The COVID-19 pandemic brought family medicine to the forefront, as pluripotent physicians were called upon to help everywhere. In some places, that meant bringing outpatient clinicians back into inpatient environments where they may not have been in a while. We now have an opportunity to reflect on lessons learned from quickly ramping up inpatient services.
At our large academic medical center in Wisconsin, we had two distinct periods of preparation for COVID-19 surges in 2020. At the beginning of the pandemic in February, we began our initial preparations for the worst-case scenario. We shut down everything non-essential. We cleared our operating rooms and turned them into critical care units. We created staffing schedules that could pull all of our primary care physicians and other providers into multi-level inpatient grids. We worried about our lack of personal protective equipment (PPE) and lack of knowledge about the virus. Ultimately, we were incredibly fortunate that this response was not needed in the spring as COVID-19 infection levels remained manageable.
During the summer of 2020, many parts of our system returned to normal operations. But by September, we were starting to see things change again. COVID-19 cases in our state were increasing exponentially. By November, hospitals around the state were overflowing and our surge plans were in full force. Every week we found ourselves opening more and more inpatient units and services.
Reflecting on these two time periods, we can see what worked well and what could have been improved. Here are three things that were important during both periods:
1. Compassionate leadership. The pandemic was hard on everyone in different ways. Approaching every meeting and interaction with compassion was critical. People made mistakes, inaccurate comments were quoted by newspapers, and not every decision was the right one (but may have seemed like it was at the time). We were all learning. Leading with compassion and understanding helped to keep our community strong.
2. Frequent communication. Our system set up an incident command center to be the primary COVID response team. From there, communication went out through frequent huddles. Meetings varied from daily to weekly depending on the group. Daily email updates went out with summaries of the day’s happenings.
3. Transparency about decisions. This is important in any organization, at any time, but even more important when anxiety is high. Transparency both within our institution and with the public was key during the pandemic. We let news stations in to the hospital, increased our organization’s presence on social media, and maintained public dashboards with case counts and vaccine allotments.
Three areas of flexibility
Some of our approaches varied between the spring, when we planned for a major surge that did not happen, and the fall, when we were better prepared and did, unfortunately, see a major surge. We learned to be flexible in three areas:
1. Choosing our staff. In the spring, we initially used all our outpatient primary care clinicians for some level of inpatient or obstetrical support. We had every clinician fill out a skills survey and, based on their responses, divided them into different areas and levels. Some were put on specific obstetrical response teams. Others were put on various inpatient response teams, based on their comfort level with ventilator management, code responses, and inpatient care. We set the expectation that everyone would be involved. Orientations and clinical skills refreshers were put in place. Including everyone and creating a robust schedule created a great deal of anxiety, particularly for those who had not worked in the inpatient setting in many years.
In the fall, we focused on using clinicians who already did inpatient medicine and kept them active in the hospital. We shifted physicians who work on academic services in the hospital part-time or do part-time hospitalist work into more full-time hospital medicine positions. Then we leaned on the other primary care clinicians to backfill their clinics. This hurt continuity of care for primary care patients, but allowed everyone to keep practicing where they were most comfortable. It decreased the need for prolonged orientation and skills refreshers. It decreased the level of anxiety.
2. Scheduling. In the spring, we built schedules that were many layers deep and shared them months in advance. We had several complex teams with multiple layers of backup, and clinics were cancelled well in advance. By the summer, we had recognized that this degree of preparation created a great deal of anxiety in clinicians who were never actually called up. It was an unnecessary burden on clinics.
In the fall, our response was more controlled. We created schedules from a smaller group of physicians, and repeated them, allowing comfort levels to build. We made decisions about whether to expand services once a week and released schedules no more than one month in advance. We put clinic schedules on hold four weeks in advance of potential inpatient transfers. Then we cancelled clinics two weeks later, if necessary. Clinicians who were not being called in for inpatient work covered the inpatient clinicians’ work as needed.
3. Implementation. In the spring, we put in place many tools. We created clinical refresher and hospital orientation guides. Our EHR support staff created mini-tutorials for inpatient medicine. We learned the nuances of ensuring everyone had badge access, computer access, and scrub access across our sites.
While not necessary during the spring, many of these tools ended up being well-used in the fall. At that time, we actually discovered that “de-escalation,” or deciding when to close extra services, was one of our biggest challenges. We closed one service too early and dealt with high censuses for the week to follow, but at that point we had already rescheduled clinic patients so there was no easy way to turn back. From then on, we closed with more caution.
We all hope we will not have to face another global pandemic (or another severe wave of the current pandemic) in the near future. But if we do, we will be better prepared. Every institution will have its own unique challenges, but we have learned so much and can document and utilize this knowledge again in the future.
— Nicole Bonk, MD, clinical assistant professor, University of Wisconsin School of Medicine and Public Health
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