30 Sep COVID-19: Operational Crisis Management in Hospitals from a Leadership Perspective
This article is the third of the IHF Young Executive Leaders’ subgroup, working on Towards post-Covid-19: Lessons Learned and Challenges for Hospital Leaders. Since the working group members bring in professional experience in hospital management, healthcare leadership and nursing management, they quickly defined the most urgent issues. Furthermore, they discuss what makes a good leader in a special situation such as the pandemic and what people-centered actions have proven to be effective and indispensable in running successful healthcare operations, using their different perspectives and personal experiences. What to focus on and what precautions and changes in leadership should be taken /in the future? This third article focuses on COVID-19 operational crisis management and risk mitigation strategies.
Authors: Alhammadi, S. (UAE), Bartolo, A.M. (Portugal), Braga, V. (Portugal), Castela, E. (Portugal), Lahuerta-Valls, L. (Spain), Obwaka, Ch. (Kenya), Rodriguez, O. (Spain), Trummer, F. (Austria), Ulrich, K. (Germany), Edited by Bogues, R. (UK)
When the World Health Organization (WHO) declared COVID-19 to be a pandemic and called on countries to take action to contain the virus, many countries quickly implemented a containment strategy while accelerating their efforts to control the disease. At that time, cases had been confirmed on every continent (except Antarctica), and secondary disease hotspots had emerged in places such as South Korea, Iran and Italy.
Since then, hospitals across the globe tried to ensure they have the capacities, staff, structures and supplies needed to respond to COVID-19 (referring to the transmission scenarios: clusters of cases or large numbers of cases). Of course, preparing for an unpredictable pandemic is a big challenge and a difficult exercise for every healthcare system in the world, especially in regions that have less or no experience. However, all hospitals must learn from others’ experiences and implement precautionary and mitigation strategies in order to prevent or mitigate a potential global outbreak due to an infectious organism, such as SARS-CoV-2. Moreover, this preparation is crucial as it guides resources allocation, including staff and consumables, allows early procurement of key materials and prepares healthcare staff. So, these measures aim to quickly and effectively react so as to lessen the pandemic’s effects.
Anticipation, based on as many facts as available, is the best way to respond to a pandemic. Facing an unknown disease, hospital leaders must observe the events in the initial stages of the infection, identify the factors that facilitate the spread, understand the strategies for each context and evaluate the effectiveness of the responses found. In UAE for example, it was believed that the coverage for health care should be for all people. By this a spare of the disease will be controlled and thousands with no financial capacity to pay for healthcare can come forward when they are affected instead of spreading it to the community. And so, the country has allocated what was called the “COVID-19-Insurance”, that allowed anyone to receive full medical care without any payment if they were COVID-19 positive. Moreover, a temporary accommodation was created for workers who lost their jobs or salary, in order to minimize the risk of speared among other workers. Did that strategy work out it terms of pandemic control?
In this article, we will discuss crisis management challenges, bed management/ allocation and other risk mitigation strategies in hospitals during the COVID-19 crisis. Our experiences reflect different impacts of COVID-19 in each of our countries and hospitals, different types of hospitals (public and private), as well as different roles in our organizations.
What impact did the pandemic have on patient flow?
The Ministry of Health (MOH) of Kenya, as many other governments, advised citizens on hygiene, including regular hand washing, avoiding contact with suspected cases and prompt medical treatment if symptoms occur. Yet, thousands of Kenyans got infected, millions in the world. Many healthcare systems applied a strategy in the following 8 – 10 weeks to identify thousands of symptomatic and thousands of asymptomatic cases and to further subdivide cases into high and low risk groups. High risk group and symptomatic cases continued to be accepted in hospitals while others were accepted in hotels made for isolation only (e.g. in Dubai) or sent to quarantine at home.
The Hospital of St. John of God in Vienna (Austria) as well as the Jewish Hospital Berlin (Germany) and many other hospitals had been closed for non-urgent surgical interventions and outpatient services, except emergencies. All patients were only allowed to enter in the hospital with a negative PCR test. A pre-entry test lane was established for planned patients and a triage system was set up before entering the hospital for emergencies. In this case of an emergency admission the patient is placed in an isolation room, until the results are ready, or taken into a special made operation room, only for suspected COVID-19 cases. In many hospitals, waiting room seats were reduced to keep patients distanced from others.
Visits to the inpatients were mostly suspended or visitors were only allowed in for terminal patients or with special permission. In Kenya, all hospital management in public and private hospitals were requested to restrict patient visitation to family and relatives of patients who have been expressly contacted by the hospital. This impacted the inpatients negatively as they felt isolated and sometimes, e.g. in Hospital Fernando Fonseca (Portugal), lacked access to essential commodities, namely bottled water and oral care products. Through donations from businesses, corporations and civil society this situation could be overcome. However, the advantages brought by (new) technologies of information and communication were many, e.g. they enabled virtual visits for patients.
Special care should be taken with patients with chronic conditions such as oncology, rheumatology, diabetics, or pregnant women. Additionally, pediatric patients must not be forgotten, children who need to have a person of reference and trust near them. So, their right to being accompanied by a parent or other relative remained, following the hospital protocol for these cases, which have been given by each pediatric hospital (e.g. in Spain). All this was possible by taking safety measures such as facilitating diet, hygiene to the companion of positive patients, internet and technological devices.
Emergency Rooms rapidly put special protocols and equipment in place to make sure to treat patients safely when they are having a medical emergency. At the same time, as the pandemic took hold, the number of emergencies in hospitals, including serious cardiovascular emergencies such as strokes and heart attacks, dropped exponentially from March to July, for many reasons. Emergency Rooms suddenly were almost quiet.
Regarding medical appointment, the telemedicine resources for non-priority consultations became a strategy. Other options in e.g. Hospital Fernando Fonseca were changing service hours for medical appointments, home hospitalization care as well as appointments at the Primary Care Health Center. Finally, in the same hospital emergency center, the low risk urgency episodes, according to Manchester triage protocol, were referred to Primary Care Health Center or other Hospitals in Lisbon area.
Hospital Sant Joan de Déu in Barcelona (Spain) created new patient and staff workflows and spaces to be able to test before performing any surgical or diagnostic intervention such as a CT scan, MRI or others. Since it was essential that the patients, before attending the appointment, were well informed about these special conditions, why it’s done that way and the type of procedure they will have, a nurse on duty or an administrative provided this information.
What impact did the pandemic have on staff?
On top of the changes described above, the working time of many hospital employees was affected by the crisis management measures. Rosters needed to be changed often during the initial outbreak. For many health professionals, work schedules (fortnightly) were planned, which included long-term work periods to reduce the risk of contracting COVID-19 (e.g. Austria, Portugal, Spain).
Due to the lack of medical human resources, more specific regarding anesthesiology and intensive care services, the accumulated tiredness of staff caused profound changes in working schedules. Therefore, the Hospital Fernando Fonseca provided, since the beginning, a psychological support phoneline for health professionals and their families, which has been used above the expected, all over the hospital. Fortunately, some hotels located in the districts nearby the hospital offered free accommodation for health professionals during the COVID-19 pandemic to facilitate resting time and to reduce the close touch with the families.
For non-clinical staff in many hospitals, working from home was encouraged and enabled where possible. It was made readily available thanks to digital platforms and new technologies. In some hospitals, the leaders’ groups shared data and made decisions during the pandemic progresses using virtual meetings.
The permanent usage of PPE while on duty in hospital was also a very common risk mitigation strategy – and one of the major management challenges. The following algorithm was made by the Portuguese Directorate-General of Health – it can be adapted and suitable to be used accordantly. It is an algorithm to guide a proper and efficient PPE use.
Concerning other clinical services, that were not directly involved in the support of COVID-19 patients, there was an effort to collaborate with overloaded services. This was the case of physical and rehabilitation medicine service in Centro Hospital de Leiria (Portugal), where half of the doctors and one third of the therapists helped in the COVID areas. The other staff, although working apart from COVID areas, was organized in separate teams, using different bathrooms, showers and dining areas. At the beginning, only the most serious acute patients (e.g. stroke, traumatic injuries, etc.) were treated face-to-face, always with one patient per therapist, always with a 10-minute break and cleaning between the patients. Some high infectious risks were assisted/monitored by phone.
Nowadays, with the waiting lists increasing, the admission criteria are not as restricted, but in-person appointments and treatments are reduced. In addition to the infection prevention and control protocols, the hospital is promoting teamwork and earlier complementary examinations, achieving more efficient decisions and minimizing the time spent in hospital.
Some hospitals guaranteed full pay to all staff, even if they were not performing full hours. Other strategies that were implemented for staff include:
- No contract terminations during crisis
- No short-time work in any department
- PCR mass testing of staff
- Maximum protection guaranteed for staff
- Employee supermarket
- COVID-Hotline for employees
- Additional kindergarten places
- Free disinfectant for employees’ families
Since grandparents were not recommended to take care of children but schools and kindergartens were closed (e.g. in Austria, Spain, Germany etc.), there were summer schools or summer camps in some of these countries. These centers were located close to the hospitals and at a reduced price, to facilitate family reunification for professionals. In Germany, a special care service was offered for children of certain occupational groups, including hospital staff.
Crisis management challenges and risk mitigation strategies
In summary, the measures to minimize risks are very similar in all hospitals (Austria, Kenya, Portugal, Spain, UAE and Germany) and in all areas. The main strategy was to reduce contagion by reducing contacts and isolating COVID-19 patients. The main focus in the first phase was to increase the number of hospital beds, mainly for critical patients. Planned activities and appointments for chronic or non-acute patients were initially postponed. So, as previously mentioned, the workplace required an adaptation by the most of hospitals.
At the same time, some of the main crisis management challenges were:
- Hospitals were asked to build up intensive care capacities. Many hospitals introduced a training for multidisciplinary healthcare workers, mainly from surgical or intermediate care units, to reinforce ICUs in times of need. However, no new ventilators were available on the market for months.
- Healthcare workers were instructed to use PPE at all times while on duty. The consumption of medical masks etc. rose sharply, while the supply chains collapsed, so it became difficult for many hospitals (and very expensive) to get as much PPE as needed.
- Changes in behavior (e.g. social distancing) needed to be implemented very quickly. Some employees did not follow the instructions and got infected, others were overextended or too scared and did not want to work in the isolation unit or COVID areas (e.g. cleaning staff), using sick days to avoid that.
As a result of this pandemic, leaders have to find solutions and strategies for these and other challenges to prepare for future crises.
The most common hospital strategy in order to cohort patients and prevent or reduce the spread of the virus was (and still is) to create new organized areas, with new teams and new patient flows, as the following:
Possible infected patient areas:
These “grey zones”, located mainly at the hospital emergency department, are important buffer zones and require tests availability in order to reach the patient cohort as quickly as possible.
Pre-hospital care, with the responsibility to take care for the majority of non-symptomatic cases of COVID-19, can also be a cornerstone of hospitals´ ER success.
These are the areas where the most trained staff works and where the adequate personal protective equipment cannot be depleted. Mainly these are at the ICU services, but other improvised areas, with fans or well-ventilated rooms, have been prepared as well.
Despite the adequate equipment and staff, good communication between intensive care units in other hospitals has a great importance. Patients might need to be transferred to another hospital for regeneration, in order to free up ventilation units for further acute patients.
These “clean areas” include those Covid-19-negative patients that need to be hospitalized. They are organized with completely different flows. Patients are supported by different staff and supplementary examinations and surgical interventions are carried out in separate areas from Covid-19-positives.
Patients accessing to these areas are not necessarily tested, but a risk triage is performed. The daily schedule is carefully planned. All patients wear face masks and staff wears defined PPE (appropriate to the risk to health professionals).
Managing and guiding patients and employees in this very difficult pandemic is a major challenge for governments and healthcare managers. This pandemic results in an enormous change in daily life for both, healthcare professionals and patients. To keep a hospital functioning during a pandemic, executives need to take steps to create a safe patient care process, as well as a safe work environment for employees. Changes in the processes and structures need to be carried out and implemented very quickly right from the beginning of the crisis. This leads to a greatly increased workload for many healthcare workers. All employees in the hospitals and health centers must respond to the needs of patients and maintain the quality of their medical services by adapting to the changed working conditions. Crisis management and risk mitigation strategies are essential to make this possible – as well as good management, thought leadership and a large number of motivated employees.