Louis Brusco's first challenge in his new CMO role was the most daunting of his career.
The new chief medical officer of two New Jersey hospitals says the coronavirus pandemic has left an indelible mark on the practice of medicine.
Louis E. Brusco Jr., MD, was appointed as CMO of Hackensack Meridian Health Raritan Bay Medical Center Old Bridge and Perth Amboy early this year. Previously, he had served as CMO at Atlantic Health System's Morristown Medical Center in Morristown, New Jersey.
Prior to working at Morristown Medical Center, Brusco served in several physician leadership positions at Mount Sinai St. Luke's and Mount Sinai Roosevelt hospitals in New York. He earned his medical degree from Columbia University, and completed his residency in anesthesiology and fellowship in critical care medicine at Columbia Presbyterian Medical Center.
Brusco shared the lessons he has learned from the coronavirus pandemic with HealthLeaders as a new CMO. The following is a lightly edited transcript of that conversation.
HealthLeaders: What is the essential element of clinical care leadership during an epic challenge such as this pandemic?
Brusco: As the chief medical officer, I was tasked with leading the clinical response and the clinical care for a disease that no one had heard of six months before. This disease acted differently than anything else we had seen, and it required people to be nimble and up to date.
The biggest challenge I found was trying to keep up to date with what was being published. Much of the information came in a nontraditional fashion. A lot of the good information to be shared came from podcasts. I put many podcasts on my phone so that I could listen to them driving back and forth to work. That's where we learned not to put patients on ventilators as quickly as we would in the past. That was a big change.
The people on the frontlines were too busy to gather information, so I felt that was my responsibility—to be the clinical leader because the physicians on the frontlines did not have the time to read. Then, I had to present information to the physicians in a way that was not traditional because usually you make a scientific argument. But a lot of the information was not scientific—someone would report that they tried a therapy on 20 patients, and it worked. We didn't have randomized, double-blind trials.
HL: What are the primary lessons learned from Meridian Health's response to the pandemic?
Brusco: Flexibility and breaking down barriers were key. We had to stop thinking of people in a rigid way. So, an anesthesiologist could work as an intensivist.
The emergency rooms were relatively quiet except for the COVID patients coming in. We took emergency medicine nurses, physician assistants, and nurse practitioners and had them take care of patients on the inpatient floors. It took us a while to break down the barriers—the emergency medicine staff did not have access to the computers on the floors. It took a day or two to figure out how to train them to do things that they normally did not have to do.
We learned that flexibility was crucial. People can learn fast when they have the base knowledge. We had people doing things that they had never done before. We used tiered models—you might have four nurses working under an ICU nurse and they had never worked in an ICU before. Then you had an ICU nurse who could take care of eight patients instead of two.
HL: How did you engage staff members to work in new roles?
Brusco: Thankfully, we quickly hit upon the realization that you can't assign people to work in new roles—you have to get volunteers. We knew we were going to have people reassigned; and the question was, where will each individual feel comfortable being reassigned?
For example, I have a physician assistant who works with the orthopedic surgeons. Since she had got out of training, she had never done anything other than work with orthopedic patients. I called her up and said, "Let's figure out what you can do to help us."
It was very clear that she could not be reassigned as a physician assistant working with COVID patients on the floor in the way that an emergency room physician assistant would be reassigned. Then I asked her, "You have worked in the operating room during spine surgery. How comfortable are you with flipping patients onto their stomachs?" She said she did it all the time. So, we had developed proning teams and she joined one of them. We used her skill set in a way that she was comfortable.
Another example is family practice physicians. Our network wanted us to use them—their offices were closed, and we needed to use them in some way taking care of patients at the hospital. I spent about a week talking with them and with the clinical people. In the end, we decided they would be perfect for screening patients at drive-thru testing sites. We found a niche. We found something they were very good at and they could handle.
HL: Did you encounter clinical care pitfalls that should be avoided in future pandemics?
Brusco: The pitfalls we encountered were not specific to the pandemic as opposed to this particular virus.
When our first patients came in, we treated them just like we would have treated any other patient pre-COVID. Obviously, we realized later on that this was not the way to treat these patients. What we learned is to not always categorize a disease into what you think it is. COVID has changed medicine forever. It looked like a disease we had been treating for years—acute respiratory distress syndrome—and it wasn't.
The treatments that we had developed for ARDS did not work for COVID pneumonia. It was a different disease. It reacted differently. Anything new that comes up in the future, we are going to question it the same way we have COVID.
HL: Give an example of a new therapy that was developed to treat COVID-19.
Brusco: We developed a whole new approach to ventilation.
Before this pandemic, we would have never taken a patient who had low oxygen and not put them on a ventilator but have them lay on their stomach. The concept of awake proning was brand new. Nobody would have thought of that before.
What clinicians found is that when you put COVID patients on their stomach, their oxygen got better, and they didn't have trouble breathing. When we started awake proning, it helped keep patients off ventilators, which in certain cases damages the lungs. By keeping these patients off ventilators, you are doing them a favor. So, we came up with proning protocols and proning teams, and it worked very well.
Photo credit: Lev Radin/Shutterstock.com
Christopher Cheney is the senior clinical care editor at HealthLeaders.
During the coronavirus patient surge in New Jersey, flexibility and breaking down barriers were keys to success, says Louis E. Brusco Jr., MD, CMO of two Hackensack Meridian Health hospitals.
When reassigning medical staff members to new roles during the pandemic, an autocratic approach is ineffective, he says.
Awake proning has been a pivotal therapy for severely ill coronavirus patients.