The Doctor’s Advocate | First Quarter 2021
An Ounce of Prevention

Flexibility and Communication Save Lives in NYC: Incorporating Lessons Learned Through Waves of COVID-19

Andrew D. Racine, MD, PhD, Systems Senior Vice President and Chief Medical Officer, Montefiore Health System, and Executive Director of the Montefiore Medical Group

In spring 2020, residents of River Park Towers in the Bronx dubbed their home the “Death Towers” when neighborhood rates of coronavirus infection spiked.¹ Home to many essential workers, including some on the healthcare frontlines, the Bronx is also home to Montefiore Health System.

On March 10, 2020, Montefiore Health System admitted its first COVID-19 patient. One month later, we had 2,000 COVID-19 patients in the hospital. Over the course of that spring, our 11-hospital system cared for more than 12,000 patients hospitalized with COVID-19.

While we are proud of how we handled the first surge, we now know so much more. Those lessons, learned at a profound cost, provide valuable insights for managing what remains of this pandemic—and the next one.

We remain aware of three factors: (1) our physical responses to the pandemic; (2) our mental responses to the pandemic; and (3) the central role of clear, empathetic team communication.

PHYSICAL RESPONSES

SPACE

First Surge: In the spring of 2020, lack of standard bed spaces forced us to establish alternative care venues overnight. We admitted adult COVID-19 patients into our pediatrics hospital. We converted conference rooms, lab space, dining rooms, ICU space, and OR space. We put a bed any place we could find space.

Now: Pandemics are fought with preventive measures. Fortunately, the government in New York recognized this and, with increased preventive engagement, later spikes in our patient census were less extreme. That could yet change if we do not remain vigilant and aggressive with public health measures. In our hospitals, after learning which spaces are conducive to what level of care, we have elaborated surge plans to be responsive to any contingency.

STAFFING

First Surge: We called upon healthcare professionals not accustomed to looking after patients with COVID-19–related conditions and complications, and they came. Surgeons worked in the ED. Pediatricians cared for adults. Non-ICU nurses looked after ICU-level patients. Via distal monitoring, intensivists monitored patients anywhere in our system 24/7, and they guided physicians from other specialties in the care of those ICU patients in real time.

Now: By soliciting input from frontline staff, we learned how to support healthcare professionals in transitioning from ambulatory to inpatient settings—such as refresher training in skills like monitoring IV medications, oxygen administration techniques, and social support. We learned to train staff in groups, reinforcing team dynamics.

EQUIPMENT

First Surge: Sourcing personal protective equipment (PPE) when every other institution in the region needed the same equipment from the same suppliers at the same time proved chaotic. The same was true for other equipment and supplies: Ventilators, dialysis equipment, sedation medications, testing swabs and reagents, refrigerator trucks, body bags—each presented its own procurement challenges and supply chain idiosyncrasies. There came a point, for example, when we needed trucks to supply enough oxygen for the patients on ventilators.

Now: We’ve had months to stockpile PPE, and we’ve achieved clarity about what layers of PPE are best for which clinical interactions. We are fully prepared to meet any PPE challenges, and we continue to stockpile.

MENTAL RESPONSES

A FLEXIBLE MINDSET

First Surge: Cast adrift in the ocean in the midst of a hurricane, we interrogated everything about our familiar ways of providing care. We asked: Where shall we deploy? What equipment shall we use? Whom can we call upon to act? How should we best communicate the situation to our community?

Now: The once unimaginable is now routine; the once inconceivable is now anticipated. Knowing what we have done gives us the assurance that we can do it again. And we can add plans to our preparations for the distribution of monoclonal antibodies, multiple vaccines, and the belief that an end to this very dark night is in sight.

A CENTRAL COMMAND CENTER

First Surge: Paradoxically, in order to be flexible, we required structure. We needed a command center where responsible leaders could be reached for decisions regarding respiratory equipment, nursing, physicians, etc. Leaders needed a single virtual place where they could coordinate activities twice a day or more.

Now: Our crisis command center leaders have been actively engaged in planning and know that we can now phase our response to rising patient demands.

REAL-TIME DATA RECONCILIATION

First Surge: In mid-March 2020, our internal data collection and modeling (which depended on pandemic trend data from China and Italy) told us that two weeks later, we would run out of ICU beds. Because predictive modeling allowed us to prepare, we were able to add new ICU bed capacity to accommodate what would otherwise have been an impossible demand on our system.

Now: We now have U.S. data—even local data. We pay particular attention to the rate of change in our inpatient census. Linear increases are easier to accommodate than when the slope of that increase is itself increasing. The lesson: If you see the line on the chart bending, act quickly.

PROACTIVE BEHAVIORAL HEALTH

First Surge: Given the magnitude of the suffering our staff witnessed, we knew that the levels of psychological distress were monumental. We quickly established telephone access to behavioral health support, not waiting for staff members to call. We matched psychiatrists and other behavioral health specialists directly with individual associates, and the specialists proactively reached out.

Now: We have identified specific quiet areas at each campus. We have also continued proactive outreach, linking psychiatrists with some of our hardest-hit teams to encourage healing as a team-reinforcing goal.

DELICATE VISITATION DECISIONS

First Surge: Visitation was an extremely delicate issue for us. During one period, New York State prohibited visitors. It was our position, however, that visitors cannot be prohibited for pediatric patients, some geriatric patients, or women in labor and delivery. We never agreed, despite the practices at some of our sister institutions, that we would allow women to labor alone. We also made exceptions for people at the end of life. And then, as the visitation protocols eased up, we accommodated even more access.

Now: We will continue to flex our visitation protocols as the situation dictates. With the recognition that coronavirus can be introduced by unsuspecting visitors, we screen everyone who enters the facility.

TEAM COMMUNICATION

FREQUENT, EMPATHETIC, AND AUTHENTIC COMMUNICATION

First Surge: Our president and CEO, Philip O. Ozuah, MD, PhD, decided early on that he would communicate directly with the entire institution—all 40,000 people. He personally screened and answered questions that associates sent.

You can’t communicate too frequently. We were having calls daily or more frequently. As leaders, we had to coordinate to make sure that our message was consistent.

During this time, people were very frightened. They were anxious. Some were angry. They were grieving. Our communications had to acknowledge all of that and lean into it. In the beginning, we could not promise them when the ordeal that we were experiencing was going to end. In addition to empathy, therefore, we needed to speak with authenticity—because people would not accept communications they could not trust.

Now: We continue to maintain our communication values of transparency, authenticity, and empathy. As needed, we will resume direct communications from our CEO and repeat other crisis communication measures. Frequent communications to the entire institution help ensure all team members simultaneously receive the same message.

The Gift of Humility

More than just a disease, COVID-19 is a metaphor for our healthcare system. It has exposed or brought forward many areas of disparity within and beyond healthcare delivery. In working through this pandemic, we’ve learned lessons that apply well beyond the walls of the hospital. It has given us a certain degree of humility.

The best expression of humility that I’ve come across is attributed to Mark Twain: “It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.”

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