How SCCM’s FDM Course Helped One New York City Hospital Address the Pandemic

For hospitals in surge cities, novel coronavirus 2019 (COVID-19) was a disaster such as they had never seen before. Most disasters—natural, nuclear, mass shootings, and other forms of terrorism—are one-time events that quickly overwhelm intensive care units (ICUs) and then ease within a few days. COVID-19 was a “mass casualty in reverse,” said Richard H. Savel, MD, CPE, FCCM, director of adult critical care services and vice-chair for inpatient clinical services in the Department of Surgery at Maimonides Medical Center in Brooklyn, New York, a hotbed of the COVID-19 outbreak. ICU needs grew steadily—rather than all at once—and then remained at high levels for weeks without a break. Between its first COVID-19 case on March 9 and the peak on April 21, Maimonides transformed from a 700-bed hospital with one 20-bed medical ICU and 57 ICU beds, to a hospital with 10 ICUs and 140 ICU beds.
 
While no hospital was truly prepared for COVID-19, Dr. Savel said that, because he had taken the Society of Critical Care Medicine’s Fundamental Disaster Management (FDM) course twice and taught it twice during the past decade, Maimonides was in a far better position. “Our COVID-19 cases are dropping and, while we’re still addressing the pandemic, to the extent that we got through the worst of it, it was due to this course,” said Dr. Savel. “I remain eternally grateful for every drop of information I gleaned from it.”
 
The FDM course focuses on the role of the critical care specialist in managing disasters. Dr. Savel recommends that all attending physicians and fellows take the course. During the New York City outbreak, Dr. Savel’s role at Maimonides was as the “boundary spanner,” meaning that he acted as the interface between critical care clinicians and operational leadership. Constant communication was of the utmost importance, and he rounded with those groups twice daily. Ultimately, he was part of the team responsible for ensuring that the hospital had enough staff, equipment, and rooms to treat COVID-19 patients. There was no time to employ normal protocols, and decisions that normally took months were made in minutes, by necessity. Through it all, he was impressed with the dedication of the staff, all of whom faced daunting experiences every day. “I’ve never been prouder to be part of a critical care community,” he said.
 
He noted a number of important take-aways from the FDM course that applied to the pandemic, beginning with having a disaster plan in place, employing rules that have been agreed upon in advance and must be adhered to. He said five key lessons learned from FDM apply directly to pandemic management:

1. Employ a military approach to planning.

​A military-style structure will help ensure that you are making optimal use of resources.
 

2. Set up a hospital command center.

Critical care specialists should be in charge and work directly with hospital leadership while overseeing work groups that address specific issues, such as pharmacy, operations, and ventilator management. Plan for twice-daily conference calls to discuss status and needs.
 

3. Protect clinicians first.

​Ensure that there is enough personal protective equipment to keep all clinicians safe, which will decrease their risk of becoming infected and straining already-stretched resources. This means ensuring that clinicians are fully protected before they run to help a patient in distress.
 

4. Understand that triage is critical.

​Critical care specialists should remain in the ICU, where they will be first receivers who are prepared and ready to act. For many (if not most) hospitals, ICU beds are a limited resource, and having real-time, dynamic evaluation and reevaluation by a critical care triage officer or critical care triage committee helps determine which patients should be in those beds—a key aspect to providing optimal outcomes.
 

5. Employ situational awareness.

​Inventory and fully understand your “staff, stuff, and space” to ensure that you are working as a coordinated team and have an awareness of supply chains, operations, staff, beds, ICU space, oxygen system adequacy, etc. so you can go back up the chain of command as soon as you see a problem developing. Operationalize clinical issues hour by hour, day by day, maximizing the critical care resources you have and working closely as a team with the hospital command center to provide real-time information while also planning ahead. Today you could be running out of gloves, tomorrow you may experience a staff shortage because several have tested positive for COVID-19, the next day you might run into drug shortages.

 
“Every mass disaster brings new insights for future planning, and so it is with COVID-19, and we’re still learning about them,” said Dr. Savel. He noted a number of unanticipated logistical challenges that arose. For example, patients are on mechanical ventilation far longer than is typical, prompting the need to open up more and more ICUs. Because COVID-19 is so contagious, his team moved ICU pumps outside of patients’ rooms to reduce the exposure risk to healthcare workers. Because family mem-bers were not allowed to visit, critical communication with loved ones, which used to be routine, became much more challenging. In response, Maimonides rapidly set up an innovative family communication center leveraging the electronic health record and having physicians who were not on the front lines of care provide that communication.
 
Dr. Savel said they learned that more intensivists than expected were needed to ensure the highest level of care, so the hospital hired temporary critical care specialists. And the mental distress for health-care staff was beyond anything previously experienced. It is vital to acknowledge how daunting the job is day after day and to provide mental health support.
 
Now that the number of COVID-19 cases is dropping, Maimonides is in the process of ramping down from the surge but is preparing for the next wave by keeping one extra ICU open. The hospital worked on creating a safe environment for all patients, with parallel pathways for those with COVID-19 and those without. Every hospital must figure out how they will handle this issue to continue to provide quality care while remaining solvent, within the confines of their structure. For health systems with more than one building, one could be dedicated to COVID-19 care and the other to non-COVID-19 care. At one-structure hospitals such as Maimonides, it may involve floors dedicated to COVID-19 patients and floors dedicated to other patients.
 
“As a world, we need to prepare to have COVID-19 as part of our existence, less as disaster management and more as our new reality,” said Dr. Savel. “We need to be ready to provide high-quality healthcare to patients who have the disease—including being ready to have an ICU or ICUs full of patients—while also being able to care for patients who don’t have the disease but need procedures done.”

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