The CEO of Montefiore Medicine in New York knows exactly what he would have done if he had to go back in time before COVID-19 hit the city.
“I think if we had a crystal ball and we could have somehow stockpiled [personal protective equipment] well beyond anything we thought we could ever use in the next five years, that would have had an impact,” said Philip Ozuah, M.D., who is also a professor in the epidemiology and public health department at the Albert Einstein College of Medicine.
“We went from consuming a handful of such masks a day to over 100,000 a day," Ozuah said while speaking at a recent virtual event hosted by The Atlantic about the spike in severe coronavirus cases that hit New York and New Jersey hospitals especially hard at the beginning of the pandemic.
Now, as hospitals elsewhere across the country are facing their own COVID-19 surges, they are applying lessons learned in New York and other initial hot spots to ensure they have enough capacity and supplies.
After what appeared to be a "flattening" of the spread of the virus, COVID-19 hospitalizations began rising dramatically across the country, with a total of nearly 60,000 as of July 22 compared with 28,615 on June 19, according to data from the COVID-19 Tracking Project.
Arizona is one of those states experiencing major spikes in COVID-19 hospitalizations, and the state is applying strategies it employed back in April as cases surged in New York.
“Our [intensive care units] are full. Our telemetry units are full and our COVID-19-designated units are full,” said Charley Larsen, registered nurse senior director at Banner Health, a hospital system with a large footprint in the state. “Because we watched others do this we are prepared.”
Load balancing patients and staffing
A major way that Arizona prepared for a COVID-19 surge is the development of a statewide “surge line” that enabled the system to balance patient loads across the state so no single hospital got overwhelmed with COVID-19 patients.
“When we first set up the surge line, we looked at how many beds were in the market and who owns those beds,” said Larsen, who helped develop the state-run line, in an interview earlier this month.
The state worked with information technology company Central Logic to develop a platform that pulls data from each hospital on bed availability and other information such as staffing and equipment. A team of clinicians collects the data and then uses the information to determine where to send patients.
“We go round robin and try to divide patients so it ensures one organization doesn’t get overwhelmed,” Larsen said.
Elsewhere around the country, health systems have found other ways to load balance patients between their facilities. A hospital system should work to transfer patients to their outlying facilities to conserve resources at their main tertiary hospital, which is the hospital in a system with most specialties, said Paul Haskins, an emergency physician and medical director of Virginia-based Carilion Clinic’s Transfer and Communications Center.
‘Most hospitals will directly transfer to their tertiary hospital,” Haskins said. “By making efficient use of all the hospitals in your system, you can load balance and create more capacity by using smaller hospitals efficiently and not bringing everybody to your tertiary hospital.”
But ensuring there is enough capacity comes with its own set of challenges, as Larsen found out.
"We found staffing is just as much of a challenge," he said. "We may have beds available, but we don't have the staff to man those beds."
So Arizona is deploying a tactic used by hospitals in New York and New Jersey: bringing in emergency nurses from other areas. The state is relying on emergency nurses from COVID-19 units in New York and New Jersey to help get through their own wave of COVID-19 cases.
Rethinking the supply chain
PPE shortages have been a constant problem for hospitals that aren’t even in a COVID-19 hot spot.
Price hikes from suppliers and requirements from states and systems to stockpile the vital equipment has continued to exacerbate shortages that first wracked hospitals in New York like Montefiore.
The pandemic has pushed hospitals to completely reevaluate how they manage their supply chains, giving a greater voice to its supply chain managers.
“We absolutely have to have a seat at the leadership table,” said Jim Churchman, vice president of system supply chain for MedStar Health hospital system in the Washington, D.C., area. “That is a pivot that healthcare is going through.”
Churchman said on a webinar earlier this month hosted by the American Hospital Association that the biggest challenge he has faced from COVID-19 is the lack of standardization in supplies. “Procurement out of our typical channel is probably front and center,” he said.
Hospitals have routinely had to find alternative sources of PPE as their regular suppliers either got hampered by delays from overseas manufacturers, a lack of supplies from a federal stockpile or massive demand. The problems even led some hospital systems to buy a stake in a domestic PPE manufacturer to ensure they have enough capacity if things get worse.
The mad scramble has demonstrated the importance of increased direct communication between the supply chain management teams and clinicians. When the health system is forced to take products that may not represent the system’s standard, supply chain managers can “coalesce quickly with our clinical teams to make sure we are not injecting supplies into our environment that goes without approval,” Churchman said.
Hospital systems are also rethinking whether to invest in new technology in their supply chain.
Churchman said if you walk into a retail store and they don’t have a coat you want, the store can tell you exactly where in the nation it is and ship it to you. Now, there is starting to be an impetus to implement the same type of technology in healthcare for PPE.
“Historically, supply chain is not at the front of the line for technology investments per se because we are trying to invest those capital dollars into direct patient care,” Churchman said. “But I think a lot of people are starting to see now how there is a direct correlation with these point-of-use type inventory systems and what a necessity it is.”
Whether it is PPE, load balancing or staffing, systems are needed now to take an inventory of where they are and be ready if a surge of COVID-19 comes tomorrow or in the fall.
“Heed the warning,” Larsen said. “Get your tech in place and plans, bed visibility and staffing ready.”