The New Orleans healthcare system's report from one of the nation's outbreak epicenters provides a blueprint for other hospitals and health systems preparing for a surge.
How do you prepare for a crisis when so many factors are unknown? One way is to examine how others are facing similar challenges. Operating in one of the nation's COVID-19 epicenters, Ochsner Health, a nonprofit New Orleans-based healthcare system, has a blueprint to share.
Ochsner accepted its first COVID-19 patient on March 9. Twenty-four days later, 888 patients with the virus, or suspected to have it, were hospitalized at facilities in the system. Five hundred more have been treated and discharged.
In some respects, regarding personal protective equipment (PPE), for example, "We're in pretty good shape," said Ochsner's president and CEO Warner L. Thomas, MBA, during an April 2 press briefing. The system still had a few beds available, and more ventilators were on the way. But with a continued influx of patients and plans to expand bed capacity, staffing is a huge challenge, and blood supplies are short.
Ochsner Health serves patients in Louisiana, Mississippi, and the Gulf region. It operates 40 owned, managed, and affiliated hospitals and specialty hospitals, including the 767-bed Ochsner Medical Center in New Orleans, which serves as the primary nerve center for handing the outbreak.
Joined at the press briefing by Robert Hart, MD, FAAP, FACP, executive vice president and chief medical officer, the two health system leaders outlined the situation, how they prepared for the crisis, and the strategies that are helping them navigate the complex issues involved in the pandemic—and could provide guidance for others preparing for a surge.
Longer lengths of stay and a greater number of patients requiring ventilator support create challenges for the system, says Thomas. "When you hear [about] the issue of a shortage of ventilators and a shortage of beds, that's what's driving a lot of those pieces," says Thomas. Other key metrics reported by the Ochsner CEO included:
- 12% to 14% of COVID-19 patients require hospitalization; about 3% are admitted to the ICU.
- Length of stay: "We see a significantly longer length of stay from our COVID-19 patients, both in the medical-surgical area and in the ICU," says Thomas. The average length of stay for COVID-19 ICU patients is 12 to 14 days, compared to a normal three- to five-day ICU stay.
- Ventilator usage: Normally about 30% to 35% of patients in ICU are on ventilators, says Thomas. About 85% to 86% of Ochsner's COVID-19 patients require ventilator support.
- 3,100 patients have tested positive, but their symptoms at that time did not require hospitalization.
- Interestingly, emergency department activity is slower than usual, but the cases are more acute, Hart reports. "Total volume is down from what we might normally see; the problem is the acuity," says Hart. "The number of people that are coming in needing very critical care, perhaps intubation, is dramatically [different] from what would be our routine."
Expand Bed Capacity
As of Thursday morning, Ochsner had about five or six ICU beds available and about 20 to 30 medical-surgical beds available. Availability is tracked multiple times each day, and the health system also coordinates with LCMC Health, another nonprofit health system in New Orleans to coordinate bed capacity across the city.
Thomas did not specify the number of ICU beds in Ochsner's system, but 50 additional ICU beds have been opened in the last week, and another 60 ICU beds will become available in about eight days.
"We are continuing to look at options for additional, expanded bed capacities," says Thomas. Moving patients to other locations, including its rehabilitation and long-term acute care facility, is among the possibilities being considered to free more beds at the main campus.
Apply Innovative Strategies to Address Staffing Shortages
"Staffing is really our biggest issue," says Thomas. Additional personnel are needed to provide relief to the current team and also to help staff expansion of ICU and medical-surgical beds. Among the strategies Ochsner is using to expand its workforce and recommends that hospitals in other area of the country consider:
- Redeploy staff members from other areas of the hospital. "We've got a lot of different people with different skillsets that all have value," says Hart. "You have to figure out where to plug them in to bring that value."
- Recruit nurses from out of town. Ochsner has recruited 140 nurses from other locations, and more are being sought.
- Employ upcoming graduates. Ochsner is looking at opportunities to hire students who are preparing to graduate. Some colleges and universities are allowing students to move into practice early if they've completed all their clinical practical work, Thomas explains.
- Encourage the state to issue temporary emergency licenses. Thomas says Louisiana is working to issue doctors, respiratory therapists, nurses, and others emergency temporary licenses.
Encourage Blood Donations
Blood donations are down, creating an issue for many hospital systems, including Ochsner, says Thomas.
"With the number of patients that are in our hospital, there is a critical need for blood," says Hart. "All the hospitals in the country are beginning to feel that [shortage]."
Focus on Supply Chain Innovation
Thanks to advance planning and creative tactics, Thomas reports that Ochsner's personal protective equipment (PPE) supply is currently in good shape, but "It is getting harder and harder as this becomes more of a problem across the country."
The organization began working with local companies to manufacture some necessary supplies, a process that Thomas says "will change us forever. There are probably some supply chain pieces that we'll try to keep in place beyond COVID-19."
Among the measures the system has taken:
- Constantly sourcing supplies from all over the country and the world.
- Working with a local clothing manufacturer to make disposable surgical gowns and helping them source the proper materials.
- A few weeks ago, Ochsner began using 3D printing technology to create their own protective face shields. The health system is now working with a local company to manufacture this protective gear
- Obtaining thousands of bottles of hand sanitizer from a local distillery.
"We're working closely with our staff and our team to make sure they have what they need to feel safe," says Thomas.
Seek Ventilators From Every Possible Source
While many hospitals are concerned about ventilator shortages, action Ochsner has already taken currently has the health system "heading in the right direction," says Thomas. The health system has been sourcing ventilators from "everywhere," he says, including local vendors, and recently received some additional units from the state. More equipment is on the way to help with an ICU expansion.
Ochsner is also expecting "a significant load" of critical care ventilators, but Hart says they must be used judiciously. "As patients on these ventilators "begin to get better," says Hart, "we are asking our critical care docs to think about when they can come off the critical care vent so that we have those available for [other] patients" who need the equipment.
Ramp Up Lab Capabilities and Devise a Testing Strategy
Initially, Ochsner sent COVID-19 tests to Mayo Clinic in Rochester, Minnesota for processing. That lab was overwhelmed, and some of those tests have yet to be processed. Meanwhile, Ochsner augmented its own lab capabilities and can now process about 1,000 tests daily in New Orleans and another 400 tests at its Shreveport facility. Those test results are available within 24 hours.
Ochsner no longer sends tests out for processing at commercial or state labs. The shift to in-house testing has "improved our turnaround time," says Hart.
Ochsner executives said they get a lot of questions from other health systems about how they ramped up operations so quickly. The main campus already had two machines in place that simply needed to be recalibrated to run the COVID-19 test, says Hart. In addition, he says, thanks to a "longstanding relationship with Abbott, we were able to get a couple of more machines." One was set up on the main campus and another in Shreveport, Louisiana.
It took about three days of "nonstop" work to do the calibrations, verifications, and get the tests up and running, says Hart. "It's beneficial for employees; it's beneficial for our patients; it saves on the PPE when we know whether they're positive or negative, so there are a lot of good benefits."
While the health system has also obtained access to some one-hour tests, a limited number of rapid tests, which produce results in five to 15 minutes, just became available. The leadership team is considering the best way to deploy them, starting with the emergency department. "That way we'll know right up front if a person is positive or negative when they come into our ED," says Hart. This information can help conserve PPE, he says. Other areas being considered for rapid testing include chemotherapy infusion, and labor and delivery.
Maximize eICU Capabilities
Virtual care is also available inside many of Ochsner's ICUs through its eICU beds, which are monitored by remotely located providers. A camera and television screen in the room offer two-way video communication.
While Ochsner has had this capability for more than a decade, says Thomas, "It's so critically important, now as we've had to stretch and ramp up our number of ICU beds. Having, the critical care physician that is overseeing all of our critical care patients virtually, 24/7/365 is tremendous."
Use Technology to Monitor Non-Hospitalized Patients
As the crisis accelerated, the health system set up a COVID-19 hotline to handle the influx of calls. Call volume peaked at about 1,000 calls a day, and began dropping this week, to about 700 calls on April 1, says Thomas.
In addition, Ochsner rolled out a symptom checker, designed for people with symptoms who don't yet require testing. The symptom checker connects with the patient's electronic health record and initiates a daily text asking for a symptom update. If symptoms worsen, an alert is issued to the care team, which then calls the patient to determine if further care is required.
"It gives those patients a level of reassurance that they've got somebody checking on them daily." says Hart. "It also gives us a window into how they're doing clinically."
Continue Regular Service Through Virtual Care
Last year Ochsner began offering direct-to-patient virtual visits, providing a way for physicians to connect with patients beyond traditional office visits. About 3,500 sessions were conducted in 2019, with most occurring toward the end of the year. "Yesterday," says Thomas, "we did 3,000 visits. We have 13,000 virtual visits scheduled for next week. It's going extremely well," says Thomas.
The technology is available to all primary care practitioners, mental health providers, and specialists who are receiving "extremely positive feedback from patients," reports Thomas.
I think this is going to be a sea change for virtual visits and [for] healthcare," says Hart. Thomas agrees. "I think this situation is probably going to change the view of video visits forever."
Address End of Life Care
While end-of-life conversations have always been part of the care hospital staff have provided, due to the volume and condition of patients, these discussions have become more commonplace, reports Hart. The situation is more difficult because visitor restrictions are in place, preventing family members from being at the bedside.
"We're having to have more very frank conversations with people about what their wishes are at the end of life; what they really want in the way of care," says Hart. "The sheer volume has increased. Before we intubate a patient, we want to understand what care they want to receive … and we want to be very honest with our patients about the reality of this disease."
To facilitate the process, nurses bring a tablet into the room to allow family members to have a video chat with the patient before intubation. And, if a patient is dying, family members are allowed to visit.
Encourage Frontline Innovation
"Our employees also are coming up with innovative [solutions]," says Hart. At Ochsner, nurses with Apple watches are using its "walkie talkie" function to communicate with each other when a nurse enters a COVID-19 patient's room to deliver care. "The nurse can don their PPE, go into the room and converse with the person that's outside of the room and let them know what they need while they're in there," he explains. "It allows the nurse to take care of the things they need to take care of while they're in there instead of coming in and out a lot and wasting the PPE. It's working quite well."
Advice for Other Hospitals
Thomas says he's on calls "virtually every day with CEOs from around the country" seeking advice about how to prepare for the surge of COVID-19 patients. He offers the following advice:
- Staffing, equipment, and PPE should be priorities.
- "Communication is a huge issue," says Thomas. "We communicate essentially every single day with all of our team members around the system."
- Stay connected with key personnel. Ochsner has multiple daily "huddle calls" with the leaders at each campus.
“Staffing is our biggest issue.”
Warner L. Thomas, MBA, Ochsner Health President and CEO
Mandy Roth is the innovations editor at HealthLeaders.
Innovative strategies are required to address staffing issues. Redeploy current staff, recruit from out of town, and hire students expected to graduate soon who have completed clinical requirements.
Focus on supply chain innovation and seek ventilators from every possible source.
Use technology to monitor symptoms of non-hospitalized patients, and employ virtual care inside and outside of hospitals.