HCA Healthcare has weathered the coronavirus pandemic a little bit better than most health systems. This month, the for-profit hospital chain announced that it was paying back nearly $6 billion in federal pandemic relief funding. Part of HCA’s ability to navigate the pandemic can be attributed to a long-standing approach to become what leaders there call a learning organization. Modern Healthcare Managing Editor Matthew Weinstock recently spoke with Dr. Jonathan Perlin, HCA’s president of clinical services and chief medical officer. The following is an edited transcript.
MH: On the earnings call earlier in October, it was noted that HCA saw 40,000 COVID patients in Q3. What’s your capacity like at this point?
Perlin: (As of mid-October), we’ve taken care of 62,414 COVID-positive inpatients. We’re approaching a million and a half outpatient tests, and we’ve cared for over 150,000 outpatient COVID patients.
We’ve learned how to take care of COVID better. In fact, to the point of being a learning health system—which I’ll define as one that commits to using the data that are invariably created as a byproduct of the care itself to learn and improve the system, and most importantly, to channel information back to the individual patient to improve care—it’s allowed us to increase the survival for COVID by 28%. That is, if you were admitted in March or April, compared to today, you now have a 28% better chance of surviving.
We are seeing an uptick in the country. It’s not surprising. The experts indicated that with cold weather, as we congregate more inside, that we’d see the respiratory virus loads—and certainly influenza is one of those. We haven’t seen flu significantly yet.
The peak was really mid- to late July for us. And we had to take care of not only COVID patients but patients with heart attacks and strokes, and things equally significant, and that challenged us. But it also challenged us to learn how to read what we call the five S’s of surge to make sure that we have the capacity to be open for those months.
The first S is spikes. What are the community trends? What’s going on?
Those other four S’s involve our space. That actually turns out in many ways to be the least problematic. If we needed to flex recovery rooms—that is convert post-anesthetic care units into ICUs—we can increase the acuity on the floor. The third S is supplies. We’re actually in much better shape than we were those months ago, in terms of the personal protective equipment, as well as lab testing supplies. In fact, we’ve increased our testing capacity internally roughly 300% since the beginning of COVID to meet the demand substantially.
The fourth is staffing. That’s really the most critical part. There’s been a lot of learning in that regard, but we want to make sure we have adequate nursing coverage, respiratory therapist coverage, physician coverage. The biggest lesson there is how to cross-train and make sure that we can provide the resources necessary to care for both COVID and non-COVID patients.
The final S is support, and that’s really life support—ventilator capacity, and in this day and age (extracorporeal membrane oxygenation), which is becoming somewhat a more interesting resuscitative therapy.
So those are our triggers, and we essentially have a red, yellow, green. Green means go; we’re open for all sorts of activity. Yellow means that we’ve seen some changes in the community rates on their own indicators, and we want to temper things a bit. And elective activity does not really impact the ICU. (Some things) that we call elective mean that they’re scheduled, but that doesn’t necessarily equate to it being truly discretionary. It might be cancer therapy or the like, but we can modulate those things in yellow. And red is this condition I hope we don’t get to, but it’s one we invoked in July, where we shut down certain services in deference to meeting capacity in community needs for COVID care.
MH: HCA expanded certain protocols for bringing people back in for elective surgeries, right? Can you talk about how that process has worked and can that be scaled elsewhere?
Perlin: We think that it can not only be scaled, but that it should be scaled.
We did a bit of a test internally. We took one group of hospital inpatients and we did universal testing for everybody. We took another group and we created an algorithm based on some guidance from the Centers for Disease Control and Prevention and elsewhere that stratified for high risk—people with exposures or undergoing a procedure that would likely generate an aerosol and expose the operative team. That latter protocol-driven approach only used testing for a select group.
Guess what? There was virtually no difference between universal testing and the protocol-driven testing in identifying COVID patients. That was something we published in a paper in the American Journal of Surgery. And it’s really useful, because it conserves some resources for patients who may really need that testing more critically.
More importantly though, we adopted a posture, even before the CDC, of universal protection. We went to universal masking early on. The reason we did this, is that while testing is extremely valuable, it’s possible to over-read the utility of the test. Positive means positive, but do you really trust a negative? Negative may not be negative. It allows us to conserve testing so it can be used for one, patients who are ill, or two, doing the sorts of tracing that you’d want to do to really control the transmission in a community, particularly during an increased spike of an outbreak.
MH: Along those lines, it sounds like a lot of postponed care is starting to be rescheduled. Are there things that you’re trying to share across all the markets?
Perlin: Our CEO, Sam Hazen, said on the earnings call about 68% of the care that had been deferred has either been completed or rescheduled. And so we are seeing a willingness of patients to return. That’s great, because we were really worried about some of the things that we were seeing decreases of. While you may think of certain procedures as truly discretionary or elective, we saw, as was reported in the New England Journal and everywhere else, decreases in patient presentations for stroke and for heart attack. (In May, NEJM reported) there had been a 29% decrease in U.S. presentations for stroke. I am absolutely certain that there was not a 29% decrease in stroke.
We saw even greater decreases in presenting for chest pain, and that’s catastrophic. And in our New Orleans area … emergency medical services were saying that they were reaching patients who were sicker.
The American Hospital Association has initiated a campaign to get needed care. That’s so important, and we think patients are beginning to realize that COVID is not going away. They’re also realizing that hospitals and healthcare environments, as with the best community organizations, are learning how to manage risk. They’re learning how to manage their own risk, and feeling safer.
If we do have another surge on the hospital end, not only do we increasingly know how to scale up or scale back other activities, but importantly, we know how to keep patients safe. And I think patients are increasingly beginning to understand that.
Even for some of those things that might be put off, I think the calculus becomes, “How long can I take the pain of needing a hip replacement?” The lesson for health systems, the lessons for our governmental leaders, are really that the next era is not waiting for after-COVID, but the next era is co-existing with COVID; being safe with COVID. And, to the extent our personal risk tolerance allows, resuming life, albeit in a socially responsible manner.
MH: You referenced the ability to scale up and scale down. What kind of strain does that put on an organization?
Perlin: Some people say they want to eliminate variation. My goal is to harvest variation. We want to harvest variation on the top end. We want to understand what leads to the best outcomes. We’re learning how to use steroids most effectively. We’re learning how to go back to the literature. We went back to the literature and found that something that’s really difficult for nurses to do, but is life-saving for patients. We know from the early work on acute respiratory distress syndrome that putting the patients on their belly, called proning, actually increases the capacity to breathe, and can prevent (the need for a) ventilator. We attribute the decrease in mortality for many patients to that sort of system learning.
We have a decision support system called NATE (Next-Gen Analytics for Treatment). It allows us to track across the entirety of HCA which patients have COVID. We can see whether we’re clustering (patients) to reduce exposures, and conserve PPE. We can also, thanks to our care providers on the front end, find out what the respiratory status is.
This is not only a learning mechanism for COVID, but these are durable tools that make us better for the longer haul. Other lessons that I think are tremendously important are that we’ve seen staff flex from their usual activities when surge occurs, and perhaps you’re tamping down in one particular area. We’re becoming multiskilled, to be able to provide care in other areas. That’s forcing us to have more standardized processes.
For us, good quality is good business. Show me a process that meanders in diagnosis and I’ll show you waste. Show me a process that meanders to the right therapy, I’ll show you waste.
If we can get to the best and most appropriate diagnosis, and most appropriate care most efficiently, not only are we serving the patient with safer and more effective, and ultimately more compassionate care, but we’re eliminating waste.