Range of challenges
Among the questions that need to be answered by a field hospital’s planners, the first is ‘where to put it?’ The answer is, hopefully, someplace not too far away, large enough, with ready access to supplies and intake. The next question is ‘who is the patient?’ Clinicians must determine who goes to the field hospital versus who stays at the standing hospital. How sick should these patients be? And when do they need to go back to the permanent hospital? Can staff be trained to recognize when patients in the field hospital are starting to decompensate? The EPIC Deterioration Index3 is a proprietary prediction model that was used by more than a hundred hospitals during the pandemic.
The hospitalist team may develop specific inclusion and exclusion criteria – for example, don’t admit patients who are receiving oxygen therapy above a certain threshold or who are hemodynamically unstable. These criteria should reflect the capacity of the field hospital and the needs of the permanent hospital. At Michigan, as at other field hospital sites, the goal was to offer a step-down or postacute setting for patients with COVID-19 who were too sick to return home but didn’t need acute or ICU-level care, thereby freeing up beds at the permanent hospital for patients who were sicker.
Other questions: What is the process for admissions and discharges? How will patients be transported? What kind of staffing is needed, and what levels of care will be provided? What about rehabilitation services, or palliative care? What about patients with substance abuse or psychiatric comorbidities?
“Are we going to do paper charting? How will that work out for long-term documentation and billing?” Dr. Bell said. A clear reporting structure and communication pathways are essential. Among the other operational processes to address, outlined in Dr. Bell’s article, are orientation and training, PPE donning and doffing procedures, the code or rapid response team, patient and staff food and nutrition, infection control protocols, pharmacy services, access to radiology, rounding procedures, staff support, and the morgue.
One other issue that shouldn’t be overlooked is health equity in the field hospital. “Providing safe and equitable care should be the focus. Thinking who goes to the field hospital should be done within a health equity framework,” Dr. Bell said.4 She also wonders if field hospital planners are sharing their experience with colleagues across the country and developing more collaborative relationships with other hospitals in their communities.
“Field hospitals can be different things,” Dr. Bell said. “The important take-home is it doesn’t have to be in a tent or a parking garage, which can be suboptimal.” In many cases, it may be better to focus on finding unused space within the hospital – whether a lobby, staff lounge, or unoccupied unit – closer to personnel, supplies, pharmacy, and the like. “I think the pandemic showed us how unprepared we were as a health care system, and how much more we need to do in preparation for future crises.”
Limits to the temporary hospital
In New York City, which had the country’s worst COVID-19 outbreak during the first surge in the spring of 2020, a 1,000-bed field hospital was opened at the Jacob Javits Center in March 2020 and closed that June. “I was in the field hospital early, in March and April, when our hospitals were temporarily overrun,” said hospitalist Mona Krouss, MD, FACP, CPPS, NYC Health + Hospitals’ director of patient safety. “My role was to figure out how to get patients on our medical floors into these field hospitals, with responsibility for helping to revise admission criteria,” she said.
“No one knew how horrible it would become. This was so unanticipated, so difficult to operationalize. What they were able to create was amazing, but there were just too many barriers to have it work smoothly,” Dr. Krouss said.
“The military stepped in, and they helped us so much. We wouldn’t have been able to survive without their help.” But there is only so much a field hospital can do to provide acute medical care. Later, military medical teams shifted to roles in temporary units inside the permanent hospitals. “They came to the hospital wanting to be deployed,” she said.
“We could only send patients [to the field hospital] who were fairly stable, and choosing the right ones was difficult.” Dr. Krouss said. In the end, not a lot of COVID-19 patients from NYC Health + Hospitals ended up going to the Javits Center, in part because the paperwork and logistics of getting someone in was a barrier, Dr. Krouss said. A process was established for referring doctors to call a phone number and speak with a New York City Department of Health employee to go through the criteria for admission to the field hospital.
“That could take up to 30 minutes before getting approval. Then you had to go through the same process all over again for sign-out to another physician, and then register the patient with a special bar code. Then you had to arrange ambulance transfer. Doctors didn’t want to go through all of that – everybody was too busy,” she explained. Hospitalists have since worked on streamlining the criteria. “Now we have a good process for the future. We made it more seamless,” she noted.
Susan Lee, DO, MBA, hospitalist and chief medical officer for Renown Regional Medical Center in Reno, Nev., helped to plan an alternate care site in anticipation of up to a thousand COVID patients in her community – far beyond the scope of the existing hospitals. Hospitalists were involved the entire time in planning, design of the unit, design of staffing models, care protocols, and the like, working through an evidence-based medical committee and a COVID-19 provider task force for the Renown Health System.
“Because of a history of fires and earthquakes in this region, we had an emergency planning infrastructure in place. We put the field hospital on the first and second floors of a parking garage, with built-in negative pressure capacity. We also built space for staff break rooms and desk space. It took 10 days to build the hospital, thanks to some very talented people in management and facility design,” Dr. Lee said.
Then, the hospital was locked up and sat empty for 7 months, until the surge in December 2020, when Reno was hit by a bigger wave – this time exceeding the hospitals’ capacity. Through mid-January of 2021, clinicians cared for approximately 240 COVID-19 patients, up to 47 at a time, in the field hospital. A third wave in the autumn of 2021 plateaued at a level lower than the previous fall, so the field hospital is not currently needed.
Replicating hospital work flows
“We ensured that everybody who needed to be within the walls of the permanent hospitals was able to stay there,” said Dr. Lee’s colleague, hospitalist Adnan (Eddy) Akbar, MD. “The postacute system we ordinarily rely on was no longer accepting patients. Other hospitals in the area were able to manage within their capacity because Renown’s field hospital could admit excess patients. We tried to replicate in the field hospital, as much as possible, the work flows and systems of our main hospital.”
When the field hospital finally opened, Dr. Akbar said, “we had a good feeling. We were ready. If something more catastrophic had come down, we were ready to care for more patients. In the field hospital you have to keep monitoring your work flow – almost on a daily basis. But we felt privileged to be working for a system where you knew you can go and care for everyone who needed care.”
One upside of the field hospital experience for participating clinicians, Dr. Lee added, is the opportunity to practice creatively. “The downside is it’s extremely expensive, and has consequences for the mental health of staff. Like so many of these things, it wore on people over time – such as all the time spent donning and doffing protective equipment. And recently the patients have become a lot less gracious.”
Amy Baughman, MD, a hospitalist at Massachusetts General Hospital in Boston, was co-medical director of the postacute care section of a 1,000-bed field hospital, Boston Hope Medical Center, opened in April 2020 at the Boston Convention and Exhibition Center. The other half of the facility was dedicated to undomiciled COVID-19 patients who had no place else to go. Peak census was around 100 patients, housed on four units, each with a clinical team led by a physician.
Dr. Baughman’s field hospital experience has taught her the importance of “staying within your domain of expertise. Physicians are attracted to difficult problems and want to do everything themselves. Next time I won’t be the one installing hand sanitizer dispensers.” A big part of running a field hospital is logistics, she said, and physicians are trained clinicians, not necessarily logistics engineers.
“So it’s important to partner with logistics experts. A huge part of our success in building a facility in 9 days of almost continuous construction was the involvement of the National Guard,” she said. An incident command system was led by an experienced military general incident commander, with two clinical codirectors. The army also sent in full teams of health professionals.
The facility admitted a lot fewer patients than the worst-case projections before it closed in June 2020. “But at the end of the day, we provided a lot of excellent care,” Dr. Baughman said. “This was about preparing for a disaster. It was all hands on deck, and the hands were health professionals. We spent a lot of money for the patients we took care of, but we had no choice, based on what we believed could happen. At that time, so many nursing facilities and homeless shelters were closed to us. It was impossible to predict what utilization would be.”
Subsequent experience has taught that a lot of even seriously ill COVID-19 patients can be managed safely at home, for example, using accelerated home oxygen monitoring with telelinked pulse oximeters. But in the beginning, Dr. Baughman said, “it was a new situation for us. We had seen what happened in Europe and China. It’s a great thing to be overprepared.”
1. Horowitz J. Italy’s health care system groans under coronavirus – a warning to the world. New York Times. 2020 Mar 12.
2. Bell SA et al. T-Minus 10 days: The role of an academic medical institution in field hospital planning. Prehosp Disaster Med. 2021 Feb 18:1-6. doi: 10.1017/S1049023X21000224.
3. Singh K et al. Evaluating a widely implemented proprietary deterioration index model among hospitalized patients with COVID-19. Ann Am Thorac Soc. 2021 Jul;18(7):1129-37. doi: 10.1513/AnnalsATS.202006-698OC.
4. Bell SA et al. Alternate care sites during COVID-19 pandemic: Policy implications for pandemic surge planning. Disaster Med Public Health Prep. 2021 Jul 23;1-3. doi: 10.1017/dmp.2021.241.