Donoho DA, Cavallo JJ, Gruen JP. Hospital Operations During a Flattened COVID-19 Curve: Results of Planning for the Nth Patient in Los Angeles County. JAMA Health Forum. Published online May 6, 2020. doi:10.1001/jamahealthforum.2020.0550
In an earlier article,1 we outlined the impending challenges to hospital capacity and operations during the coronavirus disease 2019 (COVID-19) pandemic. Although COVID-19 has remained front-page news, many hospital preparations have occurred behind closed doors. Community members may perceive this silence as a statement that COVID-19 has not affected their community or that their local hospital system remains unprepared for an impending surge. This disconnect can erode popular support for health care efforts, reduce public participation in social controls, and may even fuel conspiracy theories. To reconnect with the public, we illustrate how “flattening the curve”—a strategy that uses social controls to prevent a rapid influx of critically ill patients—has created time for Los Angeles County to improve hospital capabilities that are vital to success against COVID-19. Data in this report can be found on the public Los Angeles County Department of Health Services (DHS) dashboard.
In Los Angeles, our preparations were influenced by hard-earned lessons2 from across the world. For example, our neurosurgical colleagues in China, Iran, Greece, and Italy have shared their experiences regarding clinician risk during endonasal surgery,3 and our colleagues in New York have published eloquent descriptions of their struggles.4 This near-instantaneous sharing of experiences, exemplified by the report by Chokshi and Katz from New York, extends Martin Luther King Jr’s concept of an “inescapable network of mutuality” across the globe. Using these reports and our prior framework, we planned improvements across the preparatory domains of inpatient bed capacity (space), staff training (staff), and ventilator availability (stuff).
Our initial preparatory steps focused on increasing bed capacity. As a safety network for a large urban community, the Los Angeles County DHS cares for an underserved and indigent population with adverse posthospital care environments. Discharging patients safely to open up existing hospital beds requires significant lead time and substantial resources. In Los Angeles, we created new housing options for patients without homes, transferred patients to a naval hospital ship (USNS Mercy) to offload routine patient care, and halted elective surgical cases. It took 12 days for the DHS public hospital network to reach peak availability of intensive care unit beds (a 53% increase) and total bed availability (48% increase). During these weeks, all hospitals participating in the 911 network in Los Angeles reported similar abilities to increase their available floor beds (by 67%) and intensive care unit beds (by 59%). These fully staffed, operational beds were our buffer against a surge of inpatients with COVID-19.
Although increasing space is a prerequisite, staff expansions are required for care delivery. We expanded by recruiting staff and graduating trainees early, modifying shift location and duration, and ensuring that all clinicians were practicing at the top of their licensure. In the Los Angeles County DHS, hospitals began laboratory simulation efforts to prepare cross-trained teams of physicians, nurses, and respiratory care providers. In situ simulations with full isolation precautions improved our code blue resuscitations and daily patient care. These efforts were deployed rapidly over several days using a train-the-trainer model. We used these training sessions to empower our frontline nursing staff, who in turn uncovered further deficiencies and generated solutions.
These simulations raised secondary process considerations. Staff inside airborne infection isolation rooms cannot easily communicate with external staff during crisis situations. Hospital staff developed systems using built-in communication devices (room call buttons, telephones) and contingencies for when those systems might fail (mobile voice-over-internet protocol). All these new systems required training and trials across a multitude of different care environments and staff rosters.
Over time, novel methods for conserving personal protective equipment were developed. Techniques include modifying staff roles, eliminating unnecessary steps of procedures, and reducing response teams to the minimum necessary personnel. At other hospitals, for example, new protocols were developed for portable chest radiograph acquisition through glass doors and windows, which minimized personal protective equipment use and staff exposure. After development, these concepts were tested and verified via novel, rapid quality assurance programs.
During the weeks of time created by social distancing efforts, hospitals in Los Angeles dramatically increased their ventilator availability. Unused ventilators surged by 164% countrywide (from 398 to 1050) and by 135% (from 100 to 235) within the DHS. The federal stockpile has reported challenges with mothballed ventilators that had not been adequately maintained. Our older but full-featured ventilators in storage were carefully inspected and refurbished as needed. Although this project required significant expense, the largest hurdle was the time required to evaluate, assess, and fully repair an entire ventilator fleet. These efforts demanded hundreds of person-hours of work, weeks of lead time to acquire disposables, and additional training for staff. The stress on our purchasing and supply chain operations was notable. To supplement refurbished equipment, dozens of portable ventilators were rented, and temporary transport ventilators were purchased. To appropriately care for a surge of patients requiring ventilator support, other medical professionals were cross-trained with respiratory care providers to provide support.
Without a flattened curve, we may not have succeeded in making timely operational improvements across the domains of space, staff, and stuff. Our efforts to improve hospital bed capacity may have been stymied by our inability to rapidly discharge patients. An increased operational tempo could have prevented our daily staff training and didactic sessions. Lessons learned and best practice might not have been disseminated if staff were encumbered by hourly resuscitations and cardiac arrest responses. Early staff shortages owing to illness and absenteeism, as seen in New York, might have further hampered our ventilator refurbishment and respiratory care training.
Early warnings from our colleagues and our community’s efforts to flatten the curve allowed Los Angeles hospitals to implement operational improvements across major preparatory domains. Although we are better prepared to treat the nth patient, the pandemic remains fluid. Each day brings a new challenge. Despite our relative initial successes and the effectiveness of California’s early social distancing, we must remain vigilant during the impending incremental resumption of daily life.
Corresponding Author: Daniel A. Donoho, MD, Department of Neurosurgery, University of Southern California, GH 3300, 1200 N State St, Los Angeles, CA 90033 (email@example.com).
Conflict of Interest Disclosures: None reported.
Disclaimer: This manuscript was drafted using publicly available datasets and reflects the sole opinions of the authors. This manuscript does not reflect official policy of the Los Angeles County DHS, Yale University, or the University of Southern California.
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