Competing Hospitals Cooperate to Meet the Crisis

This story originally appeared on Stateline.

For hospitals, among the nation’s biggest and most competitive businesses, giving up lucrative surgeries to make way for a competitor’s overflow of patients does not come naturally.

But as COVID-19 threatens to overwhelm the American health care system, U.S. hospitals are cooperating in unprecedented ways. In addition to postponing elective surgeries and other procedures, they are transferring children from adult hospitals to pediatric hospitals and sharing staff, equipment and supplies. One health care system has gone as far as creating a COVID-19-only hospital.

In hard-hit New York, Democratic Gov. Andrew Cuomo has created a command center to coordinate a “surge and flex” strategy to redistribute resources among the state’s hospitals in real time.

“We’re shifting among the hospitals, ventilators, [personal protective] equipment, who has gowns, who has masks, and that happens on a daily basis,” Cuomo said Monday.

At an earlier briefing, Cuomo noted that hospitals in New York have been forced to cooperate in ways “antithetical to the foundation of the business of health care in this state.”

There has been interstate cooperation too, even without federal coordination. Cuomo said it makes sense for states that haven’t yet reached a crisis point to shift resources to states where COVID-19 cases are peaking, knowing that the recipients will reciprocate when their situations settle down. Washington state, for example, shipped 400 ventilators back to the Strategic National Stockpile to make them available to other states. Oregon sent 140 ventilators to New York.

Many hospitals around the country fear that they wouldn’t be able to handle a COVID-19 surge on their own, according to a report released Friday by the inspector general of the U.S. Department of Health and Human Services. The report, based on a survey of 323 hospitals in 46 states, noted shortages of beds, equipment and staff.

Washington Leads the Way

Ever since Washington state identified the first American COVID-19 case in January, the state health department and the Washington Hospital Association have been working together to keep communication open among the state’s 115 hospitals. The first step was to cancel all nonessential surgeries and hospitalizations.

“That was hugely bad for hospitals financially,” said Cassie Sauer, CEO of the Washington State Hospital Association. “But as a result, we still have beds available. That wouldn’t have happened had we not taken such aggressive action from the beginning. Hospitals in King County (Seattle) are only 60% to 70% full right now.”

Washington state also moved all children out of adult hospitals and into pediatric hospitals with available space. After that, it became clear that even more space was available in specialized children’s hospitals. The hospital association let adult acute care hospitals know that local children’s hospitals were willing to take their young adults, ages 18 to 22, Sauer said.

Now, when young adults show up in an emergency room at an adult hospital, they’re rerouted to a children’s hospital, unless they need specialized care not available there, she said.

Washington hospitals have not yet run out of beds and intensive care unit capacity. But that still could happen because the number of coronavirus hospitalizations continues to rise.

The state’s next step, Sauer said, is to move patients who are recovering and have only mild to moderate symptoms out of hospitals and into less acute care settings outside of the hospital. Washington state and King County have acquired two hotels, a recently closed nursing home and a fully equipped hospital that was shuttered less than three months ago to house many of these patients, she said.

“We’re keeping people who are COVID-19-positive with mild to moderate symptoms, who don’t have anywhere safe to go,” she said. “They tend to be low-income, homeless or living in a crowded apartment with lots of roommates. Some may have a vulnerable family member at home.”

These patients just need meals, personal care and temperature checks, Sauer said. They need a safe place to stay in quarantine while they recover.

Washington Democratic Gov. Jay Inslee appointed retired Navy Vice Admiral Raquel Bono as the state’s director for COVID-19 Health System Response Management. She and her team are coordinating a response across the entire health care system, including nursing homes, local clinics, tribal facilities, and the federal government and military services.

National groups followed Washington’s lead on pediatric hospitals. The Children's Hospital Association announced Friday that it is partnering with adult hospitals and with local, state and federal government to expand the capacity of adult acute care hospitals to treat more COVID-19 patients.

The medical organization, along with the American Academy of Pediatrics and the Association of American Medical Colleges, recommended “a temporary consolidation of pediatric care, and in some cases younger adults, in children’s hospitals based on local conditions.”

Amy Knight, chief operating officer of the Children’s Hospital Association, said that pediatric hospitals have deferred procedures, admissions and ambulatory visits to increase their capacity to take pediatric and even young adult patients from general service hospitals.

Acute care hospitals and children’s hospitals in many states have forged agreements about the transfer of those patients, such as one between Baptist Hospital in Miami and Nicklaus Children’s Hospital, a 309-bed pediatric hospital.

“The spread of COVID-19 is expected to challenge our capacity of hospital beds, staff and supplies,” said Bo Boulenger, chief operations officer for Baptist Health South Florida. “As we prepare for an anticipated surge of adult COVID-19 patients, this collaboration will allow us to better use our resources.”

Knight said hospitals in Connecticut, New York and Louisiana have made similar arrangements for pediatric patients.

Separating Patients

When doctors at Steward Health Care, a Texas-based hospital system with hospitals in nine states, examined the COVID-19 response in other countries, something significant stood out.

COVID-19 patients segregated in medical facilities treating only coronavirus patients were more likely to survive than those cared for in hospitals treating all types of patients.

“We found that when [hospitals] treated COVID-19 patients separately, they developed significant expertise and had much better outcomes,” Dr. Joseph Weinstein, Steward’s chief medical officer, told Stateline in a phone interview.

Steward acted on that intelligence.

Last month, Steward took the unusual step of transforming one of its 35 hospitals, Carney Hospital in Dorchester, Massachusetts, into a COVID-19-only treatment center. Patients with other ailments arriving at its emergency room are directed to one of Steward’s other nine hospitals in Massachusetts.

The company plans to turn another of its Massachusetts hospitals, Morton Hospital in Taunton, into a second dedicated COVID-19-only treatment center. Weinstein said the for-profit hospital chain is considering the same model in other regions where it operates.

Steward announced over the weekend it is creating COVID-19-only intensive care units in most of its hospitals.

Other hospitals, such as those associated with the University of Michigan and the University of California, San Francisco have converted one or multiple floors into dedicated units to treat COVID-19 patients. Emergency departments in nearly every hospital are creating a separate entrance and outside triage locations for suspected COVID-19 patients.

All health systems should create COVID-19-only hospitals, two health analysts argued in a late March piece in Health Affairs, the leading American journal on health policy.

Creating COVID-19-only hospitals would decrease the risk of exposing non-infected patients, the authors, Daniel Liebman, a resident physician in ophthalmology at Cambridge Health Alliance in Massachusetts, and Nisarg Patel, a resident surgeon at the University of California, San Francisco, told Stateline.

And health workers treating only COVID-19 patients would benefit, Weinstein said. “When they are only treating COVID patients, they are going to be much more rigorous about protecting themselves,” he said. “They are going to be absolutely compulsive about doing it the right way.”

Designating COVID-19-only hospitals also could ensure that equipment and supplies are distributed to the right places. If all hospitals believe they must be prepared to treat coronavirus patients, Liebman and Patel wrote, all of them will try to acquire ventilators, masks and protective equipment.

“The planning can be much more intentional,” Liebman said. “You have a better chance of using the same amount of resources more efficiently.”