Rethinking How Hospitals Operate
By Liv Osby
Hospitals have been preparing for disasters like plane crashes and chemical spills for years, holding annual drills that simulate catastrophes complete with injured and bloodied “patients.”
But like nearly everyone else, they were caught off guard by the coronavirus.
It was new and not well understood. It spread rapidly across the globe. And it has claimed many lives.
Hospitals had to scramble to deal with a shortage of personal protective equipment (PPE) and other supplies, to ramp up testing, and care for a surge of critically ill patients while trying to protect their staffs.
“This is different from any of the mass casualty drills or business interruption scenarios we had prepared for in the past,” AnMed Health CEO Bill Manson told Greenville Business Magazine.
Dr. Brent Powers, chief medical officer at Lexington Medical Center, agrees.
“Any novel infection is going to present new stresses and new problems the team hasn’t worked through,” said Powers. “We don’t even fully understand it today.”
But as the months wore on and the case counts soared, hospitals learned to adapt. And they say many of those changes are likely to remain long after the virus has been controlled.
“The biggest lesson learned is how much care can you deliver without the physical presence of the patient,” said Dr. Danielle Scheurer, chief quality officer for the Medical University of South Carolina.
“And we learned we can do a lot more than we thought we could.”
MUSC rapidly scaled up its telehealth program after most patients, fearful of contracting the virus, shunned in-person visits, she said. And patients were quick to adopt it.
Now MUSC is expanding those services, especially as the coronavirus numbers rise, she said.
Telehealth historically comprised less than 5 percent of AnMed’s outpatient business, but quickly ballooned to more than 60 percent, Manson said via email.
“The use of virtual visits with providers was permanently changed in those first few weeks,” he said. “This might have taken five to 10 years under normal circumstances.”
Telehealth dramatically expanded at Prisma Health too, said Dr. Eric Ossmann, chief of preparedness and vice chair for emergency medicine.
It now covers ICU, EMS and specialist consultations as well, he said.
“A lot of people are finding that not only is it effective and takes care of medical needs,” he said, “but it’s extremely convenient.”
A telehealth platform, though immature, was already in place at Lexington Medical Center, but it was quickly scaled up, Powers said.
Manson said it will be interesting to see whether the regulatory and payment barriers that were lifted to enable telehealth will become permanent.
Scheurer and Ossmann said the traditional care model was less consumer friendly so expanded telehealth is likely here to stay and grow.
As the pandemic hit, Manson also worried about having enough PPE.
“We were using PPE at 100 times the rate we were before the pandemic,” he said. “Clearly the supply chain … even with the national stockpile, wasn’t ready for this.”
So hospitals became more agile and innovative than ever before, whether that meant devising new ways to reuse face masks or a ventilator on more than one patient, Sheurer said.
Today, hospitals are shifting to several sources for supplies instead of a single distributor, she said.
“Pre-Covid, we probably got a little too used to just ordering stuff. We just assume they’ll have it,” she said. “But I don’t think (we) will ever assume that anything is in unlimited quantities again.”’
Prisma set up an incident management team which identified sources and began ordering extra PPE and other supplies immediately, Ossmann said. It also bought a hydrogen gas system that allows N-95 masks to be disinfected and reused.
The hospital continued to stockpile PPE in March and April, he said, and now shares with nursing homes and other community partners in need.
The situation has improved at Lexington Medical Center as well, though there are still pockets of need, including Clorox wipes and disposable gowns, Powers said.
The hospital worked its normal supply chain, but also went directly to manufacturers, buying hundreds of thousands of surgical masks directly from China, he said.
Meanwhile, staff has moved to using individual respirators with changeable filters that can be cleaned between uses, and instead of single-use PPE, use the same equipment all day, he said.
Powers said the nation will need better stockpiles for times like these, adding that the hospital also will keep more on reserve than in the past.
Testing was another problem hospitals faced. Initially overwhelmed, they added drive-through locations, ramped up their own capacity, and established relationships with commercial labs to expand testing volume and reduce turnaround time, changes they say will be in place so long as the virus is with us.
Nonetheless, Manson said that testing remains “a daily challenge for us and many providers.”
Powers said Lexington is still struggling with getting enough reagents for testing, and that the nation needs to dramatically increase its testing capacity.
“We get a weekly allotment of reagents and it lasts a day or two,” he said. “A vaccine is important, but we need more testing capacity.”
Besides ramped up testing, he said spending more on public health would help the nation be better prepared.
On the inpatient side, staff has struggled with restricted visitation, which is hard on patients and meant more work for nurses, Scheurer said.
“We are trying to get creative on communication,” she said. “We have plenty of iPads, Facetime, whatever modality works for the family.”
Another change involved having providers work at the top of their licensure, Scheurer said. That means nurses only do nursing, for example, with less technical tasks performed by assistants, allowing nurses to care for more people, she said. The same holds true for other providers.
And because the federal regulatory burden was eased - eliminating time-consuming reporting of quality metrics, for example - MUSC could stretch the staff by shifting the nurses doing those tasks to more front-line work.
“It was not easy on anybody … but it was a necessary move,” Scheurer said. “And people have … risen to the occasion and just frankly disrupted everything in their personal and professional lives in ways I’ve never seen in the civilian world.”
The hospital also has maximized the use of volunteers, to help with contact tracing, for example, she said.
Indeed, staffing is one of the greatest challenges highlighted by the pandemic, Ossmann said. While Prisma has enough bed capacity to handle a surge, it struggles with having the staff for those beds, he said.
So Prisma is looking for temporary staff, he said. But the country has a shortage of health care professionals that’s been exacerbated by the virus, and other hospitals are looking to do the same.
“It is super hard,” he said. “We literally have people on this 24 hours a day.”
Ideally, there would be extra staff who could be deployed in such cases, he said. The problem is economics.
“The margins are so thin it makes it difficult to justify carrying an extra 10 percent of FTEs (full-time equivalent employees),” he said.
By July 31, Prisma reported that its hospitals around the state had cared for more than 2,138 Covid inpatients and tested more than 114,000 people.
Manson said that while AnMed had used standard isolation procedures for years, it never had so many critically ill patients at once.
Until Memorial Day, AnMed had an average of six Covid inpatients, he said. It had 62 by July 10 and 87 by July 25.
“The hospital staff was very familiar with taking care of patients in isolation,” he said. “It just wasn’t 30-plus percent of our normal census all requiring isolation and many requiring critical care.”
“It’s one thing to have one patient with a novel infection, but when you have 80 patients in the hospital with this virus, it’s very different,” added Powers. “We had to adapt to the reality of the coronavirus and we had to do it to scale.”
And South Carolina still hasn’t seen the biggest surge, whether that comes with the start of school or flu season, so staff needs time to rest, he said.
“You can’t keep sprinting up a mountain,” he said. “And come fall, it will get harder.”
The pandemic affected the business side as well.
In the early days, in addition to the drop-off in doctor visits, hospitals had to cancel non-emergency procedures for weeks, impacting the bottom line.
Before the virus, hospitals had an average profit margin of 2 percent or less, resulting in cutbacks and layoffs in anything but front-line staff, Sheurer said. The reduction in elective procedures made things even more challenging.
“To make the bottom line has been painstakingly difficult,” she said. “Behind the scenes, anything that can go is already gone.”
While federal funding has helped, hospitals everywhere continue to be challenged, Ossmann said.
Health systems also had to rethink the way they market themselves, said Schipp Ames of the South Carolina Hospital Association.
“Hospitals have been somewhat stigmatized by how infectious this disease is and we’ve done everything we can to communicate to patients … that staying home is the best way to slow the spread,” he said. “However, as we enter six months and longer into this pandemic … hospitals are working harder to let people know that they are safe and ready to provide all levels of care.”
MUSC started doing non-emergency procedures again in mid-May, Scheurer said. Then the coronavirus numbers began to rise again. So it’s trying to safely balance care.
“We are not limiting any services. We are trying to geographically contain those with a Covid diagnosis in specific areas of the hospital,” she said. “The sobering reality is that this is going to be part of our lives for likely a very long period of time. So we have to figure out how to coexist with it.”
Hospitals that will do well are those that are nimble enough to ramp up with the surge and deescalate again, Powers said.
“I think this is going to be like waves in the ocean,” he said. “And another virus is waiting in the wings. We just don’t know about it yet.”
Bon Secours St. Francis Health System said via email that it has expanded its virtual care options, implemented protocols to ensure safety - such as flexible visitation policies and elective plans that protect the community - while being more agile in scaling up staff and units when needed.
Ossmann said he’s hopeful there will be a safe and effective vaccine by late fall or early winter, which will shift the playing field.
Meanwhile, he said, some good things will come from the virus: The public health infrastructure, limited before the pandemic, will be expanded, and all the scientific research will lead to profound medical advances.
“The silver lining,” he said, “is that you’ll probably see benefits in the area of immunology and research therapeutics you’d never have seen if not for Covid.”