A California Hospital’s Response to COVID-19: From a Ripple to a Tsunami Warning

As the pandemic began to affect the United States, published reports and literature on managing pandemics and COVID-19 began appearing in numerous publications and on professional societies’ websites. Hospitals worldwide were affected as the viral illness spread rapidly. With the admission to Mission Hospital of the first patients infected with COVID-19 in March 2020, the multidisciplinary team reviewed the hospital disaster plan. The Executive Leader Team (ELT) and physician and nurse leaders focused on implementing the Hospital Incident Command Structure (HICS), while the Critical Care Services (CCS) team focused on the literature to gather additional information on managing the COVID-19 pandemic. The CCS clinical nurse specialist (CNS) used the hospital’s evidence-based practice model to prepare an evidence grid with pertinent summaries on managing COVID-19. The hospital had adopted the Johns Hopkins Nursing Evidence-Based Practice Model⁵  for clinical decision-making. This model applies a structured process to evaluate and integrate the best available evidence. The process involves 3 components: (1) P: develop a focused practice question; (2) E: search, review, and appraise evidence; and (3) T: translate the evidence review into practice.⁵  The PET model provided the CNS a systematic approach for compiling evidence-based information about COVID-19.

Development of a practice question used the PICO format (P: population, patient, or problem; I: intervention; C: comparison; and O: outcomes): How does a nonacademic hospital ICU apply pandemic and COVID-19 management guidelines to optimize readiness, maximize resources, and treat patients during the peak surge of the COVID-19 pandemic? The CNS conducted an evidence search and reviewed relevant sources of literature^6-21  on managing the COVID-19 process and pandemic. As new information was published, sources were added to the grid. Each source was reviewed using the Johns Hopkins Nursing Evidence-Based Practice Model, and a level of evidence (I to V) was assigned according to the model: I (experimental, systematic reviews of randomized controlled trials); II (quasi-experimental study, systematic review of a combination of randomized controlled trials); III (nonexperimental study, qualitative, meta-synthesis); IV (opinion of respected authorities, nationally recognized expert committees, clinical practice or consensus guidelines); and V (integrated literature reviews, quality improvement, case reports, opinion of nationally recognized experts based on experimental evidence). All the sources of evidence^6-21  were compiled (Table 1) and used by the CCS team when developing and managing the plan for the influx of patients with COVID-19. The sources of evidence were related to pandemic principles and specific disease-related issues.

Pandemic management principles focused on mitigating the impact of the pandemic through prevention guidelines, including social distancing and environmental cleaning measures, developing widespread testing, creating specific vaccine and treatment measures, and maintaining adequate stockpiles of critical supplies such as ventilators, medications, and personal protective equipment (PPE).^6,18  Hospitals were advised to plan for the 4 phases of disaster management, with an emphasis on planning (Table 1).¹⁷  Conducting a hazard-vulnerability analysis was key to preparing hospitals and CCS for dealing with the pandemic.^17,20  Important hospital-wide practices included establishing a HICS, communication systems, a security strategy, decontamination facilities, a personnel pool, and critical care infrastructure and involving all services and professionals in the process.^4,8,10,17,20  The Centers for Disease Control and Prevention (CDC) provided guidelines and recommendations for managing COVID-19 and the pandemic.⁶  The recommendations were updated numerous times from March through May 2020.

The critical care planning and management guidelines provided numerous critical recommendations and frameworks.^{4,10,13,15-17,19-21}  Key to managing a pandemic is preplanning.^{4,6,10,12,13,16,17,20}  Intensive care unit practitioners are identified as key contributors to planning for and managing pandemics, especially the COVID-19 outbreak.^4,17,20,21  Hick et al⁴  provided a framework for managing an ICU surge during a pandemic or disaster. The model defined conventional, contingency, and crisis care modes as they relate to space, staff, supplies (stuff), and system strategies (the 4 S’s) (Table 2).⁴  The key components identified in the CHEST guidelines⁴  were identified repeatedly in many articles, with the 4 S’s emerging as a universal model to frame the ICU response.^13,16,20,21 

Space involved identifying usual areas for ICU care but expanded the concept to delivering ICU level of care in units not traditionally used as an ICU, including postanesthesia care units, step-down units, and endoscopy areas. Triaging patients into the ICU space was emphasized and detailed.^{6,7,9,12,15,16,19}  Staff models for treating patients in the ICU presented contingency and crisis models that included augmenting ICU practitioners (eg, using a 2-tiered staffing model; Figure 1).^{4,13,16,20,21}  Supplies and equipment were critical to managing an ICU surge during the pandemic. Essential supplies included respiratory equipment, pharmaceuticals, PPE, intravenous fluid pumps, and monitors.^{6,10,11,13-15,20,21}  The need for airborne-infection isolation rooms (AIIRs) was identified to reduce viral transmission.^6,11  System strategy or standard of care explored the treatment of patients when in conventional (usual care), contingency (minimal impact on usual care practices), and crisis modes (not consistent with usual standards).^{4,13,16,20,21} 

The literature specifically related to the COVID-19 pandemic provided guidance on managing the surge of patients, providing adequate PPE during extreme shortages, and understanding disease-specific characteristics that would influence transmission and care practice.^6-12  According to reports published from China and Italy, the practices for treating patients suspected of having or positive for COVID-19 affected how care was delivered in managing the specific disease as well as procedures such as intubation, aerosol-generating procedures, and cardiopulmonary resuscitation.^1,7,9,11,22  The relevant literature reviewed and the hospital disaster-management plan provided the CCS team with a strategic game plan for managing the surge of patients with COVID-19 in March through May 2020.

Mission Hospital, part of the Providence St. Joseph Health System, is a 523-bed, nonacademic, acute-care tertiary hospital and operates 2 facilities on campuses that are 8.8 miles apart. The hospital is a Joint Commission–certified Comprehensive Stroke Center and American College of Surgeons–accredited level II trauma center, serving approximately 645 000 people. The hospital had prepared to manage emergency situation needs through the traditional HICS.²⁰  The HICS was based on the incident command system, which assists hospitals with management planning and response and recovery capabilities for unplanned and planned disaster events.²⁰  Key members of the ELT, physicians, and staff had previously completed the Federal Emergency Management Agency Disaster Training Program. Disaster drills held before this pandemic had necessitated partial command center operations because of power failures, loss of water, and information technology outages. This prior command center use only touched the surface of the needs that a community hospital may encounter in a disaster.

On March 10, 2020, the ELT opened a modified HICS to manage key issues such as supplies and space. The incident commander, an operations section chief and a safety officer, per the HICS organizational structure (Table 3), deployed resources and kept key stakeholders informed of the plan to manage the pandemic. Within a few days of the arrival of patients infected with COVID-19, the hospital team realized the scope of the global disaster was beyond any prior disaster experience. A full HICS (Table 3) was needed to manage the escalation in cases. The command center structure was refined for long-term stability to support infrastructure, operations, finance, logistics, planning, and other key roles needed for structure and sustainment. The HICS made various decisions such as determining COVID-19 units and establishing cohorts of patients positive for COVID-19 and those who could be ruled out in a defined geographic location. The HICS halted elective surgeries, restricted visitors to the hospitals, established a labor pool, provided daily updates to key stakeholders and all personnel via conference calls and written communication, and provided emergency support of all units by staffing the center 24-7.

After the implementation of the HICS and the declaration of a code triage, the medical director of critical care and the critical care CNS met to establish a CCS task force to focus on the evidence obtained from the evidence-based practice review. The CCS task force comprised members of multiple disciplines (Table 4). In the beginning of the pandemic, the task force focused on ICU COVID-19 priorities. After the first week, the task force rapidly expanded its scope and purpose, adding other key leaders from multiple areas. Meetings were held 3 times per week for the first 4 weeks, then decreased to twice per week, then weekly by week 8. The CHEST consensus statement⁴  and recommendations from other disaster models provided the framework for Mission Hospital’s plan, described in Table 2.^{4,13,16,20,21}  The CNS and medical director of critical care created agendas, focusing each meeting on the 4 S’s model.

In early March 2020, the CCS team examined the hospital’s ICU bed capacity. The total 51-bed capacity in 3 units had served both campuses well during previous high-census seasons in the conventional mode. Planning commenced for managing the ICU capacity at contingency and crisis levels. A multidisciplinary team toured the ICUs as well as the interventional intensive care unit (IICU), used as a procedural area since 2009. One of the main priorities in managing space and the surge of patients with infectious disease was isolating this population to a single geographic space where ICU-level and non-ICU–level care would be delivered. The team examined the IICU space and the adjacent non-ICU nursing units and decided to convert the procedural area into a functioning 16-bed ICU and admit all ICU patients under investigation for COVID-19 and/or patients positive for COVID-19 to this unit. All non-ICU patients were admitted to the 2 non-ICUs adjacent to the IICU; semiprivate rooms were converted to private rooms. Temporary isolation walls, negative-pressure rooms, and isolation anterooms were constructed to create individual AIIRs, as recommended by the CDC.⁶ 

Planning space for the contingency and crisis mode required the CCS team to identify the sequence of ICUs converting to COVID-19 units, followed by repurposing areas from procedural and/or non-ICUs into functional ICUs.^10,13,16  Within 2 weeks, the number of critically ill patients with COVID-19 exceeded the IICU capacity, and the 27-bed cardiac ICU was converted into a COVID-19 ICU. This change resulted in moving patients without COVID-19 to the surgical ICU. The postanesthesia care units were repurposed to serve as ICUs to increase available ICU beds. During the pandemic, the hospital remained in the contingency phase for space, avoiding the conversion of other non-ICU spaces (Table 2).

Assessment of staffing capabilities related to ICU providers focused on intensivists, nurses, and respiratory therapists. Because the hospital was adequately staffed in the conventional mode, team discussions at the CCS task force meetings focused on contingency and crisis modes. At each meeting, the CCS team reviewed staffing levels and needs. The intensivists had an adequate supply of staff to manage the conventional and contingency modes. Staffing nurses in the ICUs became an intense area of focus. As the ICU occupancy reached beyond 51 beds, contingency staffing was implemented. Nurses with ICU experience in the previous 2 years were shifted to the ICU resource pool. After 2 orientation shifts in the ICU and an assessment of skills, these nurses were scheduled to work in the ICU. Nurses with prior ICU experience (> 2 years) underwent orientation shifts and focused education modules to retrain to work in the ICU.

Looking ahead to the crisis mode, the chief nursing officer asked the CCS nurse leaders to formalize a model for ICU staffing if staffing ratios could not be maintained during the pandemic (state-mandated ratio was 1 ICU nurse to 1 or 2 ICU patients). On the basis of recommendations in the literature, the CCS CNS adapted the 2-tiered model into the staffing plan.^{4,13,16,20,21}  If patient capacity was greater than the number of available ICU nurses, 3 different levels of the 2-tiered model were adopted (Figure 1).^{4,13,16,20,21}  In the contingency mode, a 1:3 model (ie, 1 ICU nurse paired with 1 non-ICU nurse to care for 3 critically ill patients) would be implemented. In the crisis mode, either a 1:4 (ie, 1 ICU nurse paired with 2 non-ICU nurses to care for 4 critically ill patients) or 1:6 (ie, 1 ICU nurse paired with 3 non-ICU nurses to care for 6 critically ill patients) model would be implemented. A conceptual mapping was created to identify ICU nurse versus non-ICU nurse duties on the basis of competency (Tables 5 and 6).

Managing supplies has been challenging during the COVID-19 pandemic. Typical supplies, including respiratory equipment, medications, pumps and monitors, and materials (eg, PPE, cleaning wipes), were adequate in the conventional mode but quickly changed in the contingency mode (Table 2). The supply of respiratory equipment concerned the ICU team. A total of 45 heated, humidified, high-flow oxygen units supported patients before mechanical ventilation. The hospital’s original 40 ventilators were adequate in the conventional mode. An additional 37 ventilators were provided by the county and state, and have been adequate during the pandemic. Ten bilevel positive airway pressure machines could have been converted to ventilators, if needed. Having intubation bags available allowed for rapid access to needed equipment. Medications were in short supply, requiring physicians to alter prescribed agents in all patients hospitalized in the ICU. Some days supplies of propofol, midazolam, fentanyl, and cisatracurium became depleted, necessitating conversions to other medications. Pumps and monitors for administering intravenous fluids and medications have been in adequate supply during the pandemic.

The biggest challenge was the shortage of PPE and germicidal cleansing wipes used to clean surfaces and equipment. As the entire world experienced a shortage of PPE, managing supplies became a priority for the entire organization. The reuse of N95 masks, face shields, and powered air-purifying respirators was mandatory in all areas. Gowns and gloves were in short supply. Processes were developed by the Infection Prevention Department to manage the scarce supply of PPE, on the basis of CDC recommendations.⁶  The lack of PPE has remained a significant challenge. The shortage of wipes led to the purchase of myriad products to clean equipment and the environment.

Treating patients daily in the ICU provided the CCS team with a strong foundation of critical care practice. Modifications to current practice were necessary to target specific COVID-19 interventions. A series of new guidelines and protocols was created, enabling a consistent approach among practitioners (Table 2). As an example, managing cardiac or respiratory arrest required specific alterations in bagging and compressions, because of the increased risk with aerosol-generating procedures associated with COVID-19.²²  Algorithms were created to guide the staff on code blue responses (Figures 2 and 3). Special PPE boxes were placed on every COVID-19 unit, which provided the team with immediate access to needed PPE. Laminated cards were created for use by the team inside the room to communicate needed supplies to practitioners outside the room.

The shortage of PPE had a major impact on delivering care in the ICU. Although the COVID-19 ICUs had constructed negative-pressure rooms and anterooms for donning and doffing PPE, infection control measures were a priority. Staff in the ICU were evaluated while donning and doffing PPE to ensure compliance with guidelines. Education and infection prevention teams educated staff 24-7 to reinforce proper techniques to minimize contamination and spread of the virus.

One of the biggest challenges in the first 4 weeks of the pandemic was testing for COVID-19. Whether it was a limited number of test swabs or the timing of the results, testing posed challenges and created delays in moving patients under suspicion out of COVID-19 areas to non-COVID-19 areas. During mid-April through early May, the situation eased when the hospital acquired a COVID-19 testing machine. This machine enabled in-hospital COVID-19 testing instead of having to send swabs to an outside facility. Testing will remain an issue as the hospital begins to reopen the surgery and procedural areas. The limiting factor has continued to be the number of swabs and testing reagents available for use.

Cardiopulmonary treatment of patients with COVID-19 was comparable to managing critical hemodynamically unstable patients with adult respiratory distress syndrome (ARDS). Hemodynamic monitoring was required, and vasopressor support was initiated. Many patients not requiring mechanical ventilatory support received heated, humidified, high-flow oxygen with continual monitoring of pulse oximetry. Once the flow was greater than 50 L/min, the intensivists electively intubated the patients. Ventilator management and bundle adherence (head of bed at 30 °, oral care, suctioning, turning from side to side) were done. Even with standard care, the pulmonary status and ARDS worsened in many patients with COVID-19.

Proning critically ill patients with ARDS has been cited to improve the oxygenation-perfusion mismatch.²³  Pronation of patients receiving ventilatory support in the ICU resulted in improved gas exchange in the most critical of the patients with COVID-19. Although a proning procedure with a special bed had existed, the shortage of these specialty beds required manual proning guidelines for patients in the ICU to be developed. Nurses in non–COVID-19 ICUs conducted simulations to determine the minimum number of providers required to prone. With real-time education, the ICU nurses were able to manually prone with 4 personnel in the room managing the ventilator, intravenous and/or arterial catheters, and rotation. Suggestions from non-ICU units, physicians, and nurses for early proning of non-ICU patients with COVID-19 were investigated by the CCS CNS, who found literature supporting early proning.^24,25  A new proning protocol for non-ICU patients was developed from the evidence and included input from physical therapists on properly positioning an awake patent. The proning protocol was approved and nurses in the non-ICU COVID-19 unit were educated. When the non-ICU nurses’ assessment revealed worsening oxygenation, they would contact the physician for orders to prone. Oxygenation was reassessment during the process by monitoring the pulse oximeter.

Pharmacological protocols were either created or updated to include alternative medications used during the pandemic. Physicians were encouraged to order alternatives to propofol and midazolam because these medications reached critical shortages. Expansion of sedation agents included using lorazepam or ketamine as alternatives. When the shortage of fentanyl reached critical levels, physicians were asked to change analgesics to others in more abundant supply, such as hydromorphone or morphine sulfate. Faced with the possibility of a crisis mode in which patients in the ICU required ventilatory support, pharmacological agents, or other interventions in limited supply, the ICU team collaborated with practitioners from the ethics and palliative care team to create the Ethical Guidelines Related to ICU Triage in Adult Patients During a Pandemic or Disaster Crisis Mode. These guidelines provided definitions of ethics-based considerations, identified criteria associated with an ICU crisis mode and assumptions of use, and provided physicians with key guidelines for ICU triage criteria while in ICU crisis mode. The guidelines were sent to the system legal and ethics groups for approval.

As the team evaluated the deployment of the disaster plan, the HICS underwent a metamorphosis, adapting and reorganizing to meet the needs of the hospital services and personnel affected by a large pandemic. The ELT and HICS staff developed a more advanced management strategy with focused teams managing the issues. The ability of the facilities staff to convert rooms and entire units into negative-airflow spaces with anterooms for donning and doffing PPE enhanced the placement and management of patients. As units were converted into COVID-19 areas and traditional specialty ICUs were blended, creative staffing strategies allowed the team to match patient-care needs with the competency of nurses. At the peak of the surge in April 2020, ICU nurses were deployed to the ICU, where their unique skill and competency were needed. The team had the needed respiratory and general supplies except PPE, cleaning products, and some medications. The short supply of medications necessitated the development of alternative sedation (eg, ketamine), analgesic, and neuromuscular blocker protocols. The team viewed their ability to rapidly adapt system strategies to patients with COVID-19 as a strength. The entire hospital and the ICU team working synergistically together allowed the organization to manage this disaster, and will help them do the same for future disasters.

Mission Hospital serves 645 000 people of the county’s 3.22 million total population. In early May 2020, at the time of writing, the county’s health department reported that a total 45 674 tests had been done and 2348 individuals had contracted COVID-19; there had been 52 deaths attributed to COVID-19 county-wide.²⁶  During the same time, 1154 patients were tested for COVID-19 at our hospital, 119 patients were confirmed positive for infection, and 37 required ICU care. Of those treated in the facility, only 1 patient died as a result of complications from COVID-19. By May 10, at the end of the 2 months, 7 patients positive for COVID-19 and 6 patients under investigation for COVID-19 remained hospitalized, while the county reported a total of 228 hospitalized in 26 hospitals. As the numbers decreased, the CCS task force developed a plan for de-escalation and consolidating ICU spaces opened in March 2020. Additionally, by May 10, the HICS command center was closed, and leaders worked virtually to manage any issues.

To continue to support patients with COVID-19 in the ICU setting, the translation and implementation of evidence-based care during pandemic-related surge capacity must be relied on in relation to space, staffing, supplies, and system strategies. The concept of space remains a top priority as hospitals de-escalate and potentially manage a new surge of COVID-19. Our organization designated a quarantined area to admit patients positive for COVID-19 and patients under investigation for infection. This area was in alignment with the recommendations to allocate a specific number of beds for an influx of patients who may require advanced therapies.^6,9  The hospital adapted space into AIIRs and areas to cordon off regions for caring for infected patients.

Staffing for the surge required the hospital to consider 2 possible trajectories: (1) an increased shortage of ICU nurses and thus the inability to provide an ICU level of care; or (2) a great influx of nursing into this specialty area by supplementing ICU nurses with non-ICU nurses in specific roles. To fill the gap of the nursing shortage during this pandemic, the institution introduced alternative staffing model phases to supplement existing ICU nursing staff (Figure 1). This model, with the division of roles between ICU and non-ICU staff, enhanced the flexibility of the organization to meet current and future ICU staffing needs.

Supplies have been bolstered since April 2020. Respiratory equipment has been determined to be adequate for contingency and crisis modes, after more mechanical ventilators were purchased. Pharmacological supplies of ICU medications commonly used with patients receiving mechanical ventilation have improved, but there is ongoing concern that new drug shortages will develop if another surge of the pandemic occurs. The organization created an interdisciplinary task force to address supply and demand of PPE. The Infection Prevention Department developed an internal tracking system for caregivers and units to reprocess N95 masks. Reprocessing has been done in-house with sterile processing. Increasing the supply of PPE for disaster use has become a top priority moving forward. The CCS task force has continued to meet monthly. System strategies for COVID-19 included updating disease management guidelines as new information has been published, refining infection control practices and testing, revising pharmacotherapy support as research studies revealed results from clinical trials, and revising hospital disaster-response systems in preparation for another wave of patients.

The geographic disparities of the COVID-19 pandemic in the United States led to some areas of the country moving into the crisis mode of pandemic operations. Those institutions experienced significant capacity issues at the beginning of the COVID-19 pandemic that this hospital did not experience. Issues included exhausting all available ICU beds, staffing shortages in the crisis mode necessitating use of nurses or physicians from specialty procedural and perioperative areas, and sustaining a high mortality rate that overwhelmed existing morgue capacity. Hospital-based plans should address these potential issues before the next surge or new pandemic.

The CCS multidisciplinary task force used an evidence-based approach to assess and manage the COVID-19 pandemic in our hospital. Proactively addressing key pandemic strategies before the next surge or disaster will assist ICU teams to mitigate threats, build processes to manage the crisis, and optimize patient outcomes.