key: cord-0704890-5lty18vs
authors: Orsini, Erica; Mireles-Cabodevila, Eduardo; Ashton, Rendell; Khouli, Hassan; Chaisson, Neal
title: How We Do It: Lessons on Outbreak Preparedness from the Cleveland Clinic
date: 2020-06-13
journal: Chest
DOI: 10.1016/j.chest.2020.06.009
sha: a918df1ac3ef3c2f1a4020aebfd53e00a8f7e2fd
doc_id: 704890
cord_uid: 5lty18vs

Abstract Disasters, including infectious disease outbreaks, are inevitable. Hospitals need to plan in advance to ensure that their systems can adapt to a rapidly changing environment if necessary. This review provides an overview of ten general principles that hospitals and healthcare systems should consider when developing disaster plans. The principles are consistent with an “all-hazards” approach to disaster mitigation. This approach is adapted to planning for a multiplicity of threats, but emphasizes highly relevant scenarios, such as the COVID-19 pandemic. We also describe specific ways these principles helped prepare our hospital for this pandemic. Key points include acting quickly, identifying and engaging key stakeholders early, providing accurate information, prioritizing employee safety and mental health, promoting a fully integrated clinical response, developing surge plans, preparing for ethical dilemmas, and having a cogent exit strategy for post disaster recovery.

In December 2019, clustered cases of unusual pneumonia developed among individuals exposed to the Huanan Seafood Market in Wuhan, China. The etiology was subsequently identified as a novel coronavirus, similar to the Severe Acute Respiratory Syndrome (SARS)-CoV outbreak in [2002] [2003] . 1 In four months, SARS-CoV-2, the virus which causes COVID-19, spread around the globe, challenging the ability of governments and health care systems to respond. The World

Health Organization (WHO) declared COVID-19 a pandemic on March 11, 2020. 2 Health care systems are usually prepared for endemic, or typical, levels of disease in the population. During an epidemic, hospitals may need to increase capacity to accommodate surges in clinical demand. This has been especially true with COVID-19.

The CDC estimates that the 2009 H1N1 pandemic infected 60. 8 

Approximately 275,000 individuals were hospitalized and 12,500 individuals died. 3 has surpassed H1N1 in scope and tested the capacity of healthcare in most regions of the world. 4 We propose ten principles that hospitals and healthcare systems should consider when developing disaster plans. The principles fit into an "all-hazards" approach that addresses a multiplicity of threats, but emphasizes highly relevant scenarios, such as COVID-19. We also describe specific ways our hospital applied the principles in response to COVID-19.

The most effective time for disaster planning is prior to a surge of demand on a health care system. The WHO advocates using an "all hazards" approach to emergency preparedness and program design before a disaster is imminent, 5 based on the observation that preparedness strategies for most disasters require similar coordination and planning. Hospitals should create general disaster preparedness plans with contingencies for specific threats based on the likelihood and impact to their institution.

Most of the WHO recommendations grew out of the response to the 2014 Ebola outbreak. Since we rehearsed extensively for that threat and debriefed thoroughly afterwards, we were better positioned for COVID-19. One example was our communication strategy. One of the first steps in our preparations was the deployment of a COVID-19 toolkit on our institutional intranet. The toolkit used existing infrastructure, was easily accessible and centrally managed. Providers could search and identify critical information about COVID-19 disease, policies, procedures, training, and other resources. Despite COVID-19's novelty, utilizing structures already in place let us move quickly in addressing COVID-19 specific issues. 6

Many planners make the mistake of limiting early engagement to executive leadership. While qualified leadership is essential, a command structure that engages the full array of hospital operations is essential. 7 Input from many partners allows for delegation of workload, refinement of ideas, and accountability across large teams (Table 1) . 6 In our institution, we utilized incident command models to achieve these goals. At the enterprise level, the Incident Command Center (ICC) was activated early in the course of planning for the crisis. The ICC is comprised of key clinical and operational leaders within the health system ( Figure 1 ). The ICC convened several working groups to identify, develop, and maintain communication and collaboration among key institutional, local, and state stakeholders as well as other local hospitals and the public. Regular planning and communication among these entities allowed us to coordinate strategy at the regional and local level and to escalate high priority items for rapid resolution. Within the health system, multiple smaller incident command models were also established to address specific issues. Within the respiratory institute, a twice daily call was convened for caregivers leading the ICU and infectious disease response. These calls offered a granular view of key operational issues and offered real time feedback regarding opportunities and threats to COVID-19 preparations and ongoing care.

The incident command forums also were a great opportunity to share stories of inspiration and hope in the high stress environment. These messages are frequently the final element of meetings. They have provided unity, camaraderie, pride, and motivation throughout the COVID-19 crisis.

Misinformation is common during disasters. Although social media has provided a rapid way to disseminate information, distinguishing fact from speculation can be difficult. While most contributors are well-intentioned, the rapid, unregulated nature of these platforms carries risk. 8 Misinformation can be harmful in many ways, especially as people in a spirit of panic adopt illadvised practices to protect themselves or ignore genuinely helpful measures that would protect them. 12 COVID-19 misinformation has been so widespread that the Centers for Disease Control and Prevention (CDC) formed a webpage titled "Stop the Spread of Rumors. 9" It is important to identify trustworthy and accessible "sources of truth" to guide individuals to accurate and reliable information. Governmental organizations, such as the CDC, function as reliable sources of information during infectious outbreaks and other health crises. We identified the CDC as our "source of truth," reiterated on our COVID-19 toolkit website, reinforced in meetings, and referenced in educational materials. When other sources were used, they were clearly referenced.

Despite guidance from reputable sources, there remain areas of uncertainty in a disaster. In order to foster discussion of these issues, we set up internal discussion forums among our providers.

These served to vet areas of uncertainty, propose new ideas, and reinforce best practices. The first forums were created as text messaging groups and were monitored by a designated "content expert." Later, we employed an internal, web-based chat board. In many cases, these discussions clarified uncertain areas within the enterprise response which were then communicated more broadly via the COVID-19 toolkit.

Health care workers are often considered experts in such a crisis. Our institution has benefited from the expertise of many, who through internal debate and discussion, were able to help generate institution specific guidelines, especially when national guidelines were ambiguous or rapidly changing However, we caution our caregivers from relying on or propagating on social media non-validated information which might be interpreted as "official" by others using these platforms.

It is challenging to envision all the details which allow a hospital to function on a daily basis, and still more challenging to model how these details will be affected by a disaster. One way to encourage innovative thinking is scenario simulation. A scenario is presented (e.g. during a surge, a certain resource is exhausted) to a group of stakeholders. Targeted questions help the team identify operational barriers, pathways, and policies that need to be revised.

During 2014, spread of Ebola outside of Western Africa led hospitals to plan for possible cases. 10 Leaders at Ottawa Hospital in Ontario, Canada (a dedicated Ebola patient care site) held focus groups and performed walk-throughs of patient care areas, identifying important themes to improve safety and enhance healthcare delivery. 10 Recognizing the benefits of these exercises, we convened a multidisciplinary team of physicians, nurses, therapists, unit coordinators, and quality improvement specialists, and created a simulated ICU room. In multiple simulations, providers ran through scenarios for both COVID-19 patient care and "normal" patient care, highlighting ways caring for COVID-19 patients differs from routine ICU care. Hundreds of potential interventions were explored, and the impact, cost, and effort for each was analyzed. Then we incorporated high impact, low cost initiatives into clinical care, such as banning white coats from the ICU, employing tablets with video conference capabilities in patient rooms, and disconnecting the control displays from our ventilators so they could be accessed without entering the room. Using a "plan, do, study, act" cycle, we improved upon initial ideas. Teams of clinician educators went to our regional hospitals to implement these "best practices" throughout the healthcare system.

Safety of personnel is critically important during an outbreak, both for their personal wellbeing and for the role they play in managing the disaster. Adequate supply and proper use of personal protective equipment (PPE) is a priority. Poor PPE utilization affects caregiver safety and confidence. During the 2009 H1N1 outbreak, 14 the CDC's priorities to prevent infections among health care workers included appropriate PPE use. Despite this, an estimated 50% of healthcare workers (HCWs) infected with H1N1 acquired it through workplace exposure, with a majority reporting poor adherence with PPE protocols. 11 We believe the wellbeing of everyone depends on prioritizing caregiver safety. Early on we created videos demonstrating proper donning and doffing of PPE when treating COVID-19 patients. All providers were required to watch the videos and attend in-person simulation training to reinforce appropriate techniques. Compliance with proper donning and doffing did improve, but overall adherence was still not ideal. Analysis showed that caregivers felt they were donning and doffing correctly even if they were not. This led to a "buddy system" within our COVID-19 units where employees were trained to observe each other donning or doffing and give immediate feedback.

Beyond enforcing proper PPE, multiple additional wellness initiatives have been adopted.

Resources including stress management and counseling are available and publicized on the COVID-19 toolkit site and elsewhere. Coffee and individually wrapped snacks are available for health care workers throughout the day and night. Capitalizing on a temporary restriction against visitors in our hospitals, we expanded caregiver work spaces into unused visitor waiting areas to enhance social distancing among providers. Caregivers possibly infected with COVID-19 can receive expedited drive-through testing and counseling with a simple phone call. Virtual rounding with video conference technology allows team members to communicate while maintaining safe distances. Each measure helps build an environment where providers feel they are part of a team where their safety is prioritized.

Most health care workers want to work during disasters, but lack of early coordination and collaboration can be catastrophic. 12 After Hurricane Katrina in 2006, thousands of medical volunteers presented to the Gulf Coast to assist, but failure to engage them impaired an effective response. 13 Early organization, direct communication, and clarity of roles allow for effective mobilization of workers as a unified team and prevents duplicate or conflicting efforts.

Like Katrina, COVID-19 has created interest among HCWs and local communities to assist.

Early in our planning process, education leaders began creating a platform to educate physicians in COVID-19 care and to provide training for non-internists who might be redeployed to internal medicine wards or ICUs. Other provider groups were interested in creating training resources as well. To avoid duplicative efforts and internal competition, we recruited leaders from interested groups to assist with the design and coordinate implementation of our learning platform.

Together, we created a comprehensive, multidisciplinary platform with a COVID-specific care resource, 41 pre-deployment video-based training modules, and over 110 disease-specific topic guides for practitioners to access while deployed (healthcareedu.ccf.org). Keys to our success were setting clear expectations of each group's role and a clear vision of the end product.

We also used this crisis to collaborate with our local communities. For example, after the CDC recommended the use of cloth masks in public settings, we partnered with local Amish communities in Northeast Ohio who sewed thousands of cloth masks for hospital employees to wear in non-COVID areas of the hospital.

Disasters are inherently resource limited settings, because of inadequate planning, scarcities created by the disaster itself, or both. This applies to material resources and to personnel.

Hospitals should anticipate staffing needs for all roles involved in patient care. This includes ancillary providers such as laboratory support, information technology, and pharmacy services.

Elective surgeries and procedures can be cancelled to allow space, personnel, and material flexibility. Existing patients should be transferred as needed, based on the appropriate level of care. 14 With COVID-19, hospitals have struggled to maintain adequate PPE, including N-95 masks. An inventory audit showed we had sufficient N95 masks for one year under normal circumstances, however hospitals should assume higher rates of PPE utilization during respiratory virus outbreaks. A significant increase in use and fractured supply chains forced us to conserve masks.

Data on droplet transmission of COVID-19 allowed us to conserve N-95 masks by initially using them only for high risk procedures (intubation, bronchoscopy, etc.). Following our transition to COVID-19 cohort units, providers were taught how to reuse N-95 masks on those units. Entry to patient rooms was minimized to one provider per clinical team, whose physical exam served as the basis for consultant exams in most cases. In light of ongoing supply chain shortages, we partnered with a local company to sterilize used N95 masks. These efforts reduced concerns around N-95 availability and highlight a multimodal approach to ensuring adequate material supplies during a disaster.

Material resources are only one element of the essential resources hospitals rely on. In a disaster situation such as COVID-19, hospital employee shortages occur for many reasons. In March, one article reported a hospital in Italy where over 450 nurses were unable to work. 15 Several of these nurses were incapacitated for reasons other than COVID-19 infection. Examples like these highlight the need for employees to be flexible in their roles. We anticipated potential shortages by embedding non-ICU nurses and physicians within existing ICU teams to learn skills and workflows should they be redeployed. Feedback suggests this strategy has improved communication and lowered anxiety among redeployed providers.

Outbreaks are stressful for HCWs and their families. Fears include the risk of personal illness, spreading it to others, inability to continue working, and potential stigmatization, all of which contribute to psychological distress. 16 Fears for personal safety are not unfounded. During the SARS outbreak, infections among HCWs were common, despite use of PPE. 17 A survey of HCWs during the H1N1 pandemic found that fear of infection was associated with absenteeism, restriction of social contacts, and psychological distress. 18 While institutional counseling resources are helpful, caregiver support does not necessarily require funded support from institutions. For example, we created a COVID Peer Support Task Force to assist hospital employees during the COVID-19 crisis. These volunteer employee groups from various departments are available via telephone to talk through concerns with their peers. This program exists in addition to professional counseling, but was rapidly deployable and required minimal institutional investment beyond granting time for the activities. Another effort identified providers by where they live and established small neighborhood-based support groups. These have been a welcome addition to providers with child care issues, who are quarantined or otherwise need support near home.

In addition to peer support, it is important for hospital leaders to acknowledge the stress and fears of health care workers. The institution can act to address those fears. After the SARS outbreak, studies did not find increased mental health disorders among health care workers, but rather increased stress, absenteeism, and professional burn out. Caregivers who felt adequately trained and supported by their hospitals were less likely to experience long-term stress. 19 A key concern among our healthcare providers has been fear of disease transmission to loved ones. To address this, caregivers working in COVID-19 units or who have been infected with COVID-19

can access free alternative housing provided through partnership between our hospital and local hotels. Actions like these address real needs and bolster workforce engagement both during a crisis and long afterwards. Chest Physicians emphasize the need for appropriate triage planning, as modeling data show that selecting appropriate patients for critical care interventions, rather than on a "first come, first serve basis," saves lives and increases overall access to care. 21 These decisions should be based on individual patients' "medical status and predicted response to treatment," and should be compliant with local, regional, and national guidelines. 20, 22 During an infectious outbreak, difficult decisions are often required regarding allocation of care.

Institutions must have a plan for resource allocation and triage. The Italian College of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) issued recommendations specific to COVID-19 to alleviate the emotional burden of triaged care and provide allocation criteria for health care resources. 23 We recommend having a team (palliative care, legal, clinicians, administration) perform table top exercises to develop recommendations on resource allocation. Ideally, general discussions should occur prior to an actual disaster, as part of the all-hazard planning process. Guidance from these discussions can then be tailored to an immediate disaster scenario.

One of the most difficult issues to imagine in the early stages of disaster planning is how to transition back to a "new normal." This piece is often overlooked, but is essential. 24 The Federal Emergency Management Agency and other organizations provide resources for hospitals and communities to navigate this unfamiliar territory. 25 Keys to recovery planning include many of the same principles used in planning for the actual disaster. These include collaboration, effective communications through an incident command structure, identifying potential system failures or resource limitations, and coordinating local, regional, and national resources. In our hospital, task forces have convened to advise on topics such as how to resume elective surgical procedures, how to modify the physical space for long term social distancing, and how to optimize virtual healthcare as a long-term option for patients. For example, we have implemented cell phone based virtual check-in for outpatient appointments to allow people to avoid crowded waiting areas and lines.

Early consideration of long-term recovery issues can help shape initial disaster planning. Peer support and mental health capabilities can scale for immediate and long-term needs. Changes in hospital workflow offer opportunities to address pre-disaster concerns and investments in technology may anticipate both short-and long-term needs. For example, prior to this pandemic, virtual visits were encouraged, but many providers avoided them as the video platform was slow and cumbersome to use. In response to COVID, the healthcare system was forced to rapidly expand the use of virtual visits and we decided to replace the old system with a new platform with direct integration with our electronic medical record. The hope in these changes is to leverage spending from a short-term crisis to the benefit of long-term systemic improvement.

Disasters and outbreaks have coexisted with humanity since antiquity and will continue to remain an inevitable part of human existence. 26 Disaster preparedness planning should be incorporated into routine hospital functioning. An integrated clinical and operational response will allow hospitals to mobilize available resources at the time of an incident to provide the highest standard of care to critical patients. While preparedness for all disasters share common themes, our understanding of any specific disaster evolves as the disaster unfolds. These principles are derived from the literature on disaster management and our own hospital's experiences managing the COVID-19 pandemic. While this outbreak is still unfolding, we believe these principles have prepared and empowered our health care workforce and we offer them as an aid to those who are working to adapt to the current emergency, as well as to those who will work similarly in the future. 

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