The X’s and O’s Behind Setting Up Alternate COVID-19 Care Sites

May 6, 2020
Lots of preparation and strategy goes into setting up alternate care delivery sites, though the planners themselves hope some—such as field hospitals—will never be needed

Last month, when Lowell General Hospitalbased in the Merrimack Valley region of Massachusetts wrapped up its final preparations for standing up an alternate care site to provide additional hospital bed capacity if COVID-19 cases were to surge, clinical, operational and IT leaders at the organization hoped all the work that went into the development would be for naught. If there wasn’t a need to “activate” the alternate care delivery site—set up at the UMass Lowell Campus Recreation Center—that meant that local hospitals were handling COVID-19 cases without the need for extra support.

Lo and behold, that’s’ exactly how it’s played out so far. With two primary inpatient campuses located in Lowell, Mass., the patient care organization was determined to turn the college recreation center, situated about five miles from the main facility, into an improvised field hospital for low-acuity COVID-19 patients who were not quite ready to recover at home, yet not in need of intensive care in the hospital. But as of the time this piece was published, although the two facilities have been caring for dozens of COVID patients, leaders have yet to “flip the switch” on the alternate care site.

Of course, just because the site hasn’t needed to be activated doesn’t mean that a tremendous amount of work and team collaboration didn't go into its planning and development. A team of clinical and IT leaders from the Massachusetts Emergency Management Agency (MEMA), Circle Health, the parent organization of Lowell General Hospital, and others, were able to quickly construct the new facility once the initial site survey to inspect core elements such as electricity, network connectivity, physical entrances and exits, bathrooms, and running water, was done. It was also determined at this time that 90 patient beds could fit in the stood-up location. As such, MEMA was tasked with setting up the “bare bones,” such as cots and partitions, and then turned it over to the Lowell General team to operationalize and staff the site, explains Angel Santana, senior support manager at Lowell General Hospital.

From a technology perspective, the new field site has been equipped with the same technology at Lowell General’s two hospital campuses, including full access to its Cerner EHR. Similarly, all medical devices necessary for COVID-19 recovery have been connected to the EHR, with information flowing from the alternate care facility to the main hospital. These include EKG machines, portable X-ray machines, portable lab carts and wireless glucometers, according to officials.

“It took MEMA three days to turn it over to us, and from an IT perspective it took two-and-a-half or three days from the initial network connection all the way through the end. The [final steps] were doing things such as connecting portable radiology devices to the picture archiving and communication system (PACS). Everything [IT-based] was basically up-and-running in less than three days,” says Circle Health CIO John McLendon. From a technology perspective, “you wouldn’t have been able to notice the difference if you were at this site versus being at the [actual] hospital,” Santana attests.

At the site, five “pods” were built, labeled A through E. The original plan, notes Santana, was to open pod A first—inclusive of 14 beds, with one physician assistant or nurse practitioner, as well as nurses, medical assistants and patient care technicians.  However, neither pod A, nor any of the other pods at the rec center, have been needed so far, though according to Nick LeClair, emergency preparedness coordinator at Lowell General Hospital, at one point the team was “right on the edge” of activating, even going as far as shipping a nurse call system that used Wi-Fi technology overnight. “The [COVID surge] numbers were teetering along the lines of meeting the criteria, but then they dropped a bit the next morning, so we didn’t need to activate. We were very close, but ultimately didn’t need to,” LeClair recounts.

Another key component of the site’s development, he notes, was making sure it met all the necessary safety requirements. To this end, the organization’s safety officer was heavily involved in risk assessments from day one through its completion, LeClair says, adding that for utility and other infrastructure examinations, both state and local plumbing and electrical inspectors were required to sign off. “Even though we are in a state of emergency, there are still standards in place we are upholding,” he says.

Even so, when emergency strikes, regulators typically try not to be barriers, offers Tanya Leshko, a healthcare attorney at law firm Buchanan Ingersoll & Rooney. In regard to implementing emergency operation plans,  she says, “There are times when regulators can’t be quite as nimble as some would like, and to some degree, healthcare providers will [deploy] their services and ask for forgiveness later. And if they haven’t done anything crazy, they’re going to get it. Medical providers are largely dedicated to serving people who need [care]. So in a circumstance like the [COVID-19] crisis,  I don’t think regulators get in the way much,” she contends.

Going forward, although local healthcare and IT leaders hope to never have to activate the site, the location is equipped to field patients from other area hospitals as well, rather than just the two Lowell General campuses, notes Santana. Adds LeClair, “These [alternate[ care sites are ultimately part of the state’s strategic plan. We had plans in place to serve as a regional asset of sorts if and when we activate.

As of May 5, the state has seen more than 70,000 confirmed cases with over 4,000 deaths. “In the beginning stages, we were discussing how field sites were opening in Worcester, at the Boston Convention Center, and on Cape Cod, but there was  gap in the Merrimack Valley, which is our region. That’s where this all started,” LeClair says.

Alternate considerations for testing, too

Throughout the past several weeks, drive-thru COVID testing sites continue to pop up across the country, aiming to prevent traditional healthcare facilities and ERs from overcrowding via minimal-contact screening labs. Similar to standing up field hospitals, there are plenty of clinical and operational challenges involved with developing mobile testing sites.

In late March, UConn Health opened up a drive-thru testing site on its Farmington, Conn. campus after organizational leaders identified a remote parking lot as an ideal testing site. UConn Health’s network team then performed data drops, enabled Wi-Fi connections, and set up tents and a registration trailer, recalls Roberta Romeo Shannon, project manager, strategic projects and clinical systems, at UConn Health.

The team then decided it could expedite testing by using Apple iPhones combined with a communications platform from healthcare technology company Voalte to take photos and send patient information via secure text messages, she adds. Further explaining how the workflow process is deployed, Shannon, in an e-mailed response to Healthcare Innovation, outlines the following:

  • The patient must first get a testing order from his or her physician, then drive to the site and present this to the attendant along with a health insurance card and driver’s license. Staff members who take this information assign themselves the role of COVID Collector in the Voalte smartphone directory.
  • The “COVID Collector” then takes photos of the patient (with the window rolled up when possible), the doctor’s order, insurance card, driver’s license and license plate.
  • These photos are sent in a secure text message to the designated “COVID Receiver” at the registration trailer, who receives this information on a Voalte smartphone or desktop client and enters it into the Epic EHR.
  • By the time the patient drives up to the testing tent, he or she is pre-registered. With the patient still inside the car, one nurse at the testing tent swabs the patient and the other captures the sample in a test vial.
  • Using a wireless printer, a nurse prints the specimen label without leaving the tent and sticks it on the test vial.

Shannon notes that the process of testing specimens is expedited “through our partnership with [research institute] The Jackson Laboratory, which is just a stone’s throw from our parking lot. [They] began testing for COVID-19 roughly the same time we opened our testing site on March 23.”

As of April 25th, Shannon says UConn Health’s COVID Call Center has received nearly 4,000 calls and collected over 800 test samples at its drive-thru site, which includes approximately 350 tests for employees.

She believes that one key lesson learned has been that IT processes in a remote area of UConn’s campus can present challenges. “So we established a lot of redundancy. For example, as a downtime precaution, we have another label printer in the truck on-site and have walkie-talkies available if the headsets have problems.” Shannon also says it is wise to prepare for unpredictable weather, especially in New England, and the team has battery-operated lanterns at the site in case power is ever lost.

Of course, when preparing for an emergency, there is only so much specificity that’s feasible when constructing crisis management plans. Leshko, who was the legal advisor to the Office for Public Health Preparedness at the Pennsylvania Department of Health during the H1N1 outbreak in 2009, says, “Obviously you can’t tell you how many field hospitals or mobile testing sites you’ll need, or which parking lot you will set up now. The plans are a guide and when you pull them out to implement, you hope a lot has been pre-identified, so can put into operations those parts of the plan that are functional for you.” However, she adds, things do inevitably change over time. “COVID-19 has presented an unprecedented [need for] response in terms of a pandemic. People will simply have to be nimble and do their best.”

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