The Northwell Health system has been the epicenter of the epicenter, caring for 20% of all COVID-19 patients in the state of New York during the pandemic.
They’ve had help handling the surge. Fourteen physicians and other staff came from the University of Rochester Medical Center in Western New York and another 50 professionals came from even further west—Salt Lake City’s Intermountain Health system.
But some of the helping hands came from much closer. Those hands belonged to Northwell specialists whose offices had closed to support physical distancing and as part of the effort to focus as many resources as possible on the pandemic.
If positive developments can be gleaned from the pandemic experience, one could be the “enhanced interdisciplinary nature” of how care teams are working together in the ICU and elsewhere, Northwell President and CEO Michael Dowling said in a panel discussion hosted by AMA Chief Experience Officer Todd Unger.
“Doctors and nurses have moved from their traditional ‘narrow specialties’ to working in much broader areas and work together in cohort,” Dowling said. “You go into the front lines in the ICU, and you have your cardiac people there. So, there's a lesson here where the little silos have been completely broken down over the last five or six weeks. We have got to make sure we keep them broken down, and not let people go back again to the way they were before.”
In a blog post on the Northwell website, internist and emergency medicine physician Jeffrey Zilberstein, MD, wrote how separate neuro, surgical and cardiothoracic ICUs have been set up for COVID-19 patients.
“Each has a separate staff/team, although we are all working to care for COVID-19 patients together,” wrote Dr. Zilberstein, vice chair of medicine-pulmonary medicine and critical care, at Northwell’s Southside Hospital in Bay Shore, New York.
“Given the large number of very sick patients that we’re caring for, I am inspired by our staff every day and am seeing examples of us being ‘truly together,’ one of our values, on a daily basis,” he added. “They are willing to help any way they can, often ‘running into the fire’ very willingly. Cardiologists and nephrologists, for instance, are helping me and my team care for our COVID-19 patients. I’m working with them in a capacity that makes the best use of their skills, supports the team and, ultimately, helps our patients.”
Visiting volunteers witness teamwork
The collaboration didn’t go unnoticed by the visiting staff. “There was so much collaboration and teamwork, and incredible resiliency,” Wendy Allen-Thompson, emergency department director of nursing at the University of Rochester Medical Center (URMC) said.
“We saw their hospital, all departments, coming together to care for patients,” Allen-Thompson said in a news article on the URMC website. “Providers from different services doing whatever needed to be done.”
Dowling said the experience has destroyed the theory that people can’t contribute to care outside of their specialty.
“It has been a phenomenal cross-fertilization, education-wise, for everybody,” he explained. “In other words, no crisis goes to waste. There are wonderful benefits coming out of this—despite the horror of what we've been experiencing.”
Quality improvement requires inclusion
As senior vice president and deputy chief medical officer, Mark Jarrett, MD, serves as Northwell’s chief quality officer and is responsible for the system’s quality and patient-safety initiatives. The AMA member said in an interview that collaboration and team building has been a focus of this work.
“In quality improvement, everything is multidisciplinary,” Dr. Jarrett, an internist and rheumatologist, said. “We’ve always worked together, but now we’re working together in different ways.”
Being “inclusive” has been a major part of the COVID-19 response as Northwell specialists closed their offices and headed to the hospital floor. They were given “just in time” training and were paired off in a buddy system to help them adjust to their new roles.
“We had internal medicine subspecialists and specialist like orthopedists and urologists on the floor,” Dr. Jarrett said. “It was all hands on deck because of the volume of patients.” Northwell was adding 200 new beds a day at one point, eventually adding capacity for 1,600 more patients.
Dr. Jarrett noted that the internists teamed up with hospitalists in the ICU, while the orthopedists, urologists and others whose background did not include taking care of patients with severe respiratory illness, went to work on medical-surgical floor helping COVID-19 patients that were not on ventilators.
Often, they needed to be oriented in the medical documentation necessary for respiratory patients, but Dr. Jarrett said the influx of newcomers to the floor was helpful. “They had a fresh viewpoint and would ask questions ‘Why do you do it that way?’ and it got people thinking differently,” he explained.
Fragmentation leads to silo building
Like Dowling, Dr. Jarrett wants to see the enhanced collaboration continue. He said that breaking down silos is a key objective in health care quality improvement. “It’s completely about that, to be honest,” he added. “It’s about being inclusive and that’s absolutely necessary.”
Increasing complexity has helped build medical specialty silos, he said. But the fragmentation of health care has made it worse and the lack of electronic health record (EHR) interoperability adds to the problem.
EHRs at Northwell’s different facilities are interoperable and very well connected, but if a patient comes to a Northwell emergency department and they say there were in another system’s department two days ago, “we can’t get documentation,” Dr. Jarrett said.
The value of Northwell’s interconnectivity was displayed in a recent JAMA study where researchers were able to analyze EHR data on 5,700 patients who were seen at 12 Northwell hospitals between March 1 and April 4. They found that comorbidities were common among COVID-19 patients, with 57% having hypertension, 41% having obesity, and 34% had diabetes. The patients with diabetes were more likely to need a ventilator, receive treatment in the ICU, or develop acute kidney disease.
Dr. Jarrett said one of the key learnings of the COVID-19 experience has been gaining efficiencies, particularly with transitioning patients to other levels of care which, in the past, could be troublesome on weekends. Now, he said, such transitions take place seven days a week because “the need to change out beds was constant.”
A chief concern he has is that it seems some parts of the country are not taking the pandemic serious enough and won’t be prepared if they are hit with a surge of patients. “My biggest issue is that people outside of areas like New York don’t realize how bad things are,” Dr. Jarrett said. “Because, if they don’t begin to realize it, they’re not going to plan appropriately.”