Hospitals are accustomed to evolving and adapting to new technologies and ebbs and flows in patient needs. But the current COVID-19 pandemic has thrust medical facilities into unprecedented crisis modes and is testing the extent of even the most adept operations managers’ creativity.
As surges occur, clinicians have been mobilized to work well outside their areas of expertise and are necessarily learning on the job. COVID-19 units are supplanting other treatment units, and all kinds of resources have been redeployed as leadership analyzes how best to care for the sickest patients. As the pandemic unfolds, caseloads and related staffing decisions, shift details, and care and discharge workflows are constant moving targets, says James Hudspeth, MD.
Hudspeth, a hospitalist at Boston Medical Center (BMC) and associate program director for the Boston University Internal Medicine Residency program, specializes in inpatient treatment and hospital operations. An expert at collaborating with hospital staff to coordinate resources and maximize efficiency to improve treatment, he’s been at the forefront of preparing inpatient floors at BMC to take on Boston’s surge.
HealthCity spoke with Hudspeth about the challenges of redeploying patient-floor resources in the face of great uncertainty and need, and the real effects on both clinicians and patients.
Editor’s note: This interview took place on April 7, 2020. Facts and circumstances are subject to change in the developing COVID-19 crisis situation.
HealthCity: Operationally, what are you facing on the patient floors in this pandemic?
James Hudspeth, MD: Our entire apparatus, the entire structure that we've built up with the course of many years, including how we work with the case managers, how we get physical therapy, how we meet with the nurses, how we do rounds of patients, how we interact with patients — all those elements have had to change because of this.
In an April 8 update from inside Boston Medical Center, James Hudspeth, MD discusses how the hospital is reorganizing physicians, repurposing spaces, and using data and models to inform decisions and create new systems.
This is not a static situation. Over the last two weeks, we have gone from having one nursing unit with four patients who are COVID-positive to now having 170 patients*. We are going through a process where we are saying, “OK, we filled up this space, what’s the next space?” That kind of rolling approach has been novel. It’s not something any of us have ever had to do before. It’s challenging, but I think also we’ve been pretty effective at it. Our system has been sound and it’s really held up.
*At the time of publishing, BMC’s census was 226 inpatients requiring 13 COVID floor teams over seven nursing units.
HC: What has enabled the hospital to adapt to the rapidly changing situation?
JH: The social connections we’ve built up with people who are here for the mission, plus having a lot of managers and leaders who’ve been here for some time, really gave us an edge when we were coming to the realization that everything’s going to have to change. We needed to figure out in rapid succession the what most important maneuvers were, what their order would have to be, and who we needed to pull in. It’s been an impressive display of organizational work. We’ve had remarkably strong collaboration between the nurse managers, the strategy folks, the infectious disease department, the pulmonary department, the family medicine department, my internal medicine hospitalist group, the numerous BMC residency programs, the lab department, and more to stand up our clinical work.
"If I don't have the stuff as well as a system to get me that stuff, I can't be effective as a healthcare provider."
There's a lot of media love for physicians and nurses right now, but our colleagues in logistics, hospital transport, our phlebotomists, our environmental services staff who are cleaning rooms and spaces to keep us safe — they are also incredibly intrinsic to this process. Many are just as much at-risk, and they also deserve praise and respect. If I can't get the drug I need, if I can't get a nurse to put the IV in, if I don't have the stuff as well as a system to get me that stuff, I can't be effective as a healthcare provider. COVID lays bare how much healthcare depends on a team, and BMC’s adaptation has relied on the entire team being thoughtful and flexible.
HC: What unique operational considerations are being made in the face of COVID-19?
JH: Every patient population is going to have some COVID infections. That's going to happen. So we're doing a lot to tailor our approach and workflows for the different patient populations we serve.
For example, for our population who are homeless, we’ve worked with our partners over at Boston Healthcare for the Homeless Program to figure out how we can safely discharge patients from the hospital. It’s been proactive thinking through, ‘Okay, when COVID hits here, here's where we're going to put the patients who have homelessness and are sick. Here's where we're going to put patients who have homelessness and are well enough to take care of themselves, but can't go back to the shelters. Here's how we're going to avoid infections within the shelters proper.’
There's almost a ladder of inequity, in some ways. We're appropriately focused upfront on the people who have the least, but there's a large corpus of patients who also have very real needs and constitute a larger portion of our population overall. That's a group we have to pivot towards as we move forward.
HC: With thoughtful input like that, what sort of impact on patient care are you seeing as operations evolve and adapt to COVID-19?
JH: There’s been a lot ink spilled on the potential ventilator issue, and it’s a very dramatic matter, but there’s a lot of gray space before any black-and-white decisions. People don’t appreciate the effect of shifting resources and having to use providers who are not inpatient physicians and who lack experience in these contexts. Well before we would reach the point of being unable to ventilate everybody, we’re already going to be really challenged to keep care at the highest standard that we aim for. And not because we want to, but just because those are the resources hospitals have.
So we will provide the best care feasible for every one of our patients in our situation, but it will not be feasible to provide the ideal care for each of our patients. Ongoing care of patients with chronic problems in the outpatient setting, for example — we’re not attending to these things as much as we confront the current emergency. These needs are going to keep building up, and they will have consequences, even if we won’t see them for months to years.
HC: How are COVID-19-related challenges impacting clinicians and staff at your hospital?
JH: It has a been a really emotionally turbulent few weeks for providers. A lot of us have gone through periods of being very anxious and at times scared. At the same time, there’s also been a huge sense of fulfillment in doing the work these last few weeks — healing is our calling. For a lot of us in the health professions, be it physician, nurse, respiratory therapist, whatever — we just want to help people.