Drawing from the United States Government Global Health Security Strategy for planning, coordinating, and responding to a major public health emergency (GHSS 2019), the US Army has executed a flexible three-pronged response to the COVID-19 pandemic. The response comes together in the following ways:
- Prevent. The prevention line of effort protects healthcare workers and keeps people from getting sick. Prevention involves both education and thoughtful implementation of current guidelines from the Centers for Disease Control and Prevention (CDC) and local evidence- based practices. Measures include social distancing, handwashing and equipment decontamination procedures, wearing proper personal protective equipment (PPE) and face coverings in appropriate settings, and engaging in research with interagency and industry partners to develop a vaccine.
- Detect. Detection involves implementing screening procedures to identify potentially infected persons and thereby reducing exposure to others, developing or expanding COVID-19 diagnostic testing capability and capacity, exploring antibody testing, and applying precise surveillance capabilities to determine who is infected or may have been exposed to the virus but remained asymptomatic.
- Treat. Treatment involves ensuring that staff are well trained to care for COVID-19 patients in our military hospitals; Active, Guard, and Reserve medical personnel are trained and ready; and sufficient equipment and supplies can be mobilized and deployed to areas across the country as needed. These efforts also involve applying appropriate clinical practice guidelines and leveraging partnerships and ongoing research efforts to develop safe, effective, and accessible treatments and therapeutics.
Under the “treat” line of effort during the initial stages of the pandemic, the Army mobilized and deployed Army field hospitals to Seattle and New York City, fully configured to treat non-COVID-19 patients at first and then, eventually, COVID-19 patients. The Army also deployed and integrated medical personnel and teams into local hospitals and alternate care facilities such as convention centers in New York, New Jersey, Connecticut, and Massachusetts to relieve the stress on local healthcare systems. In aiding the local COVID-19 response, US Army field hospital leaders have learned enduring lessons that will help them better support civil authorities in future healthcare missions.
Defense Support to Civil Authorities
Defense Support to Civil Authorities, or DSCA (pronounced “diska”), is nothing new to the Army. This mission typically entails natural disaster response and other domestic activities. In fact, Army units are constantly in a state of preparedness for this type of mission and sit in various stages of alert to deploy and provide support anywhere in the country. This latest deployment has been unique because Army hospitals not only have been providing crisis relief to beleaguered civilian hospitals but also have been doing that in a pandemic. They forged a successful government–civilian partnership and built an operation that demonstrated the life-saving power of a “one team, one mission” mentality.
Field Hospital and Hospital Center Activation
Shortly after the COVID-19 pandemic started to grip the nation in March 2020, multiple Army field hospitals and their higher headquarters, called hospital centers, were placed on alert. Each mobile, 148-bed hospital can provide a broad range of services: primary care, behavioral health, dentistry, physical and occupational therapy, emergency medicine, orthopedic surgery, cardiothoracic surgery, neurosurgery, and more. Surgical services are accomplished in two operating room isolation shelters (four beds) with the support of anesthesia, a full pharmacy, laboratory (including microbiology), and radiology (including computed tomography services). Patients recover in advanced intensive care units (ICUs) and intensive care wards (ICWs). Additionally, the field hospital is able to handle its own dietetics and nutrition care services, instrument sterilization, power generation, laundry and bath service, and water supply.
Modular construction enables the field hospital to deploy separate functions simultaneously. Essentially, this means that the hospital can set up a fully capable, 32-bed early-entry component as well as a separate 60-bed ICW detachment; a surgical augmentation detachment with an additional operating room isolation shelter, ICW, and ICU; and a medical augmentation detachment that can provide ICW and ICU capability as well as dentistry, maxillofacial surgery, and laboratory services. This modular configuration allows maximum mobility and the capability for separate detachments to independently support a large variety of operations and contingencies around the globe.
It is difficult to create a capability in the midst of a crisis, so civilian healthcare systems must maintain a certain level of contingency response capability. Army healthcare systems are no different. Their field hospitals are always in a high state of readiness. Additionally, because disease and nonbattle injuries have accounted for large percentages of hospitalizations in combat—as much as 77 percent (Belmont et al. 2010)—and have historically been a significant problem for many armies, today’s field hospitals are focused on much more than trauma and battlefield injuries. They are prepared to handle a wide range of patients on very short order.
The 11th Field Hospital and the 9th Hospital Center received their “prepare to deploy” orders on March 18 for either Seattle or New York City. The next day, the official warning order provided clear details and guidance. In just six days, the deployment order was issued—the advance party was launched early the next day, March 25, to New York City to set conditions for the arrival of the main unit. On the way, the advance party stopped in Fort Campbell, Kentucky, to pick up an advance party from the 531st Hospital Center and 586th Field Hospital. At this point, the field hospitals’ planning staffs were determining possible locations for operations, including Wall Street and one of the many piers in the city.
The first wave of the main force arrived on March 26 and fell under the command of the 44th Medical Brigade from Fort Bragg, North Carolina, which decided that personnel from the field hospitals would run an alternate care facility in support of state and federal health services in the Jacob K. Javits Convention Center, with equipment and support from the Federal Emergency Management Agency. This facility was essentially a shelter that could be put in place following a natural disaster such as a hurricane or earthquake. While highly effective in this configuration for those scenarios, a shelter was not the best base operation for relieving the burden of COVID-19. Local healthcare providers needed the Javits Center to accept COVID-19-positive patients who still required moderate to high levels of oxygenation and care.
Javits Medical Station Operations
With the admissions criteria for the Javits Center broadened to allow higher-acuity patients, the mission faced new challenges. First, many uniformed services (Army, Navy, Air Force, Marines, US Public Health Service), governmental agencies, and private healthcare organizations all had to rapidly integrate and develop highly effective and safe operations, both administrative and clinical. Second, the expanded admissions criteria allowed the census to balloon from 0 to 453 patients in just 15 days (including accelerated growth in the course of just 11 days), placing great strain on personnel and logistics support systems (Exhibit 1). This rapid growth in COVID-19 patients also created concern for the well-being of the staff.
To preserve the health of the force, rigorous infection prevention procedures received immediate attention. Upon entering the building, everyone was subjected to a temperature check and was asked a series of standardized questions regarding their current health and any recent contact with COVID-19 patients. Before entering and exiting the treatment floor, all personnel were ushered through a step-by-step PPE protocol. This one-on-one procedure was led by an individual escort to ensure all personnel were properly outfitted before coming into contact with COVID-19 patients. A similar procedure was followed to decontaminate and properly doff PPE upon exiting the patient treatment floor to prevent the spread of the virus to clean areas. Thanks to these deliberate protection measures, on-site testing for staff, and adherence to strict quarantine protocols, only 11 personnel tested positive for COVID-19. Considering the more than 73,000 nursing care hours during this operation, the value of protective discipline when treating highly contagious patients became clear.
In response to the increased treatment requirements from the more inclusive admissions criteria, all available federal and commercial supply chains were activated. Additionally, both portable and liquid oxygenation systems were procured and installed to support a higher volume of patients who required oxygen beyond the field hospitals’ capabilities. The field hospitals also equipped their ICUs to accept patients who required even more complex care, including ventilation and remote monitoring.
This swift growth stressed all systems, greatly increased the staff-to-patient ratio, and raised concerns about staff burnout and potential negative care outcomes. To rapidly scale any barriers to effective operations and prevent adverse outcomes that could follow such an accelerated patient census, the multiorganizational team at the Javits Center adopted a tiered huddle system to manage daily operations and patient care. These huddles addressed everything from daily clinical and ancillary support service operations to staffing, records and reporting, supply chain management, liaison operations, and patient safety reporting. The huddles presented a somewhat novel experience to those of us from military operations because they followed the principles of a high-reliability organization. Operational positions were led more by expertise than by rank. So, in some instances, personnel who were more suited to a particular operation might take the lead over a person with a higher rank or leadership level. Anyone even remotely familiar with military operations knows that this significant cultural shift could have posed great difficulties. However, the unique nature of the collaborative experience and urgency of the situation kept everyone focused on the shared mission, so this was never a problem at the Javits Center.
The Value of Partnerships
The operation at the Javits Center served as a powerful example of how to leverage professional networks and partnerships, both new and preexisting, to benefit healthcare operations, regardless of organizational affiliations. Public health crises such as the current pandemic require an accelerated ability to nest with multiple and diverse partners for immediate problem solving. In this operation, all agencies were able to accelerate a shared understanding of the mission and adopt a common language and procedures—even extending the work by embedding auxiliary treatment teams into other local hospitals.
Another beneficial result of the well- integrated partnerships in this operation came in the form of liaisons between the Javits Center and local hospitals. When the city’s hospitals were overwhelmed with patients, communicating the shifting admissions criteria for the Javits Center to the local hospitals made it difficult to transfer patients into the center for care. To address this problem, we created a liaison program with military doctors and nurses and transfer coordinators from the Javits Center. These clinicians systematically reviewed the hospitals’ treatment records to find suitable patients for transfer, and the transfer coordinators facilitated patient movement.
Finally, conversations with local healthcare executives (contacted through their professional networks and the Greater New York Hospital Association) drove initial medical intelligence estimates. These conversations allowed us to adopt best practices and determine potential requirements for staffing ratios, facility layouts, oxygenation, and other clinical services. These conversations and the resulting treatment protocols saved lives.
Future Pandemic Response Considerations
While operations at the Javits Center were ultimately successful, this pandemic has highlighted areas of potential improvement in the event of future outbreak responses.
First, aggressive identification of the most beneficial healthcare delivery requirements as soon as possible—based solely on clinical necessity—allows all partner organizations to develop treatment protocols, healthcare operations support plans, and public health decisions that serve the population best. Because pandemics require a whole-of-nation approach and resources are finite, an accurate determination of requirements as soon as possible also allows for the most efficient distribution of supplies, capital, and human resources.
Maintaining strategic stockpiles of supplies and equipment to address contingencies is an established practice among federal agencies. This practice enabled the DOD to distribute more than 2,000 ventilators, 20 million N95 masks, 7 million test swabs, and $1.1 million in laboratory and diagnostic supplies to support early COVID-19 response efforts. Given the challenges with global supply chain resilience and distribution delays exposed during the COVID-19 pandemic, healthcare systems should consider maintaining strategic medical supply reserves for future contingencies.
The COVID-19 pandemic has driven a whole-of-nation response on a scale unprecedented in our time. The effort highlights the importance of strategic partnerships and the tremendous capabilities and expertise that can be harnessed across the military and civilian healthcare systems during times of national crisis. The prevent, detect, and treat framework offers the military and civilian healthcare systems a flexible and integrated approach for improving healthcare delivery, informing public health decision making, and allocating healthcare resources during pandemics and other public health emergencies.
At the Javits Center, more than 3,000 people of all stripes integrated and rapidly spanned diverse cultural and operational barriers to help the citizens of New York City. The mission yielded many lessons and proved that military, civilian, and other governmental agencies can conduct joint operations on very short notice in the face of a challenging situation.
By the mission’s end on May 1, the staff at the Javits Center medical station treated 1,095 patients and saved many more by alleviating the stress on the local healthcare system. The professionalism and “one team, one mission” mentality of all involved is exactly what allowed them to succeed.