth visits, integrating WSRH into WellSpan’s bed placement system, and creating a float pool of nurses who can work between settings within the WellSpan system.
WSRH admission criteria
WSRH created the below list of admission criteria to help ED staff triage new admissions into WSRH.