By: Thomas Sugarman, MD and Hartwell Lin, MD
As COVID-19 surged through New York City this spring, local hospitals increased their ICU capacity by 500%. But despite this feat, they still hit a wall.
They didn’t have enough critical care physicians to staff those beds.
The takeaway: when it comes to pandemic preparedness, your clinical staffing plan is every bit as important as your facilities plan. You not only need more beds and providers; you also need the right expertise — plus systems to support and manage it.
As emergency physicians, we learned this firsthand while providing critical care relief in New York.
In April, California Gov. Gavin Newsom’s office asked our physician group, Vituity, to provide clinical support to New York City Health and Hospitals. In addition, we were charged with helping develop policy recommendations to prepare California for future COVID-19 surges.
When we arrived at our assigned hospitals, we were moved by the resilience of the New York City providers, who had been working tirelessly for weeks. At the same time, the process of integrating relief physicians with diverse backgrounds into clinical care proved complicated – especially as knowledge of COVID-19 changed daily.
Many local physicians assigned to the COVID-19 unit had minimal experience managing ICU patients. (Imagine a psychiatrist or pediatrician who hasn’t changed a central line since medical school.) As emergency physicians, we were comfortable with critical care procedures and resuscitation but were less experienced with ongoing management. We therefore depended on local physicians for both clinical direction and practical help navigating our new hospitals.
Fortunately, the strong climate of teamwork meant no provider was left behind. In addition, we were supported by Vituity critical care partners, who were available to advise and consult with front-line volunteers.
So how can health systems plan now to staff a potential surge? Here are our recommendations.
1. Adapt Your Clinical Command Structure
Because the New York City hospitals had far too many ventilated patients for the available pulmonology/critical care physicians to manage, they implemented an effective pyramid model.
- Native intensivists and pulmonologists (1-2 per hospital) served as both clinical experts and incident commanders who coordinated needed resources with hospital administration.
- Each COVID-19 unit was managed by intensivist fellows or physicians with critical care experience. Emergency physicians sometimes filled this role when needed.
- Finally, teams of clinicians consisting of an attending, resident, and intern from various specialties managed direct patient care. Physician assistants provided additional bandwidth, sometimes replacing interns and performing many procedures.
- Additionally, dedicated clinical teams covered night shifts, and specialist teams were available for renal, infectious disease, cardiology and related consults.
Relief clinicians were plugged into the pyramid based on expertise. Each team included local physicians familiar with the hospital.
2. Build Your Team in Advance
While the exact composition of your clinical pyramid will be situation-dependent, it’s never too early to start identifying key leaders. Imagine your hospital sees a three-to-ten-fold increase in critical patients. What roles you can fill from within your health system? If you notice gaps, start reaching out now to potential clinical partners.
Consider how you will integrate visiting doctors, including those working outside of their specialties. It’s vitally important that your local clinical leaders connect with incoming relief physicians to ensure they understand their responsibilities and points of contact.
Also consider logistics. When possible, centralize or outsource credentialing, travel, scheduling, training, orientation and related tasks to free up bandwidth for your front-line clinicians. It’s usually easiest to work with one or two organizations that can supply the specialists you need. Some physician groups also have the infrastructure to assist with the logistics.
3. Connect Daily with the Front Line
Finally, as a healthcare leader, stay engaged with your clinical teams. While centralized support is essential, rapidly shifting knowledge of COVID-19 requires agile decision-making that is best left to front-line providers.
Perhaps the best way to harmonize executive and clinical agendas is through daily outreach. Identify pain points and help to create solutions. Giving your teams just 10 to 15 minutes of undivided attention sends a message of support and solidarity.
In Summary
Adding beds may be the easiest part of preparing for a COVID-19 surge. Don’t forget to give equal attention to clinical capacity, including onboarding, scheduling, and providing practical and moral support to your expanded teams. Ensure that leadership stays visible and keeps communication lines open. Having a well-prepared surge plan along with leadership support will go a long way toward improving patient outcomes and boosting provider morale.
Read more insights from the New York City delegation.
Thomas Sugarman, MD, helped coordinate and deployed to New York City with the Vituity delegation. He is a practicing emergency physician and assistant medical director.
Hartwell Lin, MD, led the Vituity delegation of more than 50 clinicians to New York City. He is a practicing emergency physician, regional director, and elected member of the Vituity Board of Directors.
Article top image credit: Ventdusud via Getty Images