Rajat Kapoor MD, MBA; Tammy Poole MS, RRT-NPS; Cheri Bate MA, RRT; Vicky Strock BA, RRT; Joel Meacham BS, RRT; Brian Spencer RRT; William Fulmer RRT
COVID 19 has changed the priorities and outlook of individuals, groups, and organizations. Situated in the heart of Indiana, Indiana University Health (IUH) has not been immune to the impact. IUH Academic Health Center (AHC), which hosts the tertiary referral center for the system and the state, was tasked to be prepared as an epicenter for the surge and to help develop best practices to safeguard the health of our workforce and improve efficiency. This article highlights our approach to circumstances (foreseen and unforeseen) and the agile, innovative leadership provided by everyone in our workforce.
Indiana University Health consists of 16 facilities across the state of Indiana. We collaborate with the Indiana University School of Medicine to provide access to leading-edge medicine and treatment. The IUH system has more than 2700 beds and an army of more than 450 respiratory therapists working tirelessly to provide essential respiratory care services. Our facilities range in size and type and include surgery centers, provider offices, critical access hospitals, community hospitals, and teaching hospitals including a freestanding pediatric facility (Riley Hospital for Children).
Equipment Tracking – Maintaining Open Airways
News from around the world helped guide us in decision-making and in keeping equipment and supplies at the front of our minds as we prepared for surges and established long-term planning goals. Ventilators specifically were on our radar as potential concern for availability based on global trends.
As a system, one of the first hurdles we tackled was ventilator distribution based on regional surges. We obtained total ventilator counts from our system partners sorted by brand and by type – high acuity, low acuity, transport, heated high flow, and BiPAP devices – placed in a spreadsheet, sorted by facility, and included a tab for tracking movement across the state. Our Clinical Engineering team developed a form and process for coordinating movement of all equipment; Respiratory Care selected a point person and utilized the form for coordinating movement of respiratory equipment specifically. Ventilators were moved by brand to minimize last-minute educational needs. Additionally, reports from our electronic medical record tracked reliable and reproducible ventilator usage across the system by location and acuity.
In the AHC, we also classified our ventilators by type as noted above, and developed a line graph to provide usage trends; we updated this graph daily and shared with local leaders. Following guidance from Physician leaders, we developed an algorithm and thresholds for recruiting the next set of ventilators. These thresholds were set based on availability and potential overlap. For example, usage of 100 ventilators triggered converting non-COVID patients to lower acuity ventilators, usage of 120 ventilators triggered movement of devices between facilities. (See table below) Prior to the current pandemic, Methodist Hospital averaged 42 ventilators daily. At the height of the initial surge, we were operating 90 ventilators. We are currently maintaining a plateau of 50-60 ventilators daily.
We approached local training programs to request access to the ventilators used for education; Charity Bowling, Ivy Tech Indianapolis Program Director, donated devices delivered by the Indiana National Guard and Jan Johnson, Indiana Respiratory Therapy Education Consortium Program Director provided access to their ventilators. Both schools donated a bonus supply of personal protective equipment. IUH Homecare also lent the system 50 home care ventilators.
Staffing Strategy – Recruiting the Alveoli
As COVID positive cases increased in our state IU Health, with guidance from the state of Indiana, decreased elective procedures and testing and shut down outpatient areas where Respiratory Therapists work – Pulmonary Rehab, PFT Lab, Sleep Lab, and Home Care. Decreasing elective procedures reduced our inpatient load and allowed staff availability to train the displaced team members. Simultaneously, the IUH System Command Center started rolling conversions of multiple adult Progressive Care Units (PCU), closed units, and the Methodist Level III nursery to adult ICU capabilities effectively increasing our ICU beds from 176 to 360 and increasing our need for additional therapists. (Displaced infants were transferred to Riley Hospital for Children in the AHC and to the Level III nursery at IUH North Hospital.) Within a week of the outpatient shutdowns and first phase of ICU conversions, we had developed an orientation plan to bring this much-needed, bonus workforce to the inpatient areas of the Academic Health Center. We developed standardized workflows allowing for rapid orientation and real-time electronic scheduling for redeployed team members. The redeployed team members could see all available shifts and easily sign up to meet their regular work requirement. They had a mentor each shift to improve comfort level while covering their inpatient assignments.
Staffing model changes occurred to support COVID rapid-sequence intubation practices, rapid orientation of deployed team members, PPE conservation, and mastery of donning and doffing PPE. Dedicated procedural teams consisting of an anesthesiologist and a respiratory therapist provided rapid sequence intubation. This assisted in PPE conservation and minimized COVID exposure to multiple team members. Creation of core teams of COVID-specialized Respiratory
Therapists occurred at all levels of care allowing for mastery of donning and doffing procedures and continuity of care. Because COVID-designated units always had more than one therapist staffed, it provided consistent mentors for the redeployed team members. This model received positive feedback from bedside team members.
The Governor of Indiana executed an Executive Order streamlining the process for graduating Respiratory Therapy students to obtain temporary permits, which provided for faster hiring processes. Building on the changes in obtaining licensure, Tammy Poole, ISRC Legislative Chair, developed language requesting current employees holding Student Permits to expand their scope of practice to match what they have completed in clinical rotations. This expansion, if granted, would allow student permit holders to work in an ICU setting with mechanical ventilators and in Pediatrics under oversight of a Registered Respiratory Therapist.
Communication and Education – Connection to the Brain
Changes to practice, new devices, and System changes occurred quickly and daily. Some changes were based on known successes at other facilities around the country; some were specific to our culture and needs based on real-time staff feedback. As changes and equipment purchases occurred, our educators began the process of developing team member education. On more than one occasion, it meant developing education on items preemptively such as use of anesthesia machines at the bedside and ventilating two patients with one devices. Although neither of those scenarios was needed, the education was ready none-the-less. Education was ranked by expected needs and implementation timetable. The table below represents the devices and procedures our educators developed training on over the course of 5 weeks.
Providing educational material on several new processes, procedures, and devices was a mammoth task. Maintaining quality and safety for our patients and assuring the safety of our workforce continues to guide our educators. Clinical Specialists and Advanced Therapists met with bedside caregivers to discuss concerns, confirm workflows, and validate education and processes. All educational materials were posted on an on-line, shared platform; questions and concerns were voiced and discussed during huddles and staff rounds. To support these rapid changes, AHC supervisors adjusted their work schedules allowing for leader on-site coverage during every shift change.
Using an existing, collaborative communication network with our partner facilities around the state, we talked and e-mailed daily to discuss best practices and to share education in order to prevent duplicate work. Within the AHC, the Executive Director, Department Directors, Equipment Supervisors, Quality Manager, Education Leadership, Bedside Clinicians, and Physicians met several times a week to discuss specific respiratory initiatives and identify proactive planning for each consecutive 24-48 hours based on IUH System Command guidelines.
Uniform and consistent answers for front-line team members instills confidence and trust. The IU Health System command center set up three e-mail accounts – one each for Infection Prevention, Human Resources, and Operations – and a dedicated online resource for staff. These accounts were monitored frequently; they provided rapid, trusted answers referencing policy, research, best practice, and payroll management for quarantined team members. The questions and answers were placed in an online FAQ for all IU Health employees. This resource was one of the biggest assets provided by IUH System leadership. It came to the forefront when rumors regarding ‘false negative’ COVID tests were spreading. The Infection Prevention team was able to provide accurate data and quell fears.
Keeping 200 AHC therapists up to date with the tools and equipment required to care for COVID-19 patients, as well as keeping them up to date with the ever-changing environment was accomplished in six ways:
- Medical Director for the department conducted huddles with the team and answered questions directly
- Scheduled huddles occurring at 7am and 7pm, updated the key changes and new initiatives
- Old-school easel board used for visual management of the information including step-by-step processes with pictures and illustrations
- Key updates and changes posted on the back of staff assignment sheets
- All updates posted on our department’s SharePoint page
- Just-in-time training for new processes with clinical specialists rounding on staff to teach the new process.
Our system was not immune to the supply chain problems and the lack of basic supplies; we worked on improving efficiency and reducing waste within the system. We tasked our front-line team members with brainstorming ideas to overcome the limitations. Any new ideas were vetted through Infection Prevention Physicians, and Respiratory Care leadership; they were either introduced within the educational material or returned back to the team member for refining or more brainstorming. Examples are noted below.
Filter drying process
The expiratory filter required for some of our ventilators was a supply problem prior to the influx of COVID patients; we knew it would be exacerbated with increased ventilator use. Our Equipment Coordinators experimented and lab tested a process for drying the expiratory filters by connecting to the suction supply in the room. Testing included post-process quality checks for residual filter humidity. This innovation allowed us to reuse filters on the same patient once the drying process was complete. We shared the education with our System respiratory partners and implemented the process in mid-April. The process allowed us to conserve available supplies until our warehouse supply returned to a 30-day minimum.
Independent monitoring of two patients on one ventilator
Early in March, our Medical Director Dr. Rajat Kapoor and Critical Care Fellow Dr. Tobin Greensweig collaborated with Purdue University engineers to identify a safe way to ventilate two patients on one ventilator. They built palm-sized motherboards and used 3D printing to make custom connections and transducers. Connecting the system to a separate tablet, we were able to measure expiratory volumes and pressures, and set independent PEEP for two simulated patients in a lab setting. The final product was show cased within the Pulmonary and Critical Care group at IUH AHC and received the blessing of the department. To date, we have not implemented this technology.
Front Line Therapist perspective:
As an Adult Critical Care Clinical Specialist, staying abreast of the continually changing information and process changes was a big issue in the COVID-19 crisis. Policies and processes often changed from hour-to-hour let alone day-to-day. Management and our Medical Director did a wonderful job keeping staff informed and were always available when new issues arose.
Caring for the COVID-19 patient was very challenging. Their clinical status often rapidly declined and often required multiple interventions by all bedside staff to provide appropriate care for the patient. Luckily, we have a great interdisciplinary team here at IU Health Methodist! Brian Spencer RRT.
My primary role is with critical intakes in the Emergency Medicine & Trauma Center (EMTC). It is challenging staying up to date with ever-changing policies, and keeping providers and nurses updated. I had previously joined the newly formed Special Pathogens Unit in 2014 during the US Ebola crisis so I was very familiar with donning & doffing procedures from our robust safety checklists and SOPs. I have been amazed at the ambulatory RTs as well as RTs from other facilities redeployed into our staffing and taking on critical patient care. William Fulmer RRT EMTC Clinical Specialist.
Above are only some of the examples of innovation the department has seen in the past two months. We are proud of our workforce and of all front-line therapists who had to leave their families to help achieve the mission of health care. Respiratory Care takes pride in advancing the pillars of Indiana University Health and being the voice of the bedside team members.
We are part of a big, complicated system, but we managed to keep open, respectful communications sharing the best of ourselves in a difficult time. We proudly note that we had minimal absenteeism in the Academic Health Center during our initial surge. Having the experience of those before us, relying on in-house expertise, and blessed with a dedicated team, will keep us strong and connected for the many months of surges followed by calm yet to come.
We want to recognize several people for their help and support during purchase of new devices, and planning of projects and guidelines:
- Parveen Chand MHA, Adult AHC Chief Operating Officer
- Chris Weaver MD, MBA, SVP Clinical Effectiveness
- Mark Luetkemeyer MD, Adult AHC Chief Medical Officer
- Scott Roberts MD, Service Line Leadership, Pulmonary and Critical Care Division
- Todd Stanley MBA, RT, CRA, VP Clinical Operations
- Rajat Kapoor MD, MBA, Adult AHC Respiratory Care Medical Director
- Patricia Ingle MS, RRT, Executive Director AHC Respiratory Care
We also want to applaud the hard work with grace under pressure of all the AHC Respiratory Care bedside therapists, supervisors, equipment processing team members, equipment supervisors, department educators, management team, and administrative assistants. Thank you.