Breaking Silos: The Team-Based Approach to Coronavirus Disease 2019 Pandemic Staffing
2020; Wolters Kluwer; Volume: 2; Issue: 11 Linguagem: Inglês
10.1097/cce.0000000000000265
ISSN2639-8028
AutoresBrett R. Anderson, Natalia S. Ivascu, Daniel Brodie, Jeremy A. Weingarten, Seth Manoach, Anthony Smith, Konstantin Millerman, Natalie Yip, Grace Su, Christa Kleinschmidt, Felix Khusid, Murray Olson, Beth Hochman, Laureen L. Hill, Kristin M. Burkart,
Tópico(s)COVID-19 and healthcare impacts
ResumoTo the Editor: As coronavirus disease 2019 (COVID-19) spreads across New York, it became apparent that there were not enough ICU beds, ventilators, or staff to accommodate patients flowing in through our emergency rooms. NewYork-Presbyterian (NYP) is one of the largest healthcare delivery systems in the United States, inclusive of two large academic medical centers (Columbia University Irving and Weill Cornell), six regional hospitals serving some of the hardest hit areas during the pandemic, and one of the nation's leading children's hospitals. Like many hospital systems, NYP typically functions at or near 100% ICU capacity. Even as all elective hospital activities stopped, all pediatric patients were consolidated to a single children's hospital, and mental health patients consolidated in a single psychiatric facility, it was immediately evident that patient demand in our emergency rooms and ICUs would soon outstrip even this enhanced capacity. The authors of this manuscript were convened in real time to form a novel, intercampus leadership team, inclusive of hospital administrators, physicians, nurses, respiratory therapists, and facilities experts. The first aim was to identify minimum physical space, equipment, and personnel needs to provide care to ventilated patients under crisis conditions and then to design novel, coordinated staffing models that could be adapted for both our largest academic medical centers and our smallest regional hospitals. After systemwide standards were set, similar integrated leadership teams were designed within each campus, who met daily over the subsequent two and a half months in the Spring of 2020 to coordinate unit openings (and then closings) and directly oversee staffing. Over 3 weeks, we expanded from 422 ICU beds to nearly 1,000, with new units opening every 2–3 days, as quickly as facilities and staff could be readied. Auxiliary emergency power supplies, centralized monitors, alarms, oxygen support capabilities, renal replacement therapy drainage solutions, and suction systems were installed and tested daily in general medical/surgical floors, operating rooms, catheterization laboratories, emergency rooms, endoscopy suites, and cafeterias. In some cases, ICU patients numbered up to five per room and baby monitors and iPads were required to help teams see and hear patients who lay in converted beds behind closed, windowless doors. Novel staffing models shifted critical care attendings into supervisory "Oversight" roles to spread expertise across up to 50 patients at a time and built new, nontraditional teams around them, with rapidly upskilled nurses and other staff (1). As we reflect upon successes and failures of our Spring 2020 COVID-19 surge response, we have identified three key lessons that helped our teams thrive. We describe here in detail the teams we built and the types of people who were able to fill each role. We discuss the lessons we learned during implementation and our visions for the future of critical care, in hopes that this might provide a roadmap for others were they to face similar crises. PROVIDER SKILLS AND KNOWLEDGE WORKED SYNERGISTICALLY At our peak, we functioned at ~250% of our precrisis capacity. Over 3 months, we admitted approximately 10,000 COVID-19 positive patients. Although it was clear that the knowledge and skills of critical care physicians, critical care nurses, and respiratory therapists (RTs) were essential to providing optimal care, there simply were not enough ICU providers—or even internal medicine trained providers—to meet our increased demand via standard care models. It was also clear that, unlike the diverse patients typically admitted to ICUs, patients with COVID-19 had relatively homogeneous initial presentations. We therefore broke down the traditional roles and titles of physicians, nurses, and advanced practice providers (APPs) and developed de novo teams. Some clinical fellows were credentialed as attendings. Some attendings served as interns. Some APPs supervised attendings. Nurses, physical therapists, perfusionists, and other medical professionals relieved some of the tasks of RTs. Physicians and APPs, likewise, assisted in some of the nursing tasks. In addition, we developed and deployed just-in-time trainings. Similar to other novel models described during this pandemic (2–5), we spread critical care attending expertise across up to 50 patients at a time and built nontraditional teams around them, based on predefined competencies. In our models, we assigned "Leads" as attendings of record and carefully developed groups of non-ICU "First-Call" and "Second-Call" providers, nurses, and RTs, who worked synergistically to deliver most of the on-the-ground care. Figure 1 and Table 1 describe roles in detail. First calls were largely responsible for close attention to a small number of patients, presenting on rounds, writing rounds, and alerting the rest of the team to concerning changes. Second calls supervised first calls and assisted in more advanced decision-making. In addition, ICU Leads (who were not ICU attendings) functioned in a more traditional attending role, leading rounds, writing patient notes, and guiding major care decisions, with ICU attendings in the role of Oversight Attendings, supervising multiple ICU leads and teams. The oversight role had no note writing responsibilities, allowing them to expand the volume of patients on whom they rounded, but ICU Leads wrote notes on each patient as a unit attending traditionally would. Some centers were also supported by remote Oversight Attendings, either from within our medical system or outside, who partnered with in-house teams to off-load select patients or decisions that do not have immediate hands-on needs (6). Nursing models were designed similarly, as described in Table 2 and Figure 1, and a central nursing deployment team met daily to coordinate staffing across all campuses. Depending on the acuity and additional supports within each unit, ICU level nursing ratios increased from 1:2 to a maximum of 1:6. Gracious assistance from nurses from outside the region eased the stretch at many of our campuses. Challenges of nursing staffing implementation, documentation, and nursing-specific lessons learned are described elsewhere (7). TABLE 1. - Physician and Physician Extender Staffing Roles During Coronavirus Disease Emergency and Examples of Providers Who Successfully Filled These Roles I) Oversight II) Lead III) Second call IV) First call V) Remote ICU attending VI) Novel COVID-19 consult teams Role Supervise across units Manage complex vent decisions, multiple organ system, and escalations Oversee unit team Manage daily medical decision-making Coordinate care across services Progress notes Supervise first calls Assists in general medical decision-making Closely attend small number of patients Writes orders Follows-up labs Alerts others to changes Document Partner with in-house teams to off-load select patients or decisions that do not have immediate hands-on needs Augment specific floor team skills and relieve team of time-intensive activities Personnel Profile (Examples of people who might fill roles) Oversight: Comfortable with and used to being the attending of record, managing 15–20 ARDS patients, ready to be stretched to < 50/pts. (Medical intensivists) Lead: Comfortable with vent management and critically ill patients; requires support on complex in patient medical management. (General medicine and medicine subspecialist attendings; pediatric intensivists) Medicine/Surgery Second: Experience rotating through medicine/surgical ICUs. (Medicine and surgery fellows and third year residents, and medical ICU advanced practice providers can also be filled by fellows and attendings) Medicine/Surgery First: Experience managing medicine/surgery patients & experience writing orders, documenting, tracking details. (Medicine, surgery, or anesthesia first- and second-year residents or advance practice providers; senior residents, fellows, and attendings can also fill this role) Local Remote Attending: (Intensivists on isolation secondary to COVID-19 or who cannot be in-house for other reasons) Intubation Team: Intubated and changed endotracheal tubes. (Intensivists, ICU fellows, respiratory therapists, and ICU nurses)Crash and Stabilization: Optimize initial ventilator and inotrope setting. (Intensivists, ICU fellows, respiratory therapists, and ICU nurses) Oversight with Support: Intensivists, used to caring for complex adult patients, but who might need teaching or support on nuanced ventilator management or adjunct therapies for ARDS. (Neurologic, pediatric, cardiothoracic, surgical, and burn intensivists) Lead with Ventilatory Support: Comfortable with complex in patient medical management outside the ICU; requires support on vent. (General medicine and medicine subspecialist attendings; some pediatric cardiology attendings) Experienced Second: Attending/senior fellow experience (team leadership/supervision and information synthesis) outside of scope of lead. (Medicine, surgery, and pediatrics attendings; PICU, pediatric cardiology, and pediatric pulmonary fellows) Other First: Experience writing orders and some exposure to inpatient medical care. (Residents, fellows, and attendings from a wide range of fields were successful in this role, as long as there was some medicine and order writing experience on the team. Examples included: psychiatry, physical medicine and rehabilitation, neurology pediatrics, etc.) Distance Remote Attending: (Intensivists at other institutions around the country) Procedure Team: Place central venous and arterial lines, chest tubes, feeding tubes, and others. (Surgeons, interventional radiologists, and other proceduralists)Proning Team: Prone patients on ventilators. (Respiratory therapists and physical therapists worked jointly) Lead with Other Support: Experience with medically complicated patients, but limited attending/team management experience. (Senior medical intensive care and cardiology fellows) Anesthesia Ventilator Management Team: Assist with respiratory adjustments for patients using anesthesia machines. (Anesthesia residents and anesthesia advanced practice providers)Family Communication Teams: Update families on patients' progress and assist families in making decisions regarding goals of care. (Palliative care, psychiatry, oncology, and others for complicated communications) Ratio One provider: ≤ 50 patients One provider: 12–20 patients One provider: 12–20 patients 1 provider: 4-7 patients Expand as needed Expand as needed ARDS = acute respiratory distress syndrome, COVID-19 = coronavirus disease 2019. TABLE 2. - Adult Nursing Skill Levels by Role A1) Clinical support A2) Medical/surgical A3) Step-down unit A4) Emergency department A5) Intensive care Take vitalsBasic health screenings All A1 skills, plus the following… All A2 skills, plus the following… All A3 skills, plus the following… All A4 skills, plus the following… Assisting with patient flow (admissions, transfers, and discharges) Admissions, transfers, and discharges Basic cardiac monitoring Cardiac monitoring Hemodynamic monitoring Assisting with daily patient activities (meals, grooming, ambulation, etc.) Use of IV pumps, including patient-controlled analgesia Some inotrope infusion Vasopressor and inotrope infusion Arterial line management Maintain patient environment Safe medication administration Some limited mechanical ventilator management Mechanical ventilator management Assist phone calls (discharge, family communications, etc.) Blood transfusions Airway management Monitor and support personal protective equipment Enteral feeding Advanced life support and emergency resuscitation Basic life support trained Point-of-care testing Cardioversion and defibrillation Peripheral IV insertion and maintenance Central line maintenance and care Foley catheter insertion and maintenance Wound dressing and care Figure 1.: Integrated team staffing approach during coronavirus disease 2019 pandemic.Although we draw our models as pyramids, they functioned best conceptualized as synergistic teams. All members of the team—Leads included—were expected to be physically on their units 24 hours a day, assisting in any way needed. Our guiding principle was that there were essential characteristics needed within each team, but that these characteristics did not all have to reside within every provider. These characteristics included the following: internal medicine expertise, comfort managing critically ill patients, knowledge of mechanical ventilators, team management experience, and order-writing capabilities. In one unit, for example, a cardiologist-led team was supported by pediatrics fellows and attendings, psychiatry, surgery, and physical medicine and rehabilitation residents, alongside experienced nurses and RTs. This team initially reported a gap in ICU-protocol awareness. A medical ICU nurse practitioner, therefore, was added. Overnight, teamwide knowledge of and adherence to ICU protocols and provider comfort improved. In another, fellow-led team, where more team management expertise was needed, a pediatrics attending was added in the Second-Call position, with similar reported relief. Sometimes differences in expertise resulted in slightly different rounding structures, and our management teams worked to empower each unit to regroup as necessary. Some units, particularly after rounds and at night, split teams in half, teaming more experienced first calls with the team's second call and less-experienced first calls with the ICU Lead, in a divide-and-conquer approach. To augment provider skills and relieve time-intensive activities from critical care teams, novel COVID-19 consult teams were also developed (Table 1). Examples included: Intubation Teams; Crash and Stabilization Teams to optimize initial management of respiratory failure and shock; Procedural Teams to place central lines, chest tubes, etc.; Proning Teams; Anesthesia Ventilator Management Teams for patients receiving invasive mechanical ventilation via anesthesia machines; and Tracheostomy Teams. Similarly, many end-of-life discussions were shifted to palliative care, psychiatry, ethics, and Oversight Attendings, to alleviate moral distress within the primary teams. In some units, providers with less patient care experience (such as radiology and pathology residents) were used as scribes to reduce the burden of daily note writing for ICU Leads, assisted with bedside imaging, etc. Lessons learned were that many skills make up an ideal critical care team, but these characteristics can come from any member of the medical team. TRANSPARENT FREQUENT COMMUNICATION IMPROVES TEAM STRUCTURE AND ANXIETY We did not succeed in balancing all provider teams on our first iteration. Furthermore, as our redeployed providers gained experience with COVID-19 patients, some units became relatively overstaffed. We found that overstaffing—rather than instilling a sense of relief—caused its own distress; providers are worried that they had been forgotten. Additionally, as teams stretched for longer and longer periods, it became hard for some to imagine others could be equally taxed. Transparency helped right-sizing our staffing for each unit, reminded providers they were not alone, and empowered them to adjust daily unit operations to fit their teams. This process involved daily communications from senior leadership and centralized teams. Our Executive Vice President and Chief Operating Officer provided a regular address to the entire healthcare system to describe federal, state, and local changes impacting care, detail COVID-19 patient volumes in our health system, and outline changes in hospital policies and conditions. Centralized staffing teams followed up with one-on-one conversations with departmental leaders and on-the-ground providers to understand the strengths and stretch of each department's providers, communicate the stretch of other teams, and continuously adjust staffing. Lessons learned were that transparent and abundant communication was critical to maintaining a sense of equity. MORAL DISTRESS REQUIRES ACTIVE ATTENTION We noted at every level of provider teams, a stressor was present beyond the volume and extreme intensity of patient care. The mobilization of a new critical care workforce nearly overnight was only possible by advancement in rank, reassignment to new work and unfamiliar locations, and stretch for breadth over depth. It was uncomfortable and unsettling. Even senior intensivists reported nightmares and difficulty sleeping. There was an ever-present self-questioning by staff. Calming these concerns required extensive intention by Oversight Attendings and leadership. Multiple mental health and wellness resources, including free individualized counseling, were rapidly erected and conscious messaging was implemented from all levels of clinical and hospital leadership to help staff with the notion that crisis standards of care meant that care processes were different from those to which people were accustomed, but that high-quality care could still be delivered (3). In our units, we noticed a few operational characteristics that exacerbated or alleviated moral distress. Teams expressed greater moral distress in "pop-up" units in which the physical layouts (combined with the need to conserve personal protective equipment) resulted in the isolation of our teams. They were also more likely to describe moral distress when the team composition changed frequently or they were rotated from one unit to another. Teams that included nurses with more inpatient and ICU experience/oversight also described lower levels of moral distress. Lessons learned were that psychologic stresses were widely felt and required active and continued attention. Although upskilling of providers is possible in the acute setting, preemptive trainings, smoothing of work schedules would ease provider anxiety for future surges. We recommend planning and disseminating work expectations as early as possible, mitigating reliance on residents and fellows, and allowing for deviation from a standard 7-day work week in order to encompass sufficient rest. PLANNING FOR THE FUTURE In the beginning, there was significant fear about ventilators and other equipment shortages. We modified much of our physical plant and worked in a global supply network 24 hours a day. In the end, we procured adequate ventilators and other essential equipment and supplies; it was the human capital that was most critically in need. Hospital staffing in the United States is lean; hospitals fail if they do not operate at or near capacity the majority of the year (8). We saw during our COVID-19 surge that we were able to stretch to meet unprecedented patient demand, because leadership, physicians, nurses, respiratory therapists, and APPs from across our medical system worked synergistically. Our models were flexible and able to fit both large academic centers and small regional hospitals. Our response, however, also relied on the grit and resilience of our providers. Transparency assisted with morale, but attention to moral distress was critical. We, therefore, must identify ways to support our providers, invest in resources that offload nonclinical work, and expand the workforce to meet future needs. As we plan for resurgence and look to the future, we have the opportunity to reimagine the role and structure of critical care. Historically, critical care focused on rescuing patients who were already decompensating and care was provided in the confines of the ICU. Over the last 2 decades, critical care adapted to expand resource-limited provider pools and evolved to emphasize early recognition and preventative management strategies. Implementation of electronic ICUs—remote monitoring (sometimes from the other side of the world) and machine learning—to assist hospital teams in early identification of decompensation is the representative of these changes. Simultaneously, critical care's footprint expanded beyond the brick and mortar units with the creation of intermediate care units, and critical care rapid response and triage teams (9). During our Spring 2020 COVID-19 surge, in the face of exponential ICU demand, we cut holes in walls, used baby monitors to see behind oak doors, and built ICU teams with cardiologists, psychiatrists, and pediatricians alike. We upskilled on the fly and became one unified team. Coming out of this experience, we have not only the opportunity but also the obligation to adapt, to innovate, and to meet the ever-changing needs for critical care medicine, whether it be high volumes during influenza season, a pandemic, such as what we experienced with COVID-19, or a natural disaster. As we look ahead, although we want and need many of our specialists to return to their niches, there is much good that can be learned from 3 months in which our silos were broken. As we envision the future of critical care, we aim to create a dynamic critical care model that readily adapts to meet critical care needs, both for daily surges and for surges seen with pandemics or natural disasters. We envision an expanded bench of wired, intermediate-care units, with improved patient visibility and upskilled staffing, so that they are able to rapidly be flexed up into ICUs or down into general medical or perhaps even rehabilitation units. These flex rooms will be geolocalized next to our current ICUs to promote comradery and training. The ability to flex up permits much ICU level care to be provided safely anywhere in the hospital even when ICUs are at capacity, similar to obstetric rooms flexing between the patient rooms and delivery rooms. Physicians, in consultation with nursing, will then determine how beds are used, rather than allowing bed availability to dictate care. Since our Spring 2020 COVID-19 surge, we have and continue to expand training programs to upskill providers, including nurses, APPs, and noncritical care physicians. A plan for continuous nursing education has been implemented. For example, medical and surgical nurses are being trained to use central and arterial lines and manage insulin drips and other basic ICU care. Procedural nurses are being taught to select inpatient nursing skills. Educational content on basic critical care developed during our first surge is being adapted and delivered to physicians and APPs throughout our healthcare system. We envision even greater integration of ICU and palliative care nurses, supported by ICU and palliative care attending physicians, into step-down units and floor teams. Repurposing some of the Novel COVID-19 Consult Teams might also offload time-intensive activities for critical care providers and expedite care, while potentially providing expanded opportunities at our teaching hospitals for interdisciplinary trainee education. This opportunity and obligation to meet the needs of all critically ill patients expand beyond the walls of a single institution or healthcare delivery system. Thought leaders, hospital administrators, and the critical care community must think bigger, breaking down our silos and working around institutional financial pressures. We must work together, developing programs for coordinated intersystem transfer of not only patients but also resources and staff, allowing for greater economies of expertise and clinical care, while planning ahead to address the strain on emergency medical services. Now is the time to consider and develop the infrastructure and operations, planning for a centralized, citywide (regionwide) command center to help individual hospitals and healthcare systems communicate and share resources during crises to mitigate disparities in staff, space, and supplies. As the country begins to reopen and we watch intently to see if hospital admission rates in other parts of the country will follow the path of New York, we hope these lessons and thoughts will help us all be better positioned not only for the next crisis, whatever and wherever that might be. Brett R. Anderson, MD, MBA, MS, Department of Pediatrics, Division of Pediatric Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY; Natalia S. Ivascu, MD, Department of Anesthesia, Division of Critical Care Anesthesia, NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY; Daniel Brodie, MD, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center/NewYork-Presbyterian, New York, NY; Jeremy A. Weingarten, MD, MBA, MS, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, NewYork-Presbyterian—Brooklyn Methodist Hospital, Brooklyn, NY; Seth M. Manoach, MD, Department of Medicine, Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian—Lower Manhattan Hospital/Weill Cornell Medical Center, New York, NY; Anthony J. Smith, MD, Department of Medicine, Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian—Queens Hospital, Queens, NY; Konstantin Millerman, MD, MPH, Department of Medicine, Division of Critical Care Medicine, NewYork-Presbyterian—Lawrence, Bronxville, NY; Natalie H. Yip, MD, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center/NewYork-Presbyterian, New York, NY; Grace Su, MEd, MS, RN, DNP, Department of Nursing, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY; Christa Kleinschmidt, MS, RN, Department of Nursing, Division of Cardiac Nursing, NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY; Felix Khusid, RRT, Department of Respiratory Therapy, NewYork-Presbyterian—Brooklyn Methodist Hospital, Brooklyn, NY; Murray Olson, RRT, Department of Respiratory Therapy, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY; Beth R. Hochman, MD, Department of Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY; Laureen L. Hill, MD, MBA, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY; Kristin M. Burkart, MD, MSc, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center/NewYork-Presbyterian, New York, NY
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