What used to be the heart team at Manhattan's Mount Sinai Morningside—its cardiologists, cardiac surgeons, intensivists, cardiovascular nurses—is now a COVID-19 team.
As the pandemic sweeps the U.S., prominent health systems have rolled out plans to redeploy specialists who don't typically treat infectious diseases to care for patients battling the novel coronavirus. But nowhere has this shift taken on the same urgency as in New York City, which as of Monday morning had more than 36,000 COVID-19 cases.
Mount Sinai's eight hospitals are nearing capacity to handle the influx. At 495-bed Mount Sinai Morningside, the 26-bed cardiac ICU is now an at-capacity COVID-19 ICU. Its 31-bed step-down unit has also been converted and is beginning to care for COVID-19 patients. The team is building out what will eventually be about 75 negative pressure rooms.
"It's a total transformation," said Dr. John Puskas, the hospital's chair of cardiovascular surgery. "We have literally transformed a heart team, a very sophisticated team of people which has been built up over years, to now provide a very different kind of care to a very different kind of patient in our ICU and our step-down ward."
Nationwide, anesthesiologists, orthopedic surgeons and cardiologists are among the specialists heeding calls from overwhelmed hospitals to help tackle their COVID-19 surges. Health systems like Mount Sinai, Providence St. Joseph Health and Henry Ford Health System are rolling out plans that outline which specialists can treat COVID-19 patients and in what capacity. Not all doctors have the training required to ventilate a patient, but they can still monitor a COVID-19 patient who hasn't yet progressed to that stage. Health systems are taking inventory of who is available, what their skills are and whether they're willing to step up.
"We have just been overrun with the sheer number of critically ill patients," said Dr. Daniel Katz, associate professor of anesthesiology, perioperative and pain medicine at Icahn School of Medicine at Mount Sinai Health System in New York. "There just aren't enough critical care doctors to go around to take care of them … We have had to get doctors from other areas who still have some critical care skills but might not be straight-up ICU doctors."
The most obvious recruits are those with critical care backgrounds, especially anesthesiologists and critical care intensivists, said Sanjay Saxena, a senior partner and managing director with the Boston Consulting Group. Many of those will be pulled from ambulatory surgery centers or freestanding emergency departments.
The second wave are general surgeons, orthopedic surgeons and internal medicine subspecialists like cardiologists and oncologists, Saxena said. These physicians have skills that naturally transfer to caring for critically ill patients, and many have canceled their elective procedures.
"While it feels like there is an element of chaos around it, there's also an element of thoughtfulness about it," he said.
Detroit-based Henry Ford has compiled a list of the more than 1,500 doctors in its medical group that shows their availability, specialties and capabilities. From there, administrators will contact doctors with opportunities to help, said Dr. Adnan Munkarah, Henry Ford's chief clinical officer. The health system has clear guidelines that delineate providers that can treat ICU patients, such as cardiologists, and those that can't, such as a general internal medicine physician, he said.
"We don't have, at this point, everybody deciding, 'I'll treat this patient this way or that way,'" Munkarah said. "We've developed very clear clinical protocols in that respect."
Renton, Wash.-based Providence St. Joseph Health has set up a volunteer pool where the 10,000 physicians in the health system's medical groups can sign up to work in hospitals experiencing surges of COVID-19 patients. Kevin Manemann, chief executive of the Providence Physician Enterprise, said he expects many of the 10,000 will sign up. Anesthesiologists, emergency medicine physicians and some cardiologists have already added their names to the list.
It's largely preparation at this point, though—despite having treated the country's first patient diagnosed with COVID-19, Providence St. Joseph has seen surges in certain markets, but has capacity in others.
"Honestly, some of our hospitals are half empty right now," Manemann said. He added that the health system's Puget Sound market had 35 ICU beds open. "The surge is not happening yet."
The opposite is true at Mount Sinai Morningside. As soon as it became clear to the cardiology and cardiac surgery team that they would need to eventually treat COVID-19 patients, they shadowed their medical ICU colleagues, Puskas said. Then, about 10 days ago, the cardiac team began accepting their own COVID-19 patients. They've done so with the help of infectious disease consultants, who check on their patients daily, and the hospital's pharmacists, who ensure their patients are getting the right medications, he said.
In tandem with hospitals' work reassigning specialists, regulators nationwide have jumped into action to authorize doctors and hospitals to do what's necessary to make prudent use of their resources, even if that makes working outside of their usual safeguards, according to Lowell Brown, a partner with the law firm Arent Fox and leader of its national healthcare law practice group. In California, for example, the state public health department effectively suspended all licensing regulations that apply to hospitals and advised them to do what's best for patients, he said.
"It's in the category of things I've never seen and never thought I would see," Brown said. "It's very carefully worded, but it just says, 'We're not looking over your shoulder.'"
The CMS' Conditions of Participation require hospitals to have plans in place that guide the use of volunteers in an emergency staffing situation. Such plans should specify which independent doctors will be eligible to receive medical staff privileges at the facility.
The critical decision of whether or not a COVID-19 patient needs to be put on a ventilator or not, however, must still be made by a hospital's core critical care medicine team, Saxena said. Once a patient is intubated, they can't be taken off the ventilator and put back on again.
"Once you've gone down that path, you leave them until they're ready for recovery," he said. "So you don't want to intubate too early."
Mount Sinai Morningside takes intubations very seriously, since the process can produce droplets and aerosolized particles that infect healthcare workers, Puskas said. All of the hospital's COVID-10 intubations in the hospital are performed by a rotating two-person team comprised of a senior and junior anesthesiologist, he said.
"We should not have occasional incubators intubating COVID patients," Puskas said. "That's not going to be a good way of containing this virus and protecting healthcare workers."
Physicians with critical care backgrounds are the most ideal to help with COVID-19 patients because of their training in ICU care but it should be done on a case-by-case basis to ensure safety of care, said Dr. David Ferraro, a pulmonologist and vice chair of fundamental disaster management at the Society of Critical Care Medicine.
For instance, a nephrologist has critical care training but if the physician has been working in an ambulatory setting for the past decade, they might not be an ideal candidate to help treat hospitalized COVID-19 patients, he said.
"You can make arguments for and against groups of people," Ferraro said. "It really comes down to who is willing to step up, who feels comfortable managing sick patients and are they leaving their jobs and creating gaps that are going to be challenging to fill?"
There is a domino effect to this tactic. By asking physicians — particularly hospitalists — to come help in the ICU with COVID-19 patients, it's leading to gaps in care on the medical units, Katz at Mount Sinai said.
To address that, Mount Sinai has asked outpatient doctors with backgrounds in internal medicine to help.
"Just because COVID-19 came doesn't mean we got any less patients with other pathologies. They are coming in just the same," Katz said.
Providence St. Joseph is preparing general surgeons and orthopedic surgeons to intubate COVID-19 patients, if need be. In some cases, internal medicine and primary care physicians are picking up shifts for hospitalists, although many are seeing non-coronavirus patients to allow hospitalists focus solely on COVID-19 patients, Manemann said.
Each of Providence St. Joseph's markets has a command center that monitors resources, including nurses, physicians and other health professionals. The 51-hospital health system can send its providers to other markets if need be and the providers are comfortable, Manemann said.
Internal medicine subspecialists like cardiologists and oncologists receive training early in their medical educations on the basic pulmonary issues that are prominent in COVID-19 patients, Brown said.
"It's not unheard of and I don't think it creates a liability by itself for someone to step into lower level of expertise if they have training in that level of expertise," he said.
Mount Sinai is training the physicians it's deploying to treat COVID-19 patients. Although the physicians have expertise in critical care and therefore know the basics of ICU treatment such as how to ventilate a patient, Mount Sinai is still giving doctors quick refreshers as well as training on the unique treatment modalities of COVID-19 patients.
For instance, many patients diagnosed with COVID-19 suffer from a severe form of acute respiratory distress syndrome, a condition characterized by stiff, heavy lungs due to fluid buildup. The condition is addressed by ventilating a patient in the prone position, or lying on their stomach.
Katz said it's uncommon for doctors to see these cases so all physicians treating COVID-19 patients are taught how to properly ventilate a patient in the prone position.
Mount Sinai has a simulation lab so the training can be done on mannequins. Because Mount Sinai needs doctors quickly, training is a few hours long. Although Katz said even when they are ready to help, doctors are still overseen by supervisors with more expertise to ensure quality of care.
"There is a tiered structure built in," he said. "No one is being expected to do something with no experience and that is widely outside of their scope of practice."
Mount Sinai is receiving calls from retired doctors volunteering to help but Katz said at this time the system is trying to keep staffing internal to ensure safe and effective care. Retired doctors would need to be trained on how to use the electronic medical record and order labs, all of which takes time Mount Sinai doesn't have.
"We want to make sure that we aren't putting people in harm's way unnecessarily," he added.
Generally, though, physicians are not going to take on care they know they're not competent to provide, Brown said.
"You have to recognize your limits," Ferraro added. "Every individual physician and surgeon has to know what they can and can't do."
In addition to helping in the hospital setting, health systems are also calling on providers to address the COVID-19 pandemic through telehealth.
Michigan-based Spectrum Health has brought on about 250 providers to triage patients over the phone who are concerned they have the coronavirus.
The providers, which include physicians and advanced practitioners, are from various specialties including general surgery, orthopedic surgery, cardiology, neurology and oncology.
The providers are available to help with triage because routine appointments and elective procedures have been postponed, said Dr. Kristopher Brenner, division chief of telehealth and primary care at the system.
Spectrum Health briefly trained the providers on how to appropriately triage patients by following federal and state guidelines. More than 20,000 patients have been screened since March 16.
