How One Arizona Health System Is Preparing Emergency Department, Critical Care for Surge

Hospitals in areas of the country that have not experienced a surge of coronavirus patients yet have the advantage of time to prepare themselves.

While coronavirus hotspots such as New York and Detroit are coping with patient surges, Valleywise Health is preparing for the challenge.

The coronavirus disease 2019 (COVID-19) pandemic is affecting states with varying intensity, with patient surges expected to roll out across the country in different time frames. For example, as of April 15, New York had nearly 200,000 confirmed COVID-19 cases compared to more than 3,800 cases in Arizona, according to Johns Hopkins University.

"We have been very blessed in Arizona to have the time. We have not seen the large influx of patients like they have in New York or Detroit. So, we have been able to benefit from their experience to make sure that our plans are ready if we experience that type of surge," says Michael White, MD, executive vice president and chief medical officer of Phoenix-based Valleywise Health.

The health system features an academic medical center and 11 community health clinics.

Current modeling predicts Valleywise Health will be able to accommodate a COVID-19 patient surge, he says.

"In the models that we are seeing in Arizona, as a community in Maricopa County we would be able to handle that volume of patients both from a personal protective equipment and a ventilator perspective. If the models change, then my answer will change."

The health system has been preparing for an expected surge of COVID-19 patients for several weeks, focusing primarily on Valleywise Health Medical Center's emergency department and critical care capabilities.

Emergency department preparations

In response to the COVID-19 pandemic, screening and triage protocols in the emergency department are crucial, White says. "We are planning for how we can efficiently screen and triage individuals who may be able to have their care maintained in an ambulatory environment or at home, versus those who may need admission to the hospital for further care," he says.

The medical center's emergency department has established two tracks for incoming patients—one track for patients with respiratory symptoms that could indicate coronavirus infection and another track for patients with non-respiratory acute complaints, White says.

"If a patient has a respiratory complaint, they get triaged into a track where we have staff who have elevated levels of personal protective equipment who can perform COVID-19 testing," he says. Patients who have other acute medical conditions see clinicians who treat "routine patients" who need emergency care.

In addition, the medical center has reconfigured emergency department space to have a designated area to provide critical care to seriously ill COVID-19 patients, White says.

Critical care preparations

The medical center has also concentrated on increasing ICU capacity, he says. "We have already begun to identify new spaces within the acute care hospital to keep patients together who have COVID-19 so we can treat them with ventilators in a critical care capacity."

White says the medical center has already converted the facility's step-down pediatric unit to an adult unit that can treat COVID-19 patients. Other areas that can be converted to provide critical care to COVID-19 patients include procedural space, pre-operative areas, post-anesthesia care units, operating rooms, and ambulatory clinics embedded in the hospital, he says.

In addition to repurposing space for critical care, the medical center is preparing to expand the facility's critical care workforce, White says.

"We will work very closely with our critical care partners and our medical staff to develop a team-based approach. We will have intensivist teams that could supervise hospitalists who could provide basic critical care. The same approach will apply to nursing, where nurses with intensive care training and experience will work with nurses who may not have critical care experience but can do some of those functions while being overseen."

Supporting medical staff

At Valleywise Health, another key facet of preparing for a COVID-19 patient surge has been initiatives designed to support the healthcare workforce, White says.

"We have done a lot of work preparing our staff in relieving their anxieties [such as] making sure there is adequate personal protective equipment. We have done a lot of education on the use of PPE."

Communication is an essential factor in supporting the healthcare workforce, he says.

"We have been transparent with our COVID-19 incident command—we do a daily briefing. We also do a daily newsletter that goes out to the entire staff."

He continues, "One of the early teams we created was an employee engagement and morale team that has done a number of events and other outreach to the staff within the medical center and all of our outlying clinics to make sure we are able to provide support to them. We are entering our third week of that outreach."

Other supportive efforts include displaying employee artwork and deploying mobile tool kits and carts that have snacks and supplies, White says.

Preparing for the worst

If a COVID-19 patient surge is overwhelming, Valleywise Health has established protocols for transferring patients to other health systems and rationing care, White says.

The care rationing protocol has been developed in consultation with other Arizona health systems and Valleywise Health's ethics committee, he says.

"We have that protocol in place in case we need to use it. Most of it is evidence-based around what has been established by the Society of Critical Care Medicine and previously published for these types of situations. There is some modified scoring about what the chance of recovery is based on presentation and comorbid conditions to determine medical utility."

White views care rationing such as a shortage of ventilators as a doomsday scenario that he hopes never comes to pass. "There would be some really tough decisions that we would have to make and grapple with. They would be terrible decisions for us to have to make to decide whether we are truly overwhelmed and how we are going to deliver care."

Photo credit: Valleywise Health