Breaking Silos: The Team-Based Approach to Coronavirus Disease 2019 Pandemic Staffing

Abstract

To 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 by Oversight and mental health and including were rapidly and was from all of clinical and hospital leadership to help staff with the that crisis standards of care that care were different from to people were but that care could be In our units, we a characteristics that or moral Teams moral distress in units in the physical with the need to personal protective resulted in the isolation of our teams. were also more to describe moral distress the team changed or they were from one unit to Teams that included nurses with more inpatient and ICU also described of moral Lessons learned were that were and required and Although of providers is possible in the acute of work would provider for future We and work as as on residents and fellows, and allowing for from a standard work in order to In the there was and other equipment We of our physical and worked in a 24 hours a In the we and other essential equipment and it was the that was most critically in staffing in the United is hospitals they do not at or near the of the year We during our COVID-19 surge that we were able to stretch to meet patient physicians, nurses, respiratory therapists, and APPs from across our medical system worked Our models were and able to fit both large academic centers and small regional hospitals. Our response, also on the and of our Transparency assisted with but attention to moral distress was therefore, identify to support our providers, in that and expand the workforce to meet future As we for and to the we have the to the role and of critical care. critical care on patients who were and care was provided in the of the Over the 2 critical care adapted to expand provider and to and management of monitoring from the other of the and assist hospital teams in of is the of these changes. critical expanded beyond the and units with the of care units, and critical care and teams During our Spring 2020 COVID-19 in the face of ICU we in used baby monitors to see behind and built ICU teams with and We upskilled on the and became one team. of this experience, we have not only the but also the to to and to meet the needs for critical care it be volumes during a pandemic, as we experienced with or a As we we and need many of our to to their there is that can be learned from 3 months in our were As we the future of critical care, we aim to a critical care that to meet critical care both for daily and for with or We an expanded of units, with patient and upskilled that they are able to rapidly be up into ICUs or down into general medical or even rehabilitation These rooms be to our ICUs to and The to up ICU level care to be provided in the hospital even ICUs are at similar to rooms the patient rooms and delivery rooms. in with then beds are than allowing to care. our Spring 2020 COVID-19 we have and to expand to providers, including nurses, APPs, and care A for nursing been example, medical and nurses are being trained to central and arterial and and other ICU care. 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