WakeMed Health & Hospitals was spared a dramatic impact in the first wave of the coronavirus pandemic and is ready if a second wave hits.
The coronavirus disease 2019 (COVID-19) pandemic has had varying impact across the country, ranging from dire hot spots such as New York City to Montana, which reported 505 confirmed cases as of May 29. In North Carolina, there were more than 44,000 confirmed cases and more than 1,100 deaths as of June 14, according to ABC.
Raleigh, North Carolina–based WakeMed did not have to increase bed capacity in response to the COVID-19 pandemic, but the health system learned the following eight key lessons and positioned itself to respond to a potential second wave of infections, a pair of clinical leaders from the organization says.
1. Be flexible
The COVID-19 pandemic put a premium on flexibility, says Seth Brody, MD, MPH, senior vice president of physician services. "We had to evaluate ideas that were new and different. We needed to have flexibility and willingness to listen to others," he says.
For example, supplies of personal protective equipment and directives for its use shifted several times through March and April, he says. "We had to continually modify our policies for N95 masks. As more information came out, it became clear who truly was at risk."
WakeMed had to foster flexibility in its staff, Brody says. "Getting the staff to work with us through change was critical. We had to help them understand that we were adapting as quickly as we could, we were trying to be rational, and we were trying to work within our supply chain limits. We had messaging that leadership was going to be flexible and the staff needed to be flexible with us."
2. Discover your institutional potential
Harnessing WakeMed's potential as an organization was critical in the health system's response to the pandemic, says Chris DeRienzo, MD, chief medical officer and senior vice president of quality. "When we approached the first lockdown orders—the first crisis period—members of our command center learned a lot about each other and the organization. We found that we could function under high intensity pressure and focus on needs and outcomes."
WakeMed began activating the command center in January and had a 24/7 operation by March 6, DeRienzo says. At its peak, the daily incident command call had more than 60 people. The operational command teams had as many as 300 people.
"We stood up entire functions and pillars to support the COVID response that did not exist before in terms of disaster planning, inventory, testing, and other functions. We learned what we could do as an organization when we brought the focus down to things that we had to achieve," he says.
3. Implement change quickly
Under the pandemic pressure, WakeMed was able to launch and implement initiatives quickly, Brody says. "Things that would take three to six months in the past could be accomplished in three days. It was a great lesson learned in terms of how to work together to get things done. We had the talent. We had the skills. We had people to lead change."
For example, WakeMed ramped up a modest telemedicine capability within days, he says. "We had talked about telemedicine and we had it up and running, but before the pandemic we might only see 10 patients a week via telemedicine at our physician practices. When we launched telemedicine across the outpatient continuum of care, within a week we were doing more than 60 telemedicine visits at the same time."
4. Find your untapped talent
WakeMed's response to the pandemic benefited from actualizing the potential of talent within the health system, Brody and DeRienzo say.
For example, David Kirk, MD, director of the WakeMed Pulmonary and Critical Care and director of WakeMed eICU took on a key new role, helping to lead the command center's critical resources team.
"That team turned around our critical resources dramatically. Our normal supply chain people are very good, but this was a different kind of crisis. The critical resources team figured out the burn rates for our PPE and targeted critical resources. They did vetting—we were getting 15 offers a day for PPE from around the world that were 15 to 20 times the normal cost. They also helped with communication to our healthcare workers, which gave our workers more confidence," Brody says.
Kirk has been promoted to associate CMO and critical resources management will remain one of his responsibilities.
5. Appreciate your community support
The Raleigh-area community supported WakeMed on several fronts, including money for the health system's foundation, Brody and DeRienzo say.
"Our service mentality for our community is reflected in the community's service mentality to us. As we walked into the depths of the most challenging aspects of the past 12 weeks, the community stood up for us and served our people in ways that I had certainly never seen before in my career. There were donations from food to supplies, and salutes from law enforcement and first responders," DeRienzo says.
6. Ensure your physicians are compensated
During the first wave of the pandemic, WakeMed did not lay off or furlough any physicians.
Hospital-based physicians such as critical care physicians and hospitalists were kept at their pre-pandemic salary levels, and a new payment system was created for physicians on productivity-based compensation such as operating room surgeons.
"On the frontline in the hospitals, we maintained physician salaries. We realized our doctors had to get us through the crisis," Brody says.
With overall patient volumes down and the cancelation of elective surgery to boost hospital bed capacity for COVID-19 patients, physicians on productivity-based compensation were at risk. Brody led an effort to compensate these physicians at fair market rates during the crisis, with a reconciliation process after the crisis had passed.
"We are sustaining their cash flow at a very reasonable fair-market rate throughout the crisis. It's almost like an interest-free loan for an extended period of time, so that they can stay at a fair-market level throughout the crisis. We will reconcile the compensation later, but they never dropped below a fair-market level," Brody says.
7. Cooperate instead of compete in crisis
WakeMed is based in Raleigh, one of the points in The Research Triangle region of North Carolina. Competing health systems are based in the other two points of the triangle—Duke Health in Durham and UNC Medical Center in Chapel Hill.
The rivals have cooperated during the pandemic.
"With the supply chain, it made more sense for us to work together. We shared masks and swabs for testing. We also aligned policies. For example, we created similar policies for hospital visitation. Our community benefited from getting a common message from all of the health systems," Brody says.
The cooperation extended beyond The Research Triangle, DeRienzo says. "The cooperation was not just with Duke and UNC. There was cooperation at the state level—North Carolina's health systems tried to begin thinking and acting in the statewide response. When I think back to the end of March and early April, we were not just on our internal incident command calls; we were having calls with Duke and UNC, we were having statewide healthcare leadership calls, and we were having calls with local and state officials."
8. Plan for surge capacity
One of the most valuable work products of the WakeMed command center has not been used, yet.
A capacity management team with about 30 members devised a plan to increase WakeMed's patient capacity from about 1,000 beds to more than 1,500 beds. The team was led by a senior nurse, with participation of ED clinicians, surgeons, hospitalists, and others.
The surge capacity plan has three phases.
Phase 1: Increase bed capacity by at least 25% through conversion of spaces that could readily serve COVID-19 patients such as operating rooms, endoscopy units, and post-anesthesia care units.
Phase 2: Increase bed capacity by another 20% by setting up cot facilities in conference rooms and a rehabilitation gym.
Phase 3: Establish a temporary hospital at a facility in the community.
"Having developed these plans, we now have them in hand. If COVID in the fall requires us to walk through that progression, we are ready. This is work that is tremendously valuable for whatever comes our way next," DeRienzo says.
New research provides guidance for managing the adoption of behavioral health integration.
Four factors have a major impact on adoption of behavioral health integration at healthcare organizations, a recent research article says.
About 20% of U.S. adults have a clinically significant behavioral health condition. Prejudice against people with behavioral health conditions and shortages of behavioral health workers has limited effective treatment. Integrating behavioral health into medical care is a top strategy to address behavioral health conditions.
The recent research article was published by Annals of Internal Medicine and funded by the American Medical Association and The Commonwealth Fund. The study features interviews with 47 physician practice leaders and clinicians, 20 behavioral health integration experts, and five vendors.
The researchers found four factors impact the implementation of behavioral health integration initiatives.
1. Physician practice motivations for behavioral health integration
There are three motivations for behavioral health integration at physician practices, the research shows.
Behavioral health integration can expand access to services when there are shortages of behavioral health clinicians. "One primary care physician explained that before implementing behavioral health integration, the practice was frequently unable to respond quickly to new behavioral health needs," the researchers wrote.
Behavioral health integration can boost the responsiveness to behavioral health screening. "Some practices reported that, before behavioral health integration, nonbehavioral health clinicians felt unable to respond when behavioral health screens identified behavioral health needs. This sense of helplessness led some clinicians to screen inconsistently," the researchers wrote.
Behavioral health integration can bolster a physician practice's reputation. "For example, a psychologist working for a mid-sized gastroenterology practice affiliated with an urban academic medical center explained that behavioral health integration was 'something cutting edge that sets [the practice] apart from other competing institutions in the area,'" the researchers wrote.
2. Crafting tailored approaches to behavioral health integration
Physician practices tend to tailor their behavioral health integration models in accordance with the practice's patient population needs, workflows, resources, and financial opportunities. Most of the practices in the study adopted a form of co-location—which features onsite behavioral health clinicians providing enhanced access within physician practices—because the co-location model can be a good fit with pre-existing practice workflows.
3. Behavioral health integration barriers
The research found three primary barriers to behavioral health integration.
There are cultural differences between behavioral and nonbehavioral health clinicians. "Several interviewees reported that behavioral health clinicians, who may be accustomed to 50-minute patient visits and long-term patient relationships without substantial staff supervision responsibilities, could have challenges acculturating to medical clinics," the researchers wrote. Methods identified to bridge cultural divides include utilizing organizational champions and practice leaders to engage both behavioral and nonbehavioral health clinicians.
There are barriers to flow of information. "Most participating practices reported that behavioral health records were shared infrequently with nonbehavioral health clinicians or were accessible only with special permission," the researchers wrote. Causes of poor information flow include electronic health record systems that are not designed for behavioral health integration and overly restrictive interpretations of laws and regulations such as the Health Insurance Portability and Accountability Act (HIPAA).
There are billing challenges. "Several practices in our sample reported that billing for behavioral health integration could be complex, burdensome, and unfamiliar to behavioral health providers," the researchers wrote.
4. Impact of payment models
About one third of the practices examined in the study reported losing money on behavioral health services. The practices used a range of payment models:
Internal organizational support that was not covered or fully covered by reimbursements received for behavioral health integration
Grant funding to launch behavioral health integration
Medicare fee-for-service billing codes
Alternative payment models such as shared saving and capitation
"There was no one-size-fits-all payment model that practices used to support behavioral health integration," the researchers wrote.
Promoting behavioral health integration
Leadership is crucial to overcome cultural barriers to behavioral health integration, says Patrice Harris, MD, MA, a practicing psychiatrist in the Atlanta area who stepped down as president of the American Medical Association on June 7.
"We have to start at the top, and we have to make sure there is a commitment on the part of the leadership of the organization to make it work. Then the leaders can bring together clinicians, administrators, and everyone working on all the teams to develop a plan of action," she says.
To foster the flow of information needed to achieve behavioral health integration success, staff members must have a firm grasp on the intricacies of HIPAA, Harris says. "You want to make sure everyone is on the same page regarding what is appropriate and what is not appropriate. In the service of their patients, clinicians can share information."
A team effort is required to address billing challenges, she says. "Usually, there are billing challenges regardless of the integration model. When you are having these conversations, you need to have your chief financial officer and billing team in the room. There are definitely workflow changes to process claims."
Behavioral health integration efforts can generate return on investment, but ROI should not be defined narrowly, Harris says. "We have seen financial returns, but we have to be candid—those financial returns do not always accrue immediately. That is why you have to think about patient outcomes and longer term returns on investment."
As the first drug found effective against the novel coronavirus illustrates, medications to treat the infection are likely to be initially scarce.
Decisions about allocating scarce inpatient medications for coronavirus patients should be guided by a four-part ethical framework, a recent journal article says.
The antiviral drug remdesivir is the only medication that has been shown to be effective in treating hospitalized coronavirus disease 2019 (COVID-19) patients. As is expected in the initial deployment of new COVID-19 therapies, there is a shortage of remdesivir. Healthcare providers have criticized the federal government's distribution of the drug.
The recent journal article, which was published by the Journal of the American Medical Association, calls for the setting of parameters to guide allocation of scarce COVID-19 medications.
"Evidence-based, fair guidelines to allocate scarce drugs for COVID-19 could help physicians make difficult decisions. Transparent guidelines will help promote trustworthiness when not all infected patients can receive a medication that is in short supply," the journal article's co-authors wrote.
The journal article proposes a four-part ethical framework as the foundation for allocating scarce COVID-19 medications:
1. Decreasing mortality is a primary guiding principle because reducing deaths benefits entire communities. Taking an evidence-based approach also is essential, the co-authors wrote. "Allocation policies should be revised as evidence develops. During a shortage, medications should be prioritized for indications for which peer-reviewed, randomized clinical trials have demonstrated efficacy and safety."
2. The preferences of patients should be respected, but their desired course of treatment may not be possible when there is a medication shortage.
3. Fairness should be a guiding principle when allocating scarce medications. Guidelines should avoid discrimination and ease health disparities.
4. Allocation guidelines should be established in a transparent, accountable, and responsive manner. The policies should be crafted to fit the situation such as the status of the pandemic.
"Specific goals derived from this ethical framework can provide practical clinical advice," the co-authors wrote. For example, a portion of scarce medications should be allocated to clinical trials to promote evidence-based findings.
Drug allocation recommendations
The JAMA article makes six recommendations for the allocation of scarce COVID-19 medications:
1. Distribution of scarce medications should be evidence based. Patient groups should be prioritized for a medication if clinical trials have shown the patients benefit from the therapy. When there is a shortage, compassionate use unsupported by evidence should be limited.
2. Discriminatory guidelines and administration of a scarce medication should be avoided. "Prioritization should not exclude patients based on age, disability, religion, race or ethnicity, national origin, gender, sexual orientation, or perceived quality of life," the co-authors wrote.
3. Existing Food and Drug Administration-approved medications should not be denied to patients who depend on them for non-COVID-19 therapy.
4. Evidence should guide decisions about which patients could benefit most or least from a scarce medication. "For example, although older age, diabetes, hypertension, and coronary artery disease are risk factors for poor prognosis in COVID-19, predictors of poor prognosis do not necessarily predict response to a new treatment. Physicians should provide new therapies to patients with these conditions, unless evidence emerges that shows that they do not respond to the therapy or respond less well than patients without these conditions," the co-authors wrote.
5. Fairness should be a consideration, they wrote. "Random allocation, such as by lottery, is the fairest way to allocate a very scarce drug among eligible patients. A 'first-come, first-served' approach should be avoided because it is not random, and it disadvantages those who experience barriers to seeking care. Within a lottery, workers in essential jobs may be given some priority."
6. Rationing scarce medications can prompt emotional reactions from patients and their loved ones, so clinicians should have support in making difficult decisions.
To accommodate the city's coronavirus patient surge, NYC Health + Hospitals increased critical care capacity and retooled emergency departments.
It was a nightmare scenario.
Emergency rooms were overwhelmed with coronavirus patients—sick patients walking through the door and dozens of seriously ill boarded patients awaiting inpatient beds. In some metropolis hospitals, demand for ICU beds exceeded supply.
It was March and April in New York City, and The Big Apple's 11-hospital public healthcare system—NYC Health + Hospitals (NYC H+H)—was at the U.S. epicenter of the global coronavirus pandemic. As of May 22, the city had 193,000 confirmed cases of novel coronavirus disease 2019 (COVID-19) and more than 50,000 hospitalizations, according to the New York City Department of Health and Mental Hygiene.
NYC H+H's efforts to increase critical care capacity and retool emergency departments is featured in a new article published by Health Affairs.
"As health systems nationwide prepare for potential resurgence of COVID-19 infection with relaxation of social distancing measures and the frightening prospect of a second peak, principles and actions taken by New York City Health + Hospitals provide a model for how hospitals across the United States can expand critical care capacity and manage frontline ED care to lessen the toll on human life," the article says.
Boosting critical care
Before the city's coronavirus crisis began in March, NYC H+H had about 300 ICU beds. When COVID-19 patients surged, the health system provided ICU care to more than 1,000 patients.
NYC H+H pursued three primary strategies to increase critical care capacity.
1. Increasing ICU beds
The health system organized ICU resources in two categories: "primary" spaces that were already equipped with the full suite of ICU equipment such as adequate power supply and physiology monitors, and "flex" spaces that could be quickly converted into fully equipped ICUs. Flex spaces included post-operative areas, operating rooms, procedural areas, and critical care rooms in the EDs.
For infection control in the ICU setting, the virus that causes COVID-19 was assumed to be aerosolized and airborne.
In many primary ICU spaces, individual patient rooms had negative pressure, so total personal protective equipment (PPE) only had to be donned by caregivers working in a patient's room.
Flex ICU spaces were more challenging because they often did not have single rooms that could serve as an individual isolation unit, requiring all staff to wear total PPE.
The most seriously ill COVID-19 patients were treated in primary ICU spaces.
Some hospitals experienced higher demand for ICU beds than others, so critical care beds were shared across the health system. In the six-week period starting March 20, more than 850 critical and noncritical patients were transferred between health system locations.
2. Increasing ICU staffing
Ambulatory clinic and elective surgery staff were reassigned to serve in critical care roles. Several of these staff members had specialized skills well-suited to the ICU setting such as anesthesia clinicians who could lead intubation teams and surgery staff who were familiar with proning patients.
To maximize the effectiveness of experienced critical care staff, the health system used a tiered staffing model in ICU settings, with experienced clinicians and nurses leading teams of reassigned healthcare workers. This approach freed up critical care physicians and nurses to manage more patients than pre-pandemic levels.
The health system recruited staff from across the country, including volunteers and military personnel with medical training. For example, more than 100 respiratory therapists were recruited. To maintain efficiency and efficient workflows, experienced staff members led teams of recruits whenever possible.
3. Increasing critical care equipment and infrastructure
The health system's supply of ventilators was supplemented with acquisitions from federal stockpiles and vendors. Ventilators also were sourced internally such as using operating room anesthesia machines. At the peak of the patient surge, about 1,000 patients were on ventilators, which was about five times the utilization level in pre-pandemic spring months.
COVID-19 patients require volumes of oxygen that are beyond the capacity of free-standing oxygen tanks, so installing piped oxygen systems was crucial.
Many seriously ill coronavirus patients require renal replacement therapy, and the health system had to redistribute dialysis machines and establish new peritoneal dialysis programs at some sites.
Ventilators and renal replacement therapy machines have several disposable parts such as filters and circuits. The health system had to redistribute these parts between hospitals to help manage supply shortages.
The high volume of patients put pressure on the health system's supply chain for common supplies such as IV tubing and dressings. Frontline staff and supply chain leaders monitored the "burn rate" for these supplies.
Managing emergency departments
NYC H+H established an action team featuring health system and local ED leaders to focus on three areas.
1. Protecting staff
Initially, suspected COVID-19 patients were placed in dedicated areas, where staff donned full PPE.
As the patient surge intensified, all EDs and ICUs were designated as "hot zones" requiring clinical and nonclinical staff to don full PPE.
2. Matching resources to clinical needs
The action team initiated text message campaigns to urge city residents with mild symptoms to stay home and monitor their conditions, which helped avert ED overcrowding.
As the patient surge intensified, the health system issued a citywide open letterthat gave residents more detailed medical advice such as how to self-isolate from other household members and when to seek medical attention.
The health system built a telehealth capability paired with the city's 911 call-center to provide clinician assessments of coronavirus symptoms. If more medical attention was warranted, the telehealth clinicians would direct patients to the appropriate care setting.
Some low acuity COVID-19 patients transported by ambulance were taken to urgent care centers or tents outside EDs for triage.
To increase ED throughput, protocols were created for the evaluation of potential COVID-19 patients such as streamlined clinical work-ups. Many high-risk patients were admitted, but those who did not meet admission criteria were often held in the ED for observation.
A home-monitoring program was established with text messages and phone calls to enhance discharge safety.
3. Increasing capacity and improving efficiency
ED-based ICUs were created to board seriously ill COVID-19 patients who were awaiting hospital admission. Some EDs boarded as many as 100 of these patients at a time.
Staffing was increased and workflow efficiency was improved to increase time for bedside care. Staff onboarding processes were accelerated—the duration of onboarding was reduced from a few months to a few days.
Staff efficiency was improved through methods such as dividing clinicians into key teams, including ventilator monitoring, transport, and proning.
Documentation for COVID-19 patients was streamlined in the electronic medical record, which also was updated with coronavirus-specific ordering tools.
The COVID-19 crisis has been a financial fiasco for physician practices, including decreased patient volume and canceled elective surgeries.
There are strategies physician practices can pursue to weather the financial storm associated with the coronavirus pandemic.
Ninety-seven percent of physician practices experienced a negative financial impact from the coronavirus disease 2019 (COVID-19) pandemic, according to a Medical Group Management Association survey published in April. The financial hits have included decreased patient volume and loss of income associated with the canceling of elective surgery.
The COVID-19 pandemic poses an existential threat to the primary care sector, says Ann Greiner, president and CEO of the Primary Care Collaborative in Washington, D.C. "If we do not respond to the financial challenges that primary care is facing, we are going to see an already damaged foundation of our healthcare system crumble."
Physician practices can pursue four primary strategies to keep their business finances afloat, says Al Crawford, chairman, CEO, and co-founder of Davie, Florida–based Bankers Healthcare Group.
1. Hold on to cash
"Do not spend if you do not have to spend. You should just hoard cash. The more access you have to cash, the better," Crawford says.
During the COVID-19 pandemic, physician practices should limit new spending to practice enhancements related to the pandemic such as air purification systems, he says. "There are expenses required during the COVID-19 pandemic, but I recommend that you do not go beyond those required expenses in an environment like this. We are in the middle of a pandemic, and what you do not need you should not buy."
2. Don't pay off debt, yet
"I would not be looking to pay down debt right now because of the No. 1 principle—cash is king," Crawford says.
Medical professionals should be careful about taking cash and paying down debt, he says. "For the next 90 to 180 days, I would try to stay cash-rich. If we're all back to work, there is a vaccine in the fall, your practice business is good, and you have saved a lot of money by being ultraconservative, then I would look at paying my debt down."
Although the Federal Reserve System has been taking actions to promote lending, physician practices cannot count on finding a lender if they experience a cash crunch, Crawford says. "You do not want to pay debt off, then something does not go right, and you go back to the banks and the banks are not lending. Then you do not have access to capital and that can kill your business."
"You have an interest-free period for 24 weeks, which is fantastic. It is probably one of the best gifts that the U.S. government has ever given. If you follow the rules, such as spending 60% of your funds on payroll, and you get the loan forgiven at the end of 24 weeks, it is a home run," he says.
Even if a physician practice cannot get a PPP loan forgiven, the debt terms are a bargain, Crawford says. "If you can't get the loan forgiven or you can't pay your rent, it is an inexpensive loan. It is a 1% interest rate loan. So, it may make sense to do the 30-month payback and carry the loan if you can't financially afford to bring your staff back."
For physician practices that have gotten PPP assistance, the funds should be kept in a dedicated account to pay for program-approved expenses such as payroll and rent, he says. "When a practice pays for insurance or pays for payroll, they should reimburse out of the separate PPP account for the exact, specific payments. If they are making specific payments for rent, insurance, or payroll, they will have the proof for the bank and for SBA that the PPP funds were used for the purposes outlined."
PPP has been a lifeline for the Brownsville, Texas–based general surgery practice of Carlos Barba, MD. The cancellation of elective surgery in Texas hit the practice hard, Barba says.
The general surgery practice has a 10-member staff, including another surgeon and a physician assistant. "Fortunately, the federal government created the small business assistance program. We applied to that program, and I was able to get a loan. I did not have to reduce hours or cut my staff," he says.
4. Apply for private loans
Lending from banks and brokers also can stabilize a physician practice's finances, Crawford says.
Bankers Healthcare Group has established an "assistance loan" that ranges as high as $500,000. Borrowers do not have to make a payment on the loan for the first 89 days.
The terms of the assistance loan can be crafted to limit the size of monthly payments, Crawford says.
"We are giving the medical professional a term that goes out as long as 10 years. For the borrower, the additional years lower the monthly payment. In my opinion, right now everything is about the monthly payment. If you can lower the monthly payment, increase your savings, and decrease your spend, you have a much better shot of getting the business back to running well," he says.
Primary care payment reform
Reimbursement for primary care services must be reformed, Greiner says.
"This pandemic has laid bare that fee-for-service has been an epic failure. It is a system that is based on face-to-face visits, which obviously does not work in a pandemic when you are trying to keep both patients and clinicians safe. So, the pandemic has prompted a lot of conversation both at the national level and the state level about moving to a prospective payment system," she says.
During the pandemic, the Centers for Medicare & Medicaid Services (CMS) as well as private health plans have moved in the right direction on advance payments, Greiner says. "What both CMS and private health plans have done by putting advance payments in place is help primary care practices keep their doors open. That could be a step on a path toward prospective payments, but this is a conversation that has been going on for a long time."
In addition to establishing a prospective payment system for primary care, government and private payers need to provide significant and appropriate reimbursement for innovative care delivery models such as telemedicine, she says. "We have to get to a payment system that is agnostic about the way care is delivered."
From 2009 to 2018, hospital electronic health records met basic safety standards less than 70% of the time, researchers found.
Much work remains to be done to fully realize patient safety gains from electronic health record (EHR) systems, recent research indicates.
In 1999, the landmark patient safety report To Err Is Human: Building a Safer Health System estimated that 98,000 patients died annually due to medical errors in hospitals. The Institute of Medicine report said that medication errors were the most common preventable harm and called for adoption of EHRs with computerized physician order entry and clinical decision support to improve patient safety.
The recent research, which was published by JAMA Network Open, examines EHR data from 2009 to 2018 collected at more than 2,300 hospitals.
"These findings suggest that despite broad adoption and optimization of EHR systems in hospitals, wide variation in the safety performance of operational EHR systems remains across a large sample of hospitals and EHR vendors. Hospitals using some EHR vendors had significantly higher test scores. Overall, substantial safety risk persists in current hospital EHR systems," the research co-authors wrote.
The researchers assessed computerized physician order entry and clinical decision support data collected through The Leapfrog Group's annual Leapfrog Hospital Survey. The data features information from the survey's computerized physician order entry EHR evaluation tool, which simulates physician medication orders and exposes error rates. The study targeted whether a hospital's computerized physician order entry EHR system produced an alert or stop after a simulated order that could result in an adverse drug event.
The researchers generated several key data points.
The overall mean total score for computerized physician order entry EHR systems rose from 53.9% in 2009 to 65.6% in 2018. In other words, EHRs met basic safety standards less than 70% of the time.
The mean score for basic clinical decision support rose from 69.8% in 2009 to 85.6% in 2018.
The mean score for advanced clinical decision support rose from 29.6% in 2009 to 46.1% in 2018.
Drug-allergy was the highest performing category, with the mean score rising from 92.9% in 2009 to 98.4% in 2018.
Drug-diagnosis contraindications were the lowest performing category, with the mean score rising from 20.4% in 2009 to 33.2% in 2018.
A hospital's EHR vendor accounted for 9.9% of performance variation.
"We found that overall safety performance increased modestly, while the number of institutions taking the test has increased 10-fold. Improvements in basic clinical decision support were far greater than in advanced clinical decision support, consistent with other studies," the researchers wrote.
Creating safe EHRs
The researchers suggest three ways to improve EHR patient safety performance.
1. Hospitals should conduct computerized physician order entry safety assessments at least annually and after upgrades. "Continuous assessments are also critical to identify unanticipated problems that may occur as systems are updated and customized," the researchers wrote.
2. The results of safety assessments should be shared with EHR vendors to spur development of safer systems.
3. Policy makers could include computerized physician order entry safety assessment scores in publicly reported process quality measures.
EHRs are a pivotal element in hospital patient safety, says Dawn Allbee, MA, executive director of customer engagement at the Oakbrook Terrace, Illinois-based Joint Commission Center for Transforming Healthcare.
"Leaders need to consider that the success of EHRs is an essential tool in their quest for zero harm. This includes optimizing EHRs to help keep patients and organizations safe. Patterns of errors and safety incidents need to be eliminated through the use of an orgnb anization's improvement tools," she recently told HealthLeaders.
At hospitals, a safe EHR is part of a broad landscape of patient safety efforts, Allbee says. "From our perspective, a safe electronic health record is one that is coupled with strong, understood processes for use across the organization. Having an EHR cannot take the place of extensive quality and improvement training that empowers employees as change agents."
The Joint Commission Center for Transforming Healthcare supports the use of the Safety Assurance Factors for EHR Resilience (SAFER) Guides released by the Office of the National Coordinator for Health Information Technology in 2014, she says.
The SAFER Guides feature nine guides organized into three categories.
1. Foundational guides: high priority practices and organizational responsibilities
2. Infrastructure guides: contingency planning, system configuration, and system interfaces
3. Clinical process guides: patient identification, computerized provider order entry with decision support, test results reporting and follow-up, and clinician communication
For seriously ill coronavirus patients, acute ventilator recovery units serve as a bridge between ICU care and acute rehabilitation facilities.
Northwell Health has opened two acute ventilator recovery units (AVRUs) to care for coronavirus patients who have been on ventilators for extended durations.
Many coronavirus disease 2019 (COVID-19) patients with acute respiratory distress require at least a week on a ventilator to support lung function while they recover from the illness. With immobilization required for mechanical ventilation, these patients need physical therapy once they are well enough to move and respond to commands.
AVRUs feature physical therapy while COVID-19 patients are being weaned off ventilators, says Mangala Narasimhan, DO, regional director for critical care at the New Hyde Park, New York-based health system.
"These patients are so behind the curve with long sedative times and long ventilator times that they need aggressive physical therapy to get back on their feet. To do that in ventilated patients is very difficult because most of the PT units that exist are for patients who are not on ventilators. Most acute rehab units want patients to be off a ventilator," she says.
On May 27, Northwell opened two AVRUs at Glen Cove Hospital in Glen Cove, New York, and Northern Westchester Hospital in Mount Kisco, New York. The AVRUs have a total of 27 beds and cost about $1 million each to equip. Most of the expense was associated with equipment such as monitors and oxygen systems.
"It took about three weeks from the thought process to actually opening, and that time was needed mostly for getting equipment installed and staffing in place," Narasimhan says.
The staffing includes hospitalists, pulmonary clinicians, respiratory therapists, physical therapists, and nursing. "Both units have a pulmonary team that is rounding on all of the ventilated patients," she says.
Acute ventilator recovery unit care
For most severely ill COVID-19 patients, Northwell expects its AVRUs will serve as a bridge between ICU care and discharge to an acute rehabilitation facility, Narasimhan says. "In the ICU setting, the focus is not necessarily on physical therapy and ventilator weaning—the focus is on survival and getting patients to a point where we are not hurting them with the ventilator such as reducing the oxygen. In the AVRUs, the goal is to get patients off ventilators."
Ventilated COVID-19 patients must meet three primary criteria for transfer from an ICU to an AVRU, she says.
Patients must have a tracheostomy for airway stability.
Patients must be hemodynamically stable. For example, they cannot be on vasopressors.
Patients must be able to participate in physical therapy—they must be awake and able to follow commands.
Each AVRU coronavirus patient has a tailored physical therapy regimen, Narasimhan says. "Some patients are just doing passive range of motion and trying to get their muscles strong. Some patients are doing active PT, where they are sitting up and standing. It really depends on where the patients are in that spectrum and how much muscle loss they have experienced."
The pair of AVRUs are expected to meet service demand at Northwell, for now, she says. "Whether we expand the program depends on whether we have a second wave of COVID."
Compared to ventilator care, nasal high flow therapy for seriously ill coronavirus patients has several benefits, including the ability to mobilize patients.
Nasal high flow (NHF) therapy is a less invasive alternative to ventilator care for many seriously ill coronavirus patients, UnityPoint Health experts say.
During the coronavirus disease 2019 (COVID-19) pandemic, ventilator care has been used commonly for coronavirus patients experiencing acute respiratory distress. However, ventilator care has posed several challenges, including shortages ventilators and the staff needed to manage patients on mechanical ventilation.
NHF therapy is delivered to a patient through a high flow nasal cannula. According to the American Association for Respiratory Care (AARC), an NHF therapy system usually features four elements:
Gas blender
Flow meter display
Nasal interface and heated circuit
Humidification system
"One of the hallmarks of an efficient NHF system is to be able to deliver optimally humidified gas at body temperature pressure and humidification," an AARC document says.
At three UnityPoint Health hospitals in Iowa, using NHF therapy has allowed clinicians to keep 73% of seriously ill COVID-19 patients off ventilators. In addition, the duration of NHF therapy for these patients has averaged about three days compared to about eight days for patients placed on mechanical ventilation.
For seriously ill COVID-19 patients, several criteria indicate or contraindicate use of NHF therapy, says Matthew Trump, DO, medical director of UnityPoint Health pulmonary rehabilitation, and co-medical director of the Palliative Care Department at The Iowa Clinic, which is based in West Des Moines, Iowa.
Seriously ill COVID-19 patients are good candidates for NHF therapy if they are awake, breathing spontaneously, and hemodynamically stable, he says. Seriously ill COVID-19 patients are poor candidates for NHF therapy if they cannot maintain their airway and/or have severe respiratory acidosis with a pH of less than 7.2, he says.
Advantages of NHF therapy
In the treatment of severe COVID-19, there are several benefits to using NHF therapy rather than mechanical ventilation, according to Trump and Julie Jackson, respiratory care services manager at UnityPoint Health.
With NHF therapy, the patient is able to be awake, able to mobilize, able to communicate, and able to eat and drink. The ability to mobilize patients avoids some of the weakness and debilitation patients experience when they are on mechanical ventilation.
A physiologic benefit is that the patient's lungs are not subjected to potentially injurious pressure from a ventilator.
Patients receiving NHF therapy can be managed in an inpatient ward as opposed to the ICU setting, which generates multiple benefits including lower demand for ICU beds and avoidance of ICU-related complications such as infections.
Unlike patients placed on mechanical ventilation, patients receiving NHF therapy can be active participants in their care such as involvement in medical decision-making and self-proning. "They can move themselves into a prone position, so their oxygenation is improved. Whereas, if the patient is on a ventilator, it takes a lot of resources and a lot of staff to prone the patient," Jackson says.
NHF therapy can be used when a patient is extubated, which has lowered the rate of re-intubation at the UnityPoint Health hospitals.
When small community hospitals need to transfer a seriously ill COVID-19 patient to a larger hospital for advanced care, many of the patients can receive NHF therapy during transport rather than being intubated.
Dartmouth-Hitchcock Health's Clinical Recovery Command Team leads the effort to restart medical services that were put on hold for the coronavirus pandemic.
At Dartmouth-Hitchcock Health, ensuring safety and adequate medical supplies such as personal protective equipment (PPE) are top goals in reopening services paused for the coronavirus pandemic.
As the coronavirus disease 2019 (COVID-19) pandemic spread across the country in March, many health systems and hospitals suspended some outpatient services and most elective surgeries. Now, most of these organizations are seeking to reactivate paused services without endangering patients and staff. Dartmouth-Hitchcock's strategy could serve as a blueprint for other health systems that were not innundated with COVID-19 patients.
"Our No. 1 priority has been the health and safety of our patients, our visitors, and our staff. The current situation seems manageable. We have never been overwhelmed," says Edward Merrens, MD, chief clinical officer at the Lebanon, New Hampshire-based health system.
Dartmouth-Hitchcock features a 400-bed academic medical center as well as four affiliated critical access and community hospitals in New Hampshire and Vermont.
Safety measures
Dartmouth-Hitchcock has initiated several safety measures, and a key metric shows the efforts have been effective, Merrens says. "We have not had any staff contract coronavirus from a work-related incident."
The safety measures have included:
Universal masking: Masks are provided to everyone—employees and patients—who comes into a hospital across the health system.
Patient encounters: When interacting with patients, staff must wear not only a mask but also a visor. For more sensitive environments—whether it is an operative setting or in a COVID-19 unit—there is the highest level of PPE including gowns and gloves.
Waiting rooms: Some chairs have been removed from waiting rooms to establish social distancing.
Appointments: Patient visits to hospital departments and outpatient clinics have been spread out with extended workdays and weekend visits.
Reduced patient visits: "We have clearly reduced the number of people in the hospital. We have found different ways of getting to people with visiting nurse services to reduce the number of times patients have to come to the hospital. Physical therapy for joint surgery can be done online with videos," Merrens says.
Telemedicine: "We were able to pivot many of our visits to telehealth, which has been a big part of our recovery efforts. We already had a very robust telehealth capacity with our Connected Care, which was doing everything from critical care to specialty care before the pandemic," he says.
Managing the reopening
In early April, Dartmouth-Hitchcock launched the organization's Clinical Recovery Command Team to manage the reopening of paused services.
"We have tried to look at each area and determine what is needed for patients, what are the barriers, what are the things we are trying to achieve, and how we can implement change across our health system," Merrens says.
The command team has nine work groups:
Surgical group focusing on the academic medical center's main operating rooms and the health system's outpatient surgical center
Interventional procedures that are not necessarily operative such as cardiac catheterization, interventional radiology, and electrophysiology
Endoscopy and minor procedures
Primary care and pediatrics
Ambulatory surgical and specialty care
Radiology
Lab work
Community group practice
Affiliated hospitals
The command team reports directly to the health system's president and CEO, Joanne Conroy, MD, and includes many of the organization's senior executives, Merrens says.
The multidisciplinary committee is led by a clinical-administrative dyad: Merrens and Chief Operating Officer Patrick F. Jordan III, MBA. Jeffrey O'Brien, MHA, MS, senior vice president for clinical operations, leads two vice presidents who directly oversee the nine work groups. "The individual work groups have other vice presidents, directors, and line managers who are dedicated to their areas, and they work with clinicians," he says.
Orthopedics is a good example of how the command team is approaching the reopening of paused clinical services, he says. "We have people thinking about restarting orthopedics, and they are working with our perioperative vice president, the orthopedics director, the department chair, and section chiefs. They are not only working on trauma—which has not changed during the pandemic—but also how we think about elective cases."
The command team is operating under several guiding principles, Merrens says.
"The first guiding principle has been assessing our situation. If you look across the country, Seattle, San Francisco, New York City, Boston, Chicago, and New Orleans have all had different experiences in the pandemic," he says. "We have flattened the curve in our region, so we can plan and think about what comes next. If you are in a situation like New York City, where the ICUs were filled, it can be overwhelming."
The command team is committed to simultaneously providing COVID-19 care along with a wide range of other medical services. "What we have been able to do is to think about the pandemic as a long-term process in our region. We have had low levels of infection rates—probably less than 10% of the population. This does not lend itself to herd immunity, but it does lend itself to doing COVID care and regular care at the same time," Merrens says.
Ensuring there is an adequate supply of PPE is essential. "We have had tremendous donations from the community. We have been able to source PPE with colleagues across northern New England. We have implemented a process of recycling our N95 masks—we have a hydrogen peroxide vapor system that allows us to reuse masks. Everyone on the staff has their own mask. Once they use the mask, it can be sterilized," he says.
Academic activities are a significant element of the recovery process. Dartmouth-Hitchcock has assembled a team of experts in microbiology, epidemiology, and lab services to conduct innovative research such as nearly 30 clinical trials related to the coronavirus pandemic.
Meeting community needs is a priority, Merrens says. "That could be COVID care. That could be routine screening. That could be childhood immunizations. That could be hip replacements."
Pandemic's silver lining
The COVID-19 crisis has been a driver of innovation at Dartmouth-Hitchcock, Merrens says. "The pandemic has allowed us to rapidly adopt different ways of doing things—whether it is telehealth or expanding our workday. It has allowed us to make changes that we might not have made as rapidly before the pandemic. We have been able to use the pandemic as an opportunity for positive change."
The height of the pandemic and the reopening process will have a lasting impact on the health system, he says. "This will fundamentally change who we are and how we provide care. So, this is not getting back to how we were doing things before—we will always do things differently in the future."
Reassigning medical staff to serve in new roles such as the ICU setting has been a crucial care strategy during the coronavirus pandemic.
Particularly in hotspots such as New York and New Jersey, medical staff shortages have been a hallmark of the coronavirus pandemic, requiring reassignment of staff to new roles.
To avoid being overwhelmed by coronavirus disease 2019 (COVID-19) patient surges, health systems and hospitals have redeployed medical staff to fill gaps and bolster the ranks of frontline healthcare workers. For example, anesthesiologists have been reassigned from performing elective surgery to providing respiratory care in the ICU setting.
Brian Lima, MD, surgical director of heart transplantation at Northwell Health's North Shore University Hospital in Manhasset, New York, was reassigned to care for seriously ill COVID-19 patients in a converted hospital ICU. He also is an associate professor of cardiothoracic surgery at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York, and author of a recently published book, Heart to Beat.
Lima recently shared his insights into the successful reassignment of healthcare workers with HealthLeaders. The following is a lightly edited transcript of that conversation:
HealthLeaders: For healthcare workers, what is an effective mindset for reassignment?
Lima: In a pandemic, it's all hands on deck. Everybody has to contribute. For me, I ceased being a cardiac surgeon and became a COVID doctor. At the same time, this is what we trained for. We trained to help people and to save lives. This is what the Hippocratic Oath is all about.
You have to take it one day at a time. Do the best that you can and give it your all.
It has to be a growth mindset. You see the growth mindset in a lot of the entrepreneurial literature. When there is an unexpected development or negative outcome, instead on getting down on yourself or slipping into pessimism, you flip it into a positive. If it is a single event, that is not going to define you as a person or a professional.
In this instance, no one saw the pandemic coming and it is a devastating crisis, so you have to try to flip it to a positive lens. This is an opportunity to grow. This is an opportunity to help others. It is not about you—it is about doing good for as many people as possible.
HL: How did you turn responding to the pandemic to a growth mindset?
Lima: I felt that I took care of critically ill patients all the time. As we converted our cardiac ICU into a COVID ICU, I realized these were also critically ill patients with lungs being devastated by the virus. So, it was a matter of pivoting in the way that I take care of critically ill people and going more in depth into one organ system and managing ventilators.
HL: What are the key elements of training and preparing healthcare workers for reassignment?
Lima: What worked well for us is that there were some physicians who were well prepared for reassignment—they spend a lot of their professional time managing complicated patients on a ventilator. We had refresher training with these specialists through Zoom and refresher documents, so we were all on the same page.
We established an approach for critically ill COVID patients and developed a check list for how we were going to progress through our ventilator management. So, it was nice to have concentrated expertise and to disseminate that expertise to physicians who were getting back into the fray in the area of acute respiratory distress syndrome.
It also is important to have backup, so you are not being put on an island all alone. You could always call upon others—we were all in this together. There was a lot of support from physicians who specialized in respiratory failure. It helped reassigned physicians feel comfortable in working with COVID patients.
HL: Based on your experience of reassignment to the respiratory failure ICU setting, what are the keys to success in functioning well in a reassigned role?
Lima: At the individual level, you have to check your ego at the door. Although you may be expert at a specialty, in this environment, where knowledge about the coronavirus is changing daily, you have to be humble. You have to be willing to ask for help, and the help has to be readily available.
It takes courage. Healthcare workers are in a situation where we have an imminent risk to ourselves and to our families at home. You need the courage to face that fear every day and to continue to do the right thing for the patients.
You need to have compassion. Many of these patients don't do well. This is a horrible disease—a very aggressive infection. Despite our best efforts, sometimes the patients don't pull through. Sometimes, all you can do is be compassionate for the patient in their waning moments. There is no family there for the patients because of the strict visiting rules, so being a surrogate loved one for the patients and being merciful and compassionate is huge.
HL: Are there pitfalls to avoid when assigning healthcare workers to new roles?
Lima: You want to give people the opportunity to contribute and help. You should not make reassignment like a demand. Getting buy in is key—you can't come across as being authoritative. Most—if not all—healthcare workers will step forward. For example, in our department, we volunteered to be reassigned.
Having enough personal protective equipment goes a long way because that's one thing you don't have to worry about. Not having enough PPE is a huge pitfall.
HL: How do you foster willingness for reassignment?
Lima: It comes from the top down. You lead by example. If your leadership is volunteering in the trenches, others will follow that example. In my department, our chair, Dr. Alan Hartman, told us he was volunteering to help cover COVID patients, and we all agreed to do the same. We were not told to accept reassignment, we went along with him.
