key: cord-034398-g09usvbs
authors: Kumar, Santhi Iyer; Borok, Zea
title: Filling the Bench: Faculty Surge Deployment in Response to the Covid-19 Pandemic
date: 2020-10-29
journal: NEJM Catal Innov Care Deliv
DOI: 10.1056/cat.20.0511
sha: 
doc_id: 34398
cord_uid: g09usvbs

To prepare for Covid-19 surges, a medical center surveys its entire medical staff to gauge each physician's ability and willingness to care for Covid-19 patients, and uses the results to provide additional training and devise a deployment plan.

The Department of Medicine (DoM) at the Keck School of Medicine of the University of Southern California consists of ten divisions and more than 300 faculty members. Our faculty work in two distinct health systems, the Los Angeles County (LAC) +USC Medical Center and Keck Medicine of USC, each with separate leadership, structures, and processes. LAC+USC Medical Center is a 600-bed public hospital and is the largest safety net hospital in Los Angeles. Keck Medicine of USC comprises three hospitals: 300-bed Keck Hospital of USC, 60-bed Norris Cancer Hospital and 158-bed Verdugo Hills Hospital. A tertiary/quaternary referral center, Keck Hospital cares for patients with complex medical and surgical problems and performs heart, lung, liver and kidney transplantation. The Norris Cancer Hospital is part of the Norris Comprehensive Cancer Center and provides cutting-edge cancer treatments.

Minimizing harm and maintaining the safety of our faculty and patients formed the bedrock of our surge deployment process. To guide our decision-making, we anchored our plan around four principles. First, the deployment process had to protect faculty and trainees who were most vulnerable to negative sequelae of a SARS-CoV2 infection. Second, clinical services not related to Covid-19 care needed to be appropriately staffed so as not to compromise usual patient care. Third, faculty would be prioritized to areas that align closely with work they already do. And last, the partnership between department leadership, division chiefs and program directors was essential to the deployment strategy, because they have the most comprehensive understanding of clinical operations and the specific skills of their faculty.

The DoM designed a brief survey for faculty to self-assess their comfort in the following areas: performing common intensive care unit (ICU) procedures, ventilator management, proficiency in care coordination, family meetings, electronic medical record documentation and order entry. (Table 1 ) They were also asked about their willingness to care for Covid-19 positive patients and their risk for severe sequelae of Covid-19 disease ( Figure 1 ). Using SurveyMonkey, the survey was sent to DoM faculty and results were kept confidential and only shared with the division chief. There was a 93% response rate. The survey is available as an appendix.(Appendix) 

The next step involved matching information gained from the survey with the specific roles and responsibilities of faculty members. Using survey information, division chiefs were asked to rank each faculty member from 1 through 6 in each of the care domains based on the individual's suitability. The process considered a faculty member's willingness to care for Covid-19 patients, personal circumstances that limited a faculty member's ability to work in certain care spaces (including health-related issues or family situations), and their best place to provide care in the different domains (e.g., telemedicine, critical care). Faculty were ranked highest in care domains where their skillset was best suited to match the need of the environment. Faculty who it was felt should not work in a particular care area were ranked "N/A" in those domains.

The lists supplied by the division chiefs were centrally maintained in the department. To ensure faculty members would be successful in their area of deployment, the hospitalists and intensivists created orientations to the Covid-19 patient care areas and designed processes and protocols that would support physicians unfamiliar with those clinical spaces. We used Microsoft Teams as a web-based collaboration tool and regularly updated the "Covid-19 Updates and Communication" team folder with the most current processes and protocols related to Covid-19 care practices. Also, physicians who were best suited to be deployed to the ICU were prioritized to receive "Critical Care for the Non-Intensivist" training organized by the Division of Pulmonary, Critical Care and Sleep Medicine (PCCSM).

Each week, division chiefs provide a list of faculty members who are available for "surge duty." In order to minimize the stress of having to learn new and evolving Covid-related processes at each of the institutions, faculty were assigned to be deployed in the health system where they felt most comfortable and practiced most often. Faculty were then slotted into a backup schedule by location, based on their suitability to each care domain. The backup schedule was published weekly for deployment the following week when cases were rising.

Leveraging expertise beyond the DoM was important to support non-intensivists in surge deployment. We collaborated with the Departments of Surgery and Anesthesia to develop specialized airway and procedure teams to support the frontline intensivists in the ICU. Intensivists " from all departments came together to discuss the literature, develop protocols, and align practices so that care could be seamlessly provided regardless of the intensivist's primary specialty.

The stress experienced by the DoM was determined by both the number of patients in each of the hospitals and the providers available to care for them. Keeping a pulse of the patient needs in both care settings was important to managing the appropriate deployment of faculty.

We worked with leaders in both health systems to understand how each hospital was going to increase the capacity of Covid-19 ICU beds. The Divisions of General Internal Medicine (GIM) and PCCSM then developed a faculty surge model based on the number of beds to match the increased capacity.

With early reports from China and Italy communicating increased SARS-CoV-2 infections amongst healthcare workers,2 -4 we developed a method to gauge the stress that GIM and PCCSM faculty were experiencing due to workforce attrition. Faculty members who were directly exposed to Covid-19 patients were being placed in quarantine for 14 days during the first 6 weeks of the pandemic. The "stress" within the divisions was determined by color ( Table 2 ). The surge plan would be activated when the stress within GIM or PCCSM was red. When the workforce was determined to be at black (the highest stress level), we would reach out to faculty outside of the DoM. Each color category was coupled with assigned action items related to communicating the current status to faculty and preparing for the next stage of the surge.

Information regarding patient numbers from each health system and the "stress" within each of the divisions was gathered twice a week. The data were then presented to the DoM division chiefs twice weekly as our "Surge Status" so that each division could anticipate how close we were as a system to needing to deploy faculty. (Table 2 )

From mid-April to the end of May, the Vice Chair of Quality and Safety published a list of faculty members available for surge duty. While social distancing practices and stay at home orders initially flattened the curve in Los Angeles, reopening has brought a new influx of patients into our health systems. We continue to monitor the stress across the department weekly and fortunately have been able to manage the increasing numbers without activation of our surge plan. The most significant challenge hospitals face is the inability to predict the need for additional ICU staffing moving forward. In response to the Department's surge plan, faculty members have expressed gratitude for the level of preparation the Department has done to thoughtfully deploy faculty efficiently in the event of a sudden increase in cases. Our surge plan allows us to quickly identify and deploy additional frontline care providers at short notice during these unprecedented and unpredictable times.

Nearly 3,400 Chinese healthcare workers have gotten the coronavirus, and 13 have died'Business Insider

Nearly 1 in 10 of Italy's infected are health care workers'CNN