International insights on facing COVID-19

On 9 July 2020 we had an online panel discussion in cooperation with HealthCareCAN to get insights from hospital executives from Canada, Austria, France and Spain about the challenges they are facing during the COVID-19 crisis and their experience as they transition to the “new normal”. It focused on human resources mobilization, resuming usual activities and catching-up on backlogs, and preparations for future waves.

You can watch the recording of the discussion here.

Attendees sent in questions and the following panelists provided their answers in this article.

  • Jordi Altés, CMO, Hospital Plató, Catalonia, Spain
  • Pierre Gfeller, President & CEO, McGill University Health Centre, Montreal, Canada
  • Owen Heisler, CMO, Covenant Health, Edmonton, Canada
  • Helmut Kern, Advisor and Non-Executive Director in multiple organizations and governmental bodies in Austria
  • Cédric Lussiez, CEO, GHNE Groupe Hospitalier Nord Essonne, France
  • Kevin Smith, President & CEO, University Health Network, Toronto, Canada

 

Feel free to share your own experiences in the comment box below.

 

Regarding needing specialist nurses, were there specific skills that were the most useful? (eg tending to ventilators, assessment, etc.)

Jordi Altés (JA): In Catalonia (Spain) the number of critical care beds per habitant are lower than other European countries (France, Italy, Germany,…). The COVID-19 crisis has called into question the lack of beds and the need to increase them in the event of a new wave. Training doctors and specialized nurses is not fast at all. Meanwhile, the contingency plan is to incorporate the ER and Operating Office nurses, along with anesthesiologists, to train in the care of COVID patients.

Owen Heisler (OH): The skills that we need the most are occupational health skills. We have sufficient technical skills but greater training and expertise in outbreak management and infection prevention and control techniques and skills were of great need. Proper protection including donning/doffing of PPE was invaluable.  Longer term we will be enhancing these skills. Technically we had sufficient staff to manage.

Helmut Kern (HK): We had enough IC nurses; but with the interdisciplinary wards we needed more nurses with flexibility across disciplines – we found out that many senior nurses were great trainers/buddies for junior nurses learning new disciplines very quickly (eg gynecology – general surgery; urology – gynecology; ENT-general surgery…)

Cédric Lussiez (CL): Regarding specialized nurses, our main issue was competencies for ventilation.

Kevin Smith (KS): In terms of specific skills, critical care experience is especially vital to the COVID-19 response for tertiary/quaternary hospitals including University Health Network. We receive transfers from other hospitals for critically ill COVID-19 patients, and offer highly specialized services that are used as the last line of defense when a ventilator is unable to support a patient. During the pandemic, we have also been assisting a number of long-term care homes and caring for the elderly. Excellent Infection Prevention and Control skills were greatly in demand. Nurses with more than five years of experience fared psychologically better than earlier career professionals. As a final note, The Michener Institute for Education at UHN created two courses available throughout the Province of Ontario, one which assisted clinicians in updating their ICU skills and the second available to help clinicians seconded to long-term care.

 

Our hospital has a research institute. All staff were working remotely at similar levels of efficiency. This week our hospital decided to bring staff back on site, even though research activities are still on hold until the next phase of reopening (anticipate it will be in the fall). Have any of your hospitals done something similar? What are your thoughts around having personnel on site who can work just as effectively from home?

JA: Hospital Plató is developing a telework program for all those professionals that are not directly involved in healthcare, in order to avoid risks and improve the reconciliation of working life. Video conferencing (via programs such as Teams, Zoom, etc.) has replaced face-to-face meetings. We think that teleworking can be as effective as face-to-face work, although we must avoid an excessive deal of time in it. It’s a new paradigm and we must discuss and help our professionals to learn how to organize better at home (and disconnect when possible).

Pierre Gfeller (PG): Non-COVID research has accelerated again at McGill University Health Centre and more staff are now working on site. Our Research Institute is located in a different building and we are thus able to reduce contact between researchers, patients and staff.

OH: We do not have a significant research presence so cannot comment on this.  We did find similar maintenance of efficiency for our back off staff who worked remotely.

HK: We do not have research institutes in our hospital, just departments for clinical studies; all those are back on site. Without knowing more detail, I do not understand the rationale behind asking people to come to work if they cannot execute their tasks anyway.
With respect to personnel working from home effectively, there are different opinions in the management team. Some believe everyone should be back to work to reflect the crisis is over and do not privilege certain teams/employees to others who have to work on site. I do not share this view. I believe it is prudent to let people work from home as much as is possible to not endanger them (not only in the office, but also in public transport on their way to/from work etc.). A compromise many employees would welcome is a mixture with eg. one office day per week to maintain social contact to the hospital.

CL: We do not have a research institute, and ask every nurse and physician on site even they were given before crisis some time for research.

KS: Research related to COVID-19 continued throughout the pandemic at University Health Network.  In terms of reopening, we brought back our research activity using a phased approach and operated six days per week rather than five, with a third of the research work force able to be on site at any one time. For clinical research, “return” has occurred in coordination with our clinical activity. In terms of having personnel on site versus working from home, we know working from home can be a very effective option across many domains. This is an exciting opportunity for all leading employers to offer employees more flexibility, and is something the next generation workforce has been actively asking for – certain research domains are well placed to continue this approach.

 

Shortage of PPE- specifically N95 masks or respirators – did this or any other shortage make it more difficult to staff any unit looking after critically ill COVID patients?

JA: Today, 2 months after the first wave of COVID-19, our Hospital is better prepared with respect to PPE stocks, that would cover for at least a future period of one month of maximum COVID activity. Regarding the respirators, we are limited by our size, and we have agreed with hospitals in our integral area of left Barcelona (AISBE) the possibility to share them in case of shortage. For a small hospital, well-coordinated action in territorial care to COVID-19 is essential.

PG: Even though there were moments when we thought we would be short, especially with regards to N-95s, we always had PPE available. We strictly enforced guidelines regarding N-95 usage for aerosol-producing procedures only, which created tension but mostly with surgical teams.

OH: Alberta was fortunate to have sufficient PPE so we did not have to adjust staffing due to a shortage.  However, the communication about the stockpile and the anxiety in the workforce still made this a difficult challenge.  The guidelines on using PPE varied, especially early in the pandemic which lead to distrust amongst many of the staff.  Thus, though there never was a shortage, there was angst by many staff that they were not being supported with sufficient PPE leading to distress amongst some teams.

HK: We increased stock of N95 masks as we experienced shortage for a few days and also found out that the quality of masks offered by some suppliers was not meeting our quality standards. We increased the stock for N95 for the future to 3 months crisis coverage. We never went short of other safety equipment or respirators, though we bought some extra respirators.

CL: No, our staff used to volunteer for ICU and COVID units despite these shortages.

KS: When everyone in the world is chasing the same PPE, this of course places stress on the hospital as we work to secure greatly needed supplies. Thankfully, we were able to secure what was needed for the delivery of care and staff our units – including our COVID units – as needed.  We did however face the same challenges as peers with respect to staff anxiety and the desire for a “belt and suspenders” approach. In other words, staff wanted PPE that wasn’t considered by Infection Prevention & Control to be clinically needed (i.e. N95 respirators and the daily changing science made this more challenging). We worked very early to collect N95 respirators and work through what was necessary to sterilize the masks should we need additional stock in the future.

 

What has been your experience in regards to health equity, specifically, are there lessons learned for second wave when health equity lens is applied?

JA: One of the lessons learned is that we need to improve communication. Communication between primary care professionals, nursing homes and hospital. Communication between patients and family members. Communication must be greatly improved in a second wave. On the other hand, the criteria for adequacy of the therapeutic effort have been reviewed several times, to try to have more objective and consensual decision guides, to facilitate the decision-making process of our doctors.

PG: In Québec, some categories of patients experienced reduced access to care during the first wave, such as cancer, psychiatric and cardiovascular patients. We emptied the hospitals in preparation for the wave and suspended all other admissions and treatments, except urgent ones. However, our hospital and ICU capacities were never in jeopardy.  During a second wave, we would act more gradually in shifting activities from cold to warm- hot zones, rather than at once.

OH: This experience shone a light on the staffing and support provided to patients in long term care facilities – something that will need to be addressed in the longer term.  As well, many staff worked in multiple locations which did lead to greater exposure than would be ideal and will need to be considered in the future on many levels.  Communication may not have been ideal to immigrant workers who, while the intent was to provide them with proper protection, this was not always communicated adequately leading to several meat plant packing outbreaks.  We can be better in communicating across language and culture differences in the future.

HK: Interesting one – I would not see inequity by social categories, but by need of treatment – Covid was overarching the whole healthcare system, so required preventive treatment, especially in the cancer area (Endoscopies) was not performed in a timely manner with all negative consequences we expect to face in the coming months.

CL: We were faced with ethical issues linked to selecting of equipment (solved now) and patients, which could occur in the second wave and long term postponing of patients. We have created a multidisciplinary committee to address these issues and select priorities.

KS: This is a major issue in Toronto and Ontario. There is a higher infection rate among marginalized and underhoused populations. University Health Network and other partner hospitals, working with the City of Toronto, have opened free hotels for Persons Under Investigation (PUI) and those at risk. Also, we have struggled with migrant workers who come to Canada for the picking season. Long-term care has been our greatest challenge and required a great deal of support from hospitals. For wave 2, focus is on the at-risk populations defined by housing, income, race and needed social supports. Stopping the spread in these populations – and those staff who support them – is key to controlling wave 2. Intensive testing of workers in these settings is a key deliverable.

 

What impact has COVID had on the future of work, in particular remote work and home office arrangements?

JA: Telework in health organizations is here to stay. So is telemedicine. This is a paradigm shift that has already been seen in the last decade, but has emerged as a result of the COVID crisis. In the case of chronic and elderly patients, everything that can be done at home should be done there. We must also question the role of nursing homes, and adapt them to the new post-COVID reality, in anticipation of other threats to the health of our elderly population.

OH: We were pleasantly surprised with the remote working arrangements. We fortunately already had a robust infrastructure in place to facilitate working from home. Efficiency was maintained and satisfaction was high so this will become a more regular part of the working environment. In regards to patient care, there was an increase in ‘virtual care’ and I expect in the future this will become a more common component of the medical practices.

HK: There are many different opinions on this question. Some in our management team believe that remote work/home office should not be continued and would privilege those who can work from home to others (mostly clinical staff) and therefore should be discontinued. I do not share this view. Many employees who worked from home performed even better than normally and reported high satisfaction and a wish to continue home office in a structured manner (eg one to two days per week, fixed days). From a labour law and data protection perspective that would be easy to solve. It would also allow us to save space by introducing desk sharing and changing the office setting in general to more collaborative workspace instead of single or double offices we have now. Clinical staff would not be disadvantaged as they have other work benefits not applicable to back office staff, so I believe that could be handled well. As hospitals in general also pay less than other industries, structured offering of home office would also be an asset for employer branding. So overall I believe we should use the crisis as booster for new work models (also, by the way, implementing new roster models in the clinical areas, as many staff eg liked the “one week on – one week off model” a lot).

CL: Still no policy for home work (lack of evaluation tool) but urge to move to telemedicine.

KS: COVID-19 has completely changed the future of work – especially in healthcare. We know there are many roles in healthcare which can be effectively done from home, with adequate planning and thought around how you support distance employment. One of the key challenges to overcome is making people feel part of an organization, despite not being physically there.  This won’t be for all roles, but it is clear that many of our support functions – human resources, finance, information technology being examples – can function well working remotely. The pandemic has also taught us that, in designing and building for the delivery of care, we must ensure that our new healthcare settings will be built with a view to the prevention and spread of infectious diseases. That means single rooms with washrooms, wider hallways, more negative pressure capability with sufficient space for putting on and taking off personal protective equipment, and spaces designed for physical distancing.  There is no doubt that these places will cost more, but the cost of not building in this way is human lives.

 

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