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A Multidisciplinary Innovation to Plan for the Projected COVID-19 Inpatient Surge

O'Glasser, Avital Y. MD, FACP, FHM; Stroup, Scott MD; Merkel, Matthias J. MD, PhD; Lahti, Elizabeth MD; Kubik, Sharon DNP, ACNP-BC; Vaughn, Kristi DNP, ACNP-BC, FNP-BC; Reback, Erin BS, BSN, RN, CMSRN; Rumberger, Ruth MS, RN, ONC NE-BC; Hayes, Mariah MN, RN, NE-BC; Backer, Jennifer BSN, RN, A-CM, CGS; Solani, Tee MSW, LCSW; Halvorson, Stephanie MD, FACP

Author Information
Journal of Nursing Care Quality: April/June 2021 - Volume 36 - Issue 2 - p 112-116
doi: 10.1097/NCQ.0000000000000536

Abstract

The COVID-19 pandemic resulted in the need for hospitals to plan for a potential surge of COVID-19 patients. This need provided opportunities for hospitals and health systems to employ creative solutions and rapidly implemented innovations to address local demand. Emerging literature shows that the creation and implementation of novel acute care and critical care unit redesigns in attempts to optimize hospital capacity frequently focus on creation of COVID-19 cohort units or expanded post–acute care capacity.1–4 Recognizing the simultaneous need to care for non-COVID-19 patients, we describe the development of a new acute care unit for non-COVID patients from a preexisting surgical outpatient care unit (OCU). We describe the process, outcomes, and lessons learned.

HOSPITAL-LEVEL RESPONSE TO COVID-19

The challenge

The 570-bed academic medical center at Oregon Health & Science University (OHSU) is part of a 4-hospital health system in Portland, Oregon. The main campus consists of 2 adjoining inpatient towers for adults and a separate children's hospital. A satellite campus houses an ambulatory surgical center with a 24-bed OCU approved for observation status patient care. The campuses are 2 miles driving distance but are connected by a 3300-ft span aerial tram, which offers a 4-minute commute.

Prior to the COVID-19 pandemic, the midnight occupancy in adult acute care at the academic medical center ranged between 90% and 100% with patients often held in the emergency department and postanesthesia care units prior to inpatient placement due to capacity constraints. Initial forecasting at OHSU and in Oregon predicted that inpatient capacity demand would rapidly exceed existing inpatient acute care and critical care bed capacity. Following the hospitalization of Oregon's first COVID-19 patient on February 28, 2020, OHSU initiated the emergency operations center to address the anticipated surge. Shortly thereafter, Oregon's governor issued an executive order to cease all elective surgical and procedural patient care.

The goal

The initial task facing the OHSU Emergency Operations Center was to rapidly create inpatient capacity in an already high-occupancy environment and to develop a surge plan for acute and critical care to increase inpatient bed capacity by 25% to 75% over licensed bed capacity. While canceling elective procedures resulted in a decrease in inpatient volume of 8 acute care patients and 1 critically ill patient per day, the impact of stopping elective surgical procedures was more pronounced in the ambulatory surgical center/OCU. Thus, OHSU COVID-19 response leadership decided to explore using the OCU as an inpatient, acute care unit to decompress the main hospital in preparation for the surge.

PROCESS

Execution, team, and hurdles

After receiving an emergency waiver from the Centers for Medicare & Medicaid Services and the State of Oregon to temporarily transform the OCU into an acute care unit, we formed a multidisciplinary taskforce including representatives from nursing, nursing-led case management, pharmacy, social work, rehabilitation services, surgical services, hospitalist/perioperative medicine, family medicine, respiratory therapy, and rapid response team. This group defined the logistical steps needed to rapidly convert the OCU into an acute care unit, as shown in Table 1. Two significant barriers, staffing and patient selection, are described later.

Table 1. - Multidisciplinary Care Team Roles in Preparing OCU for Acute Care and in Ongoing Care of Patients' Transfers From the Acute Care Hospital
Role Role in Transitioning OCU to Acute Care Role in Modified OCU Patient Care
Case management Responsible for overseeing success of OCU Participated in daily meeting to identify patients for transfer
Discussed discharge planning to date with inpatient case manager
Arranged transportation to OCU
Ensured that MD and RN handoff had occurred
Nursing unit leadership Responsible for patient selection for OCU
Responsible for overseeing success of OCU
Participated in daily meeting to identify patients for transfer
Ensured that MD and RN handoff had occurred
Facilitated daily unit-based multidisciplinary rounds
OCU medical team Developed 24/7 staffing model
Updated clinical pathways/protocols for medical patients
Participated in daily patient selection meeting
OCU case manager Dedicated case manager for OCU
Responsible for ensuring safe transfer of care
Assisted with ongoing discharge planning
Pharmacy Created inpatient formulary
Identified need for inpatient medication-dispensing machine
Updated restocking process
Reviewed medication list prior to transfer/ensured necessary medications available in OCU
Social work Dedicated social worker appointed for OCU Assisted case manager with complex discharge needs
Contacting family
Rehabilitation services Already available in OCU
Extended hours to 7 d coverage
Assisted with patient's identification for transfer to ensure that ongoing rehabilitation needs could be met
Nutrition services Ensure that meals available 24 h
Abbreviation: OCU, outpatient care unit.

Physician/provider staffing

During normal operations, the OCU is staffed by a surgical team during the day and 1 advanced practice provider at night (7 pm to 7 am, Monday-Sunday). Average length of stay is less than 2 days; the unit is closed on Sunday nights. Recognizing that decreasing surgical volume also decreased preoperative medicine clinic utilization, preoperative medicine clinic providers (who are part of the Division of Hospital Medicine) were redeployed to staff the OCU to provide 24/7 hospitalist coverage. The preoperative medicine clinic medical director became the interim OCU medical director to establish an effective leadership dyad with the OCU nurse manager. Additional coverage included available family medicine providers, family medicine residents, and advanced practice providers who deployed via the NP labor pool from services with lower inpatient or outpatient census. A hospitalist attending on home call provided nocturnal advanced practice provider support. The rapid response and code blue team was also staffed 24/7 in house. The RN staffing model for the unit based on unit census was maintained.

Patient selection

Based in its relative geographic remoteness from the main inpatient campus, the patient population was promptly identified as non-COVID, low-acuity patients who were close to medically stable for discharge but hindered by complex discharge needs. Identification of appropriate patients was a complex effort requiring many stakeholders. Nursing unit leadership and a lead case manager identified potential patients for review. The case manager attended a preexisting weekly meeting where patients with long length of stay and discharge concerns in our system are routinely discussed with a multidisciplinary team. The case manager then reviewed the patient's discharge plan in detail with the unit-based case manager to determine expected length of stay, discharge barriers, and whether transfer to OCU would be appropriate. Inpatient medical teams were also asked to identify potential patients for transfer. Along with the OCU medical director, this team screened eligible patients for transfer based on in-scope criteria (Table 2). The list of patients was evaluated daily with the OCU medical director and pharmacy to ensure that medical needs could be met.

Table 2. - Patient Selection Criteria for Candidates to Transfer to the OCU
Appropriate for Transfer Not Appropriate for Transfer
Medically stable but not ready for discharge (medically or logistically) Behavior (eg, sitter, active delirium, etc)
—OCU cannot run psychiatric/behaviors codes
COVID-19 negative/no current COVID-19 symptoms Person under investigation for COVID-19
Some social barrier to discharge (ie, need intravenous antibiotics but cannot go home) Hospice general inpatient who is medically fragile—requires symptom management
Stable hospice patient (including hospice general inpatient) who can discharge home with outpatient hospice Dialysis (hemodialysis or peritoneal dialysis)
Long-term intravenous antibiotics (pharmacy needs to be notified of type of antibiotics to have available) Vented patients
Cystic fibrosis (nutrition and respiratory therapy should be aware) Continuous Ambulatory Device Delivery pump
Anticipated minimum of 2 nights posttransfer Younger than 18 y
No weight restriction (keep in mind only 2 lift rooms) Requiring air mattress or bariatric wheelchair
Can do standard tracheostomy care
Abbreviation: OCU, outpatient care unit.

Patients or their surrogate decision makers were included in the decision-making process. The lead case manager organized transport to the OCU via an existing transport contract with a local emergency medical service. The provider and RN teams completed written and verbal handoff prior to physical transport between sites.

METRICS

The OCU opened as an acute care unit 11 days after the first task force meeting. Our main process measure was the number of patient transferred. Supplemental Digital Content Figure, available at: http://links.lww.com/JNCQ/A815, outlines the details of the 30 patients identified and screened for potential transfer to the OCU. Barriers to selection included medical complexity and ongoing acute care needs, bariatric and other equipment needs (eg, air mattresses, lifts), and behavioral concerns including wandering or elopement risk; patients with near-term planned discharge were also not transferred. Common care needs among the 12 transferred patients included guardianship applications, post–hospital care placement, and prolonged intravenous antibiotics. The patients were predominantly male, older (average age of 60 years), with neurocognitive dysfunction and geropsychiatric care needs, and an average length of stay of 39 days (see Supplemental Digital Content Table, available at: http://links.lww.com/JNCQ/A816).

Of the 12 patients transferred, 6 were successfully discharged after complex care coordination, including with patient families and guardians located across the country or completing prolonged inpatient therapy (see Supplemental Digital Content Figure, available at: http://links.lww.com/JNCQ/A815). Four returned to the main campus as care escalation was required or for patient preference, one of whom returned to the OCU and discharged successfully.

The OCU remained in operation as an acute care unit for 6 weeks. As Oregon successfully flattened the curve with up to 85% reduction of expected infections (P. Graven, PhD, written communication, 2020), OHSU has not yet needed to open up any surge areas in acute or critical care to date. Elective surgical cases resumed on May 1, 2020, in accordance with the Oregon governor's executive order, which required the OCU to original operation and clinicians to staff the preoperative medicine clinic. Thus, we decided to conclude the use of OCU as medical complex discharge unit at the end of April. The 3 remaining patients, with complex discharge plans underway, were transferred back to the main campus. No patients acquired COVID-19 while on this unit; other projects to maintain surgical units as COVID-free units have shared barriers to doing so.5 We did not track number of bed-days freed in the main hospital campus; we also did not perform a cost-benefit analysis.

Each organization is unique with regard to available space and ability to accommodate large number of acute care/critical care patients. Taking an inventory of existing licensed bed space is a key first step. Having an ambulatory surgical center that is connected to the main campus may allow for expansion into previously unappreciated space.

LESSONS LEARNED

We identified several benefits of rapidly converting our OCU into an acute care unit to expand inpatient capacity. First, we realized the power of interdisciplinary partnership to rapidly achieve a common goal and it epitomized rapid, adaptive, and dynamic interprofessional collaboration.

Second, we observed the successful, expedited discharge of several patients who had been hospitalized for months. During our debrief, this was felt to be a combination of more focused physician and nurse practitioner time for care (1-2 hours per patient vs 30 minutes) on a geographically cohorted unit, consistent relationships with a unit-based nursing team, and dedicated case management and social work staff who were able to focus their resources on progressing patients toward discharge and take the time to develop relationships with patients and caregivers. For example, a dedicated social worker presence permitted intense, individualized patient focus, formulation of complex psychosocial assessments, dedicated time for a thorough and systematic follow-up system, and creation of treatment alliances with stakeholders (family members, guardianship and conservatorship attorneys, case managers, etc). Prior to the conversion of OCU to an acute care unit, patients with complex discharges might have been given lower priority in day-to-day workflow. In our innovative model, team members felt that daily multidisciplinary rounds with a geographically consistent team and an “esprit de corps” also contributed to these successful discharges. Finally, we created inpatient acute care capacity by moving long length of stay patients and replacing them with several shorter length of stay patients during this 6-week period.

FUTURE DIRECTIONS

This innovation was designed to create space in our academic medical center for a potential surge in patients related to COVID-19. The successes of this unit have spurred additional conversation about how we might carry forward some of the lessons learned. For example, right-sizing individual clinicians' workload in a given shift, relationship building with nursing and nursing leadership, and developing team-based approach specific for patients with complex discharge barriers with case managers and social workers are key to a successful complex discharge unit. The proximity of care team members has also spurred interest in geographic team assignment for acute care teams. Finally, the stakeholders have demonstrated the ability to work together in an interprofessional, multidisciplinary way to rapidly create an overflow unit. Further refinement will include identification of optimal staffing models to maximize the benefit in a business-sensitive approach. While this innovation was designed to address COVID-19, the lessons learned can be applied to any other emerging infectious disease or acute care capacity crisis.

REFERENCES

1. Gupta R, Gupta A, Ghosh AK, et al. A paradigm for the pandemic: a Covid-19 recovery unit [published online ahead of print May 29, 2020]. NEJM Catalyst. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0238. Accessed August 1, 2020.
2. Mari GM, Crippa J, Casciaro F, Maggioni D. A 10-step guide to convert a surgical unit into a COVID-19 unit during the COVID-19 pandemic. Int J Surg. 2020;78:113–114. doi:10.1016/j.ijsu.2020.04.052.
3. Zangrillo A, Beretta L, Silvani P, et al. Fast reshaping of intensive care unit facilities in a large metropolitan hospital in Milan, Italy: facing the COVID-19 pandemic emergency [published online ahead of print April 1 2020]. Crit Care Resusc. https://ccr.cicm.org.au/supplementary-june-2020/point-of-view. Accessed August 1, 2020.
4. Chisci E, Masciello F, Michelagnoli S. The Italian USL Toscana Centro model of a vascular hub responding to the COVID-19 emergency. J Vasc Surg. 2020;72(1):8–11. doi:10.1016/j.jvs.2020.04.019.
5. Luciani LG, Mattevi D, Giusti G, et al. Guess who's coming to dinner: COVID-19 in a COVID-free unit. Urology. 2020:142:22–25. doi:10.1016/j.urology.2020.05.011.
Keywords:

acute care medicine; case management; COVID-19; hospital medicine

Supplemental Digital Content

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