Field hospitals can ease pressures on existing hospitals during COVID-19 patient surges.
When health systems need to open a field hospital during a public health emergency such as the coronavirus pandemic, they should be guided by emergency management principles, the lead author of a recent journal article on opening a field hospital says.
Several states across the country have had to open field hospitals during the coronavirus pandemic to accommodate COVID-19 patient surges. A common strategy has been to use field hospitals to treat low-acuity COVID-19 patients who can be transferred from hospitals and cared for safely before being discharged home.
The recent journal article, which was published by Prehospital and Disaster Medicine, features the planning effort for a 500-bed field hospital at Michigan Medicine—the health system affiliated with the University of Michigan in Ann Arbor. Planning for the alternate care site (ACS) began in March 2020, when modeling predicted that Michigan Medicine's 1,000-bed acute care capacity would be overwhelmed by April 10.
"The goal of the ACS was to decompress the main hospital, allowing critically ill patients to remain on-site while low-acuity patients were accommodated within the ACS," the journal article's co-authors wrote.
Although the predicted COVID-19 patient surge did not materialize and Michigan Medicine did not have to open the field hospital, the health system conducted extensive planning for the ACS through May 2020. There were four primary lessons learned from the planning process, according to Sue Anne Bell, PhD, MSN, MSc, an assistant professor at the University of Michigan School of Nursing and lead author of the journal article.
1. Teamwork and community response: "We learned the importance of the strength in our health system in terms of all-in effort. When the decision was made to stand up the field hospital, there was a display of teamwork within the planning team and across the health system," Bell told HealthLeaders.
"We saw an all-hands-on-deck situation within the health system of people willing to work together and within the broader community as well. As we were facing the oncoming surge that would have required the field hospital, the community locked down. The community stringently followed public health guidelines to decrease the spread of the virus, which ultimately removed the need to open the field hospital," she said.
2. Tapping resources: "We learned the importance of using resources for field hospitals. There was existing guidance on how to stand up a field hospital that helped us. It was also helpful to talk with other health systems that were standing up field hospitals," Bell said.
3. Experienced planning team: "We benefited from having people on the planning team like myself who had worked in field hospitals before or had military experience. So, having a team with experience is very important," she said.
4. Multidisciplinary approach: "The planning team was multidisciplinary, with physicians, nurses, respiratory therapists, facilities managers, and logistics and procurement specialists all working together to make decisions. That team effort was important because it was not just a few people at the top making decisions. For example, a facilities manager who had experience with air flow in buildings and electrical capabilities worked with clinical team members to figure out where to put beds that might require a ventilator," Bell said.
Emergency management principles
To avoid pitfalls when opening a field hospital, Bell said health systems should concentrate on four tenets of emergency management—staff, stuff, space, and systems.
1. Staff: "You can't open a 500-bed field hospital with four nurses," she said.
Michigan Medicine planned to staff its field hospital mainly with in-house healthcare workers, including academic staff who volunteered to expand their clinical hours, Bell said. "We found a tremendous spirit of volunteerism. Before we even put out the call to staff the field hospital, we had people calling us asking to volunteer."
For health systems with less capacity to staff a field hospital with internal human resources, there are several strategies to rise to the staffing challenge. Externally, there are resources such as federal Disaster Medical Assistance Teams, she said.
Internally, health systems can take actions to redeploy healthcare workers, particularly to boost critical care staff, Bell said. For example, elective surgery can be suspended and that operating room-trained staff can supplement ICU staff.
In addition, "task shifting" can increase ICU staff capacity, she said. "You deploy healthcare workers to take care of some of the tasks in the ICU that do not require specialized skills. These are relatively routine tasks that critical care nurses would do in a 'normal' time. Task shifting frees up the critical care staff to take care of healthcare that requires more highly skilled types of care. For example, less skilled healthcare workers can do IV checks to make sure the lines are open and running."
2. Stuff: "You must have the stuff to operate a field hospital. You need to be able to source cots, linens, and personal protective equipment, for example," Bell said.
Acquiring PPE and other supplies was one of the biggest challenges in the planning effort for Michigan Medicine's field hospital, according to the journal article. "The surge of COVID-19 patients combined with the rapid scale-up of field hospitals and ACS at multiple places across the country meant essential supplies—outside of PPE—such as cots, linens, and privacy screens were difficult or impossible to source. Items were out of stock or no longer available for purchase, as huge competition existed regionally and beyond. The PPE shortages were an ongoing concern," Bell and her co-authors wrote.
In the future, it will be essential to have the Strategic National Stockpile of medical supplies more prepared to cope with the demands of a pandemic, Bell said. "There are already efforts to address the failures of the Strategic National Stockpile. That is the starting point for addressing procurement challenges, and it is happening."
3. Space: "To open a field hospital, you must have a space that meets your needs to safely house patients. The space must have contamination zones, so there must be a zone for patients who have tested positive for the virus, a zone where you don PPE, and a zone where full PPE is not necessary," she said.
In consultation with community leaders, Michigan Medicine chose to use a new 73,000-square-foot indoor track and performance center owned by the University of Michigan for its field hospital. The facility, which is a 12-minute drive from the main hospital, has several qualities that make it suitable as a field hospital, Bell and her journal article co-authors wrote. "It could provide a 'clean' and a 'dirty' side in order to reduce the risk of transmission and to form distinct areas of function to maintain organization. A draft layout was completed in roughly two days for 519 beds, including a 20-bed higher-acuity area for decompensating patients needing transfer."
4. Systems: Planners must put several systems in place to make sure a field hospital is safe and effective, Bell said. "You must have systems in place in order to open. For example, you must have a system in place for patients who decompensate, so you can transfer them to an established hospital. You must have a system for feeding patients. You must have a system for restocking supplies."
Photo Credit: Antonio Scorza/Shutterstock.com
Christopher Cheney is the senior clinical care editor at HealthLeaders.
Health systems opening field hospitals should tap helpful resources such as other health systems that have opened field hospitals and existing plans for alternate care sites.
It is important to have an experienced planning team such as team members with military backgrounds.
The planning team should be multidisciplinary, including clinical staff, facilities managers, and logistics and procurement specialists.