An Innovative Provider Redeployment Strategy During the COVID-19 Pandemic In New York City

In early July 2020, the world was approaching 12 million confirmed COVID-19 cases and more than 500,000 COVID-related deaths, with over 22,000 deaths in New York City alone.(1,2) Some NYC neighborhoods were referred to as “the epicenter of the epicenter.”(3)

Disaster planning is a critical organizational component of emergency medicine (EM), and the COVID-19 pandemic presented an opportunity to explore innovative preparedness, including a novel ED staffing model using redeployed physicians from other specialties.

The NewYork-Presbyterian/Weill Cornell Medicine Department of Emergency Medicine staffs two hospital EDs in New York City: NewYork-Presbyterian/Weill Cornell Medicine (NYP/WCM) and NewYork-Presbyterian/Lower Manhattan Hospital (NYP/LMH). NYP/WCM is an urban quaternary-care academic medical center with more than 95,000 annual ED visits. The ED is a certified center for trauma, stroke, ST-segment elevation myocardial infarction, and burns. NYP/LMH is a community hospital in southern Manhattan with 50,000 annual ED visits. The practice comprises 100 attending emergency physicians, 48 resident physicians, 30 physician assistants, and five nurse practitioners.

Evidence-based resource allocation strategies are limited but have been described regarding optimizing and augmenting the use of existing resources in mass casualty events. Examples from a combination of actual disaster events and exercises include alternate site surge facilities, mobile field hospital deployment, federal resource activation, modified triage algorithms, load-sharing with regional systems, and conversion of nontraditional spaces.(4) All of these strategies were implemented by our enterprise in the pandemic response, though provider redeployment from specialties outside of EM into the ED during a pandemic disaster was a unique opportunity without a blueprint.

A disaster by definition requires additional resources, but also the right resources. In a disaster scenario, it is not uncommon for volunteer providers to arrive seeking to be of service; however, they may in fact disrupt an organized response. This can add to disorder when organizational clarity is paramount.(5,6) The recruitment and thoughtful onboarding of supplemental non-EM physicians has the potential to be transformative. One analogous approach was described during the 2009 H1N1 pandemic when a tertiary-care children’s hospital redeployed general pediatricians into the pediatric ED.(7)

The American College of Emergency Physicians (ACEP) supports the emergency privileging of additional physicians to supplement existing staff in the event of disaster.(8) This is in line with The Joint Commission standards that recommend a hospital may grant disaster privileges to volunteer licensed independent practitioners during a disaster.(9) By virtue of required training in preparedness and disaster management, EM is stationed perfectly to train and integrate redeployed physicians.(10)

Preparedness and Planning

Initial predictive analysis modeled New York City as approximately 20 days behind Italy, suggesting an impending patient volume beyond the city’s institutional capacity. In response, an enterprise-wide task force was formed to increase hospital and care team capacity, focusing on providing additional support to the areas of greatest need: the ED and intensive care units.

With government officials urging social isolation and a substantial increase in the number of patients electing to receive care by telemedicine, our virtual urgent care service was also identified as an area that required additional support. As the situation unfolded, the task force met with the chairpersons of multiple departments with appropriate staff to redeploy, based on estimated needs.

We in-serviced redeployed non-EM providers to supply additional coverage both within the ED as well as on our direct-to-consumer telemedicine platform. This included 10 attending physicians and 10 advanced practice providers (APPs) to join the ED team, plus an additional 25 attending physicians and 15 APPs to join the telemedicine group.

To ensure patients would continue to receive the highest quality medical care, the ED leadership developed a comprehensive orientation and onboarding process and operationalized the training, scheduling, shadow shifts, quality review, and feedback process for redeployed staff from neurosurgery, ophthalmology, neurology, physical medicine and rehabilitation, dermatology, internal medicine, colorectal surgery, gastroenterology, psychiatry, and others (see Table 1). These capable clinicians were deployed as frontline providers in our ED or as additional physicians in our virtual urgent care service.

The Execution and Hurdles

Compensation and Liability. All redeployed faculty members are employees of the physician organization, which allowed for seamless integration of payroll regardless of physician specialty; providers continued to be paid by their respective departments. Professional liability concerns for working outside a provider’s usual scope of practice were addressed by state and federal governments.

On March 7, 2020, in the early days of the pandemic, New York Gov. Andrew Cuomo issued executive order 202.10 that provided immunity to healthcare professionals and facilities from civil or criminal liability. Similarly, the Coronavirus Aid, Relief, and Economic Security (CARES) Act provided immunity from liability under federal law for care provided to COVID-19 patients.

Telemedicine Redeployment. Prior to the pandemic, about 1 percent to 2 percent of all visits in our healthcare system occurred via telemedicine; at its peak, virtual visits across the enterprise rose substantially to represent 60 percent of all patient encounters. To meet a near 15-fold increase in demand for virtual urgent care services, we onboarded 35 physicians and 12 APPs.

Using our ED-based Center for Virtual Care, we promoted COVID-19 assessment training videos across the institution with additional educational materials for providers new to telemedicine, including information on physical examination primers, technical requirements for telemedicine, and self-presentation video professionalism skills.

A training course in electronic medical record systems and video platform software required for the video visits was followed by individualized mentoring sessions during which new providers “shadowed” seasoned providers. After shadowing experiences, providers began to see patients on their own but with the real-time backup of ED telemedicine providers available on a texting platform to offer medical advice and patient-specific guidance. Through this same platform, general instruction on urgent care case management was given in the form of case-based tutorials.

This rigorous preparation and real-time team communication allowed providers from multiple specialties to see undifferentiated urgent care patients safely. Case management for these non-EM providers was further assured by review of case summaries provided by each provider at the end of a shift. The specialty diversity allowed patients to be sorted by complaint; for example, a patient with a rash could be diverted to a dermatologist. Conservatively estimated, 85 percent of virtual urgent care visits during this period were for COVID-like illness. Providers were given a standardized tool to guide appropriate disposition based on assessment, as well as standardized instructions for patients that included the most recent regulatory guidance and resources.

ED Redeployment and Orientation Process. An accelerated orientation process was developed leveraging a pre-existing EM online information system housing clinical guidelines, policies, and procedures. Prior to the first scheduled shift, redeployed faculty were given a 30-minute online video introduction, a two-hour in-person orientation, followed by a six-hour “shadow shift.” Modifications were made to an established comprehensive orientation document used for all new ED hires.

The onboarding video entitled Intro to the ED & COVID reviewed workflows, proper PPE use, and specific COVID-19 clinical workflows. Through collaboration with our departmental medical education colleagues, we identified and curated online resources to be reviewed prior to beginning.

The “shadow shift” provided clinical time without clinical responsibility, paired with an experienced EM physician, to become familiar with personnel, workflows, and several aspects included in the orientation checklist. We determined initial roles and where to best staff providers based on a host of factors including specialty-specific skills, years of training, personal preferences, and respective department leader input.

Quality Assurance and Risk Mitigation. The provision of high-quality care is the primary mission of our department; however, the introduction of redeployed staff unfamiliar with the complexities and acuity of EM has the potential to undermine patient safety. As was done for the telemedicine redeployment, a robust quality assurance program was created for redeployed physicians working physically in the ED.

An automated report was generated of all patients seen by these providers, with chart reviews performed by the departmental quality and patient safety apparatus using a standardized checklist to ensure quality care (see Table 2). The checklist evaluates the quality of documentation, clinical reasoning, incorporation of clinical data including lab and radiology studies, and supervision of PA and NP staff.

ED providers were instructed to raise any questions about the quality of care they encountered while working in real time. Safety rounds were conducted to address any issues and to ensure compliance with departmental policies and procedures. Weekly debriefs with redeployed staff were held to elicit feedback on their comfort level with managing the acuity and specific types of presentations. These strategies maintained a high standard of quality and patient safety.

Hurdles. For almost all U.S. healthcare enterprises, the redeployment of non-EM trained providers to the ED is uncharted territory. Several hurdles were recognized with respect to concern for personal safety, uncertainty with an innovative process, and strategies for establishing a comfort level with a new professional environment.

Several redeployed providers expressed concerns about caring for COVID-19 patients based on having personal comorbidities or living with immunocompromised family members. The key to addressing these concerns was communicating our personal protective equipment protocols effectively and regularly, while comprehensively training our new team members on all aspects of the institutional staff safety response.

As with any novel proposal, a degree of initial skepticism and worst-case scenario conjecture from leadership stakeholders and frontline clinical staff can be expected. The ED is a unique healthcare setting that provides unscheduled care to undifferentiated patients of all ages, at all times. Among the redeployed staff, there was some anxiety about practicing in this new environment with which they lacked familiarity with documentation, protocols, or formal training.

To address these concerns, we ensured that providers were assigned to shifts with experienced ED APP staff who could assist with the practicalities of patient care, such as placing orders or obtaining consults. Each redeployed staff member had immediate access to a board-certified EM physician either in person clinically or virtually on the telemedicine platform. Clarifying redeployment strategy to staff before the process began as a thoughtful role progression from small group onboarding, to shadow shifts, to swing shifts, to autonomous shifts with EM attending backup greatly assisted in diffusing apprehension in providers who may have been years out of their general training.

Key Take Aways

A primary challenge facing many healthcare institutions in the COVID-19 crisis has been to rapidly scale frontline ED staffing. Unfortunately, there is limited high-quality evidence about strategies available to providers in the hospital setting to optimize the allocation of scarce resources during a mass casualty event, and no single strategy is supported over another.(11)

The COVID-19 disaster pandemic provided a unique opportunity to describe the innovative redeployment of nonEM physicians to the ED workforce. Our strategy engaged 80 providers across 15 specialties to care for approximately 3,000 patients over a three-month period. Leveraging the skills of non-EM providers allowed our team to build a more diverse disaster management protocol allocating a previously untapped resource de novo. Pre-existing systems in place across operations, education, quality, and safety were crucial to the swift implementation of this strategy.

Six actionable steps were key to the success of our redeployment process:

• Establish ED Redeployment Task Force. Recognize that rapid physician redeployment during a disaster is a major undertaking and includes scheduling, orientation, education, quality assurance and frontline leadership. Establishing a formal group of department leaders with the appropriate skills is paramount to successful management of this transient workforce.

• Engage Stakeholders. Market a robust redeployment strategy to ameliorate the likely apprehension of non-EM leadership stakeholders and frontline staff. Demonstrate a confident orientation and role-progression strategy to facilitate positive engagement.

• Develop a Robust Orientation. Invest in a detailed orientation process with high-yield documents and protocols. Wherever possible, resurrect pre-existing materials and infrastructure and modify as necessary. Use the educational experience of EM team members. Allow for “shadow shifts” to establish familiarity in the clinical space prior to expecting productivity.

• Leverage Existing Skills. Leverage the pre-existing skills of providers in redeployment roles. Put the providers first by avoiding a one size fits all model of redeployment. Factor in years since general training as well as specialty expertise and individual provider comfort level.

• Staff and Monitor for Quality and Safety. Use a model of co-management and available backup by pairing non-EM providers with experienced EM providers. Develop a quality assurance process via chart review and staff interviews as non-judgmental performance evaluation tools. Use data from the QA process to inform on changes in roles and autonomy. Foster a supportive clinical environment with assigned roles.

• Invest in Leadership Visibility. Invest in direct EM leadership visibility in the clinical environment during this staffing transition. Irrespective of pre-launch strategy, questions and concerns from both EM and non-EM team members frequently arise and must be addressed in real time. Model teamwork by demonstrating appreciation and building camaraderie. Meet daily to communicate updates on disaster management strategy and to understand challenges.

Conclusion and Next Steps

Relying on an innovative strategy and a team-based approach, we rapidly redeployed non-EM physicians to meet the demands of a busy ED inundated almost entirely with a singular disease at the initial epicenter of the world’s COVID-19 experience. This redeployment strategy has direct applicability to other arenas of the healthcare system critically affected by this pandemic.

In addition to EDs, intensive care units and hospital wards face similar threats of overwhelming patient volumes with limited resources and may benefit from a comparable model of training and oversight using nontraditional staffing.

While no significant quality concerns were identified, further work and research are necessary to better quantify the efficacy, impact, safety, and long-term outcomes data comparing redeployed physicians to EM physicians in a pandemic disaster in addition to process measures.

Overall, the anecdotal and unprompted written feedback from actively redeployed physicians and their chairpersons was remarkably positive. Many expressed feeling privileged to contribute to the frontline battle against the COVID-19 pandemic, a certain pride in directing their diverse skill sets wherever possible, and an appreciation for the unique complexities of ED care. This shared experience has the potential to amplify departmental bonds, good will, and collaboration throughout our institution and enterprise.

Redeployment was not only supportive to patients, but also to the EM staff who appreciated the additional crucial support in this challenging time working side by side with our valued colleagues. We hope other institutions may learn from our experience and consider implementation of these lessons around the meaningful redeployment and integration of non-EM physicians into the front lines of care for future disasters.

References

1. Centers for Disease Control and Prevention. Past Pandemics. Centers for Disease Control and Prevention. https://www.cdc.gov/flu/pandemic-resources/basics/past-pandemics.html . Accessed March 24, 2020.

2. Dong E, Du H, Gardner L. An Interactive Web-Based Dashboard to Track COVID-19 in Real Time. Lancet Infect Dis. 2020 May;20(5):533–34. https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30120-1/fulltext . Accessed March 24, 2020.

3. Correal A, Jacobs, A. A Tragedy Is Unfolding: Inside New York’s Virus Epicenter. New York Times. April 9, 2020. https://www.nytimes.com/2020/04/09/nyregion/coronavirus-queens-corona-jackson-heights-elmhurst.html . Accessed April 9, 2020.

4. Timbie JW, Ringel JS, Fox DS, et al. Systematic Review of Strategies to Manage and Allocate Scarce Resources During Mass Casualty Events. Ann Emerg Med. 2013; 61(6):677-89.

5. Hodge JG, Gable LA, Cálvews SH. Volunteer Health Professionals and Emergencies: Assessing and Transforming the Legal Environment. Biosecur Bioterror. 2005;3(3):216–23.

6. Whittaker J, McLennan B, Handmer, J. A Review of Informal Volunteerism in Emergencies and Disasters: Definition, Opportunities and Challenges. Int J Disast Risk Re. 2015;13:358-68.

7. Scarfone RJ, Coffin S, Fieldston ES, et al. Hospital-Based Pandemic Influenza Preparedness and Response: Strategies to Increase Surge Capacity. Pediatr Emerg Care. 2011;27(6):565–72.

8. American College of Emergency Physicians. Hospital Disaster Physician Privileging. American College of Emergency Physicians Policy Statement, October 2017. https://www.acep.org/patient-care/policy-statements/hospital-disaster-physician-privileging . Accessed March 24, 2020.

9. Emergency Management Standards Supporting Collaboration Planning. The Joint Commission. 2016; EM.02.02.13. https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/assetmanager/em_stds_collaboration_2016pdf.pdf?db=web&hash=61306121B8D8EB2C53A4DAC313654B48. Accessed March 24, 2020.

10. Accreditation Council for Graduate Medical Education (ACGME). ACGME Program Requirements for Graduate Medical Education in Emergency Medicine. Accreditation Council for Graduate Medical Education (ACGME); 2019. https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/110_EmergencyMedicine_2019.pdf?ver=2019-06-25-082649-063. Accessed March 24, 2020.

11. Timbie JW, Ringel JS, Fox DS., et al. Allocation of Scarce Resources During Mass Casualty Events. Evid Rep Technol Assess. 2012;207:1–305. https://www.ncbi.nlm.nih.gov/books/NBK98854/ . Accessed May 20, 2020.