Protecting the healthcare workforce: a prerequisite in the COVID-19 crisis

As have our peer organizations, Yale New Haven Health has been preparing for the tidal wave of patients sick with COVID-19. While we work with state and local officials to flatten the curve, we are simultaneously identifying critical equipment, facilities, treatment algorithms and workflows. Perhaps most importantly, we are organizing and safeguarding our healthcare workers—both clinical and nonclinical staff.

Healthcare is a human-intensive industry; we must deliberately focus on protecting our staff from harm as a first principle.

Several months ago, we assembled health-system incident command structures for each hospital within our system to command, coordinate and control the activities of independent groups toward the common goal of reducing event impact and limiting mortality. We augmented the structure with "action teams" charged with optimizing public communications, running testing for COVID-19, defining personal protective equipment use standards, managing workforce planning, and establishing treatment protocols.

Among the 27,000 employees and 8,000 medical staff at Yale New Haven Health, a majority have direct face-to-face contact with patients—in our emergency departments, ambulatory clinics, operating rooms, procedural suites, radiology departments and, importantly, inpatient and intensive-care units. These include staff with specialized skills both in care delivery and in the support of those activities. We recognize that what is in our staff's interest is simultaneously in our organization's and patients' interest. Namely, a healthy staff can provide much needed critical care. If we fail to protect our teams, we fail to treat our community.

Our strategy has six components: Optimize external and internal communications; apply social-distancing policies; optimize testing strategies; enhance stewardship of personal protective equipment; create scalable and redundant teams; and focus on the physical and mental well-being of our staff members.

Before the first admission of a COVID-19 patient, we established a single COVID-19 call center staffed by members of our clinical team to answer questions from patients, employees, medical staff and members of the community. Calls can result in questions answered, immediate telehealth visits, appointments for testing where appropriate, and referrals to other resources in the system. Internally, we hold regular videoconference town halls in which we address staff concerns directly. Daily command center calls across the system initiate cascading communications via e-mail and subsequent videoconference across all hospitals.

Many of the issues raised at the command center level are in response to concerns articulated by staff through the centralized call center and town halls. Multidirectional communications remain a critical source of information and build trust amongst stakeholders.

We have expanded telehealth capabilities for patients and providers in outpatient and inpatient settings, rescheduled elective surgeries, grouped patients in the emergency department and inpatient settings, and minimized staff performing bedside care to those critical to the procedure. These measures minimize exposure and preserve valuable personal protective equipment.

Testing provides us with the ability to cohort patients, optimize use of personal protective equipment, and directly protect our workforce. While we enhance our native testing capability, we perform rapid turnaround testing in ICU patients first, then inpatients and healthcare workers, and we reserve slower commercial testing for ambulatory cases.

Healthcare workers see personal protective equipment as one of the strongest signals of support from administration. We have established a standard system policy for routine use of surgical masks in the ED, labor and birth, and other public acute-care areas. We created guidelines for N95 mask use in COVID-19 units and during performance of potentially aerosolizing procedures. Simultaneously, we collect used masks for reprocessing and are implementing a process for safe and effective sterilization.

In order to care for our staff and patients over the long term, we have built team redundancy. This is largely accomplished through cross-training. In some cases, this has required emergency rapid credentialing across our hospitals. Additionally, we have found affiliated individuals and community groups, such as private primary-care providers and physician-owned ambulatory surgery centers, willing and able to contribute. We have created a labor pool of healthcare workers comprised of individuals internal and external to our system to support this effort.

We recognize that certain staff members are at particular risk if they become infected. A large published series from China's experience with COVID-19 showed case fatality rate increased dramatically with each decade over 60, and with common conditions such as cardiovascular disease, diabetes and hypertension. Given this, leadership identifies those at risk, arbitrarily age greater than 65, and recommends avoiding face-to-face patient care by relocating to telehealth or other functions. Though still fairly early in this crisis, we have already seen emotional exhaustion and the effects of chronic stress and uncertainty on our staff members. In response we have initiated virtual counseling by mental health professionals, held Schwartz Rounds via Skype, and supported other mental health well-being efforts.

None of our myriad projects can be successful without substantial organizational agility. America's hospitals are not known for speed to execution or flexibility of function. Protecting our staff requires institutional preparedness with structures that allow the rapid evolution of policy and procedure. In this moment, we must allocate resources under conditions of substantial uncertainty, largely without the benefit of evidence. We lack the luxuries of time, ample supplies, and rapid testing capacity.

What we do have is an excess of talent and commitment in our workforce. We have an inexhaustible stream of great ideas with an energized group of colleagues who will work tirelessly to implement them and a noble calling to help our communities in a time of great need.

We are honored and humbled to be entrusted to help protect those who care for us all—the American healthcare worker.