Response of the HealthCare Systems to the Pandemic

Inter/Intradepartmental Communication

HFHS quickly recognized the need for an organized response. Incident command centers were developed in each of the five sister hospitals. There were daily discussions among hospital and unit leaders with the rapid exchange of information and ideas. Real-time decisions were made in a quickly changing environment. These were communicated to all system employees with daily communications and team meetings. Analytical dashboards were developed to facilitate situational and operational awareness.

The necessity of this (almost exclusively virtual) structure became apparent at a departmental level. This was especially the case during the pandemic surge because the entire Neurology department was being deployed in novel ways, the rules of social distancing and bans on in-person gatherings meant that social and communication networks were disrupted. With so many daily strategic changes, it was important to have a common touchpoint. Starting on March 15, 2020, every evening at 5 PM for 50 days, a voluntary huddle call was made, led by GLB, but with a planning call at 4 PM with the Clinical Vice Chair, Quality and Informatics Vice Chair, Residency Program Director, West Bloomfield Service Chief, and Administrative Manager. A call summary was sent out to each department member after the call. Each call featured open time for any questions. Most calls also had specific reports by department members. Each call included references to information on the state of the surge in Michigan, the HFHS, Ontario, Canada, and the USA as well as news items on the virus, research findings, information on PPE, economic support, etc.

Similar incident command systems allowed for disaster preparedness in the setting of the COVID-19 pandemic. The Mayo Clinic has reported the need to activate an Incident Command Center early and maintain discipline in structure. This allows for coordination and improves preparedness, particularly in the context of a pandemic that threatens to overwhelm routine clinical operations. This model was also followed at the Cleveland Clinic, a complex, integrated health-care system, that stressed the need to be proactive, clarify the model of governance, and act quickly. Similar administrative structures were created worldwide and allowed for optimal pandemic response in the setting of limited resources.

Infrastructure Transformation

At HFHS, it was soon realized that this pandemic would result in a “surge” that would require extreme measures to create capacity and allow for efficient care of large numbers of patients with COVID-19. In February 2020, GLB approached the Associate Medical Director (AMD) and told him that he realized that we would close the Epilepsy Monitoring Unit (EMU) once the virus had spread to Detroit, since no patients would volunteer to come into a hospital where infected patients were being housed. The EMU was offered as a new source of patient rooms and was effectively converted to a COVID-19 unit a few weeks later.

Not only was the EMU turned into a COVID-19 ward, but the entire Henry Ford Hospital was rapidly transformed to care for almost exclusively patients with COVID-19. The number of patients admitted increased exponentially in March 2020, then showed a linear growth in the first week in April before declining ( Fig. 13.2 ). All patients were placed in private rooms which greatly reduced total bed capacity since, prior to this, most general ward rooms were double occupancy rooms.

Our Neurology/Neurosurgery ICU, NICU, was maintained as a COVID-19-free unit, largely because of the fact that half of the beds in the NICU are in an open configuration, separated only by curtains. This arrangement is ideal from the point that a nurse, at a workstation can provide direct observation of several patients at one time but, in the face of a pandemic, this open arrangement is not adequate for the care of infected patients . As such, the NICU became a multipurpose ICU for noninfected patients requiring ICU care and served as one of the places where ischemic stroke patients were housed for the first 24–48 h postthrombectomy.

Our Stroke Unit was transformed into a Medical ICU (MICU) ward under the direction of a MICU staff. The Neurology and Neurosurgery nurses remained on duty in the Stroke Unit . One of our Stroke Nurse Practitioners, who had previously been an ICU nurse, began a new assignment as a supplemental Nursing Educator for the unit. In addition, MICU nurses were also assigned to help supervise and assist in the care of these patients and provide training for the Stroke Unit nurses.

As the number of admitted patients began to rise, plans were made to convert outpatient rooms in the clinic tower to inpatient beds. There were two groups of patients being considered for such beds. The first group was patients who were recovering from COVID-19 but who needed inpatient rehabilitation. These patients were housed at the hospital because inpatient rehabilitation facilities were at capacity and/or were not accepting the transfer of patients with COVID-19. This was only put in place briefly in the K-13 Oncology Infusion clinic starting on 4/9/2020. Our departmental inpatient Physical Medicine and Rehabilitation specialist was one of those trained in caring for patients on 9 this ward. Very few patients were actually admitted to this unit. The second group of patients who were being considered for these beds if needed was COVID-19 infected patients who might be designated hospice patients. Fortunately, no such need arose.

An additional inpatient unit was developed at our Fairlane Medical Center. This ward was also assigned for convalescing patients with COVID-19 who were no longer infectious but who were too sick to be discharged home. A 15-bed ward was opened on April, 4, 2020, but by that time, hospital admissions had started to wane, and no patients were ever transferred there.

Another of our surge capacity methods was to utilize our five-hospital network to shift patients as needed. Intrahospital transfers are common between our hospitals but most of the transfers are from one of the other four hospitals to Henry Ford Hospital for quaternary care only provided at Henry Ford Hospital. HFH was at Triage Level 1 by April 1, 2020. On April 4, HFH transferred three patients to Allegiance Hospital in Jackson and two patients to UM Hospital in Ann Arbor due to escalation of triage level. The peak admission at HFH was on April 7, 2020 when 331 patients with COVID-19 were hospitalized at the 877-bed Henry Ford Hospital.

Similar measures to improve surge capacity were taken by the City of Detroit and State of Michigan governments in conjunction with Federal Emergency Management Agency (FEMA). The TCF Convention Center was mobilized in early April 2020. The center was prepared to house up to 1000 patients. It opened on April 10, 2020 and closed on May 7, 2020. A total of 39 patients were treated there with an average daily census of 15–20 patients for the first few weeks of operation but only a few patients were cared for in the last couple of weeks of operation. A 250-bed Suburban Collection Regional Care Center was also set up by FEMA and opened in April 2020. It had five patients admitted on May 7, 2020, its busiest day, and discharged its last patient on June 11, 2020. A total of 16 patients were cared for at this temporary field hospital.

The exponential rise of cases required modifications of clinical operations in health-care systems worldwide. Italy was one of the first countries to become severely affected by the pandemic. The Italian experience revealed the potential that entire health care systems could be overwhelmed and demonstrated the potential need to increase the number of ICU beds, in order to accommodate the increasing numbers of patients. However, the uncertainty with regard to the course of the pandemic made resource planning challenging, particularly in early 2020. Complex predictive and planning models were developed in order to project surge capacity requirements over time, taking into account length of stay, occupancy, and ventilator capacity.

Trainee Redeployment

In the effort to treat acutely ill, hospitalized patients with COVID-19, medical residents-in-training of different subspecialties were rapidly trained, and redeployed in COVID-19 units. As the numbers of patients with COVID-19 surged, the HFH general neurology ward was converted to a COVID-19 ward. After a “general emergency” was declared by the Graduate Medical Education (GME) Department at HFH, five of our neurology residents were placed under the direction of an Internal Medicine staff. Nationwide, the Accreditation Council for Graduate Medical Education (ACGME) adapted its procedures and policies to allow for local decision-making that would enable effective care of patients by physicians-in-training. At the same time, it set a number of “inviolate” principles: Sponsoring institutions and their programs were required to ensure infection protection and safety for residents, adequate supervision, and compliance with work-hour requirements. The impact of the pandemic on resident training, and the effects of redeployment continue to be evaluated and reported in the medical literature.