What lessons can you take with you once the pandemic subsides?
(Part 1 of 2)
Raise the warning flag
Last fall I wrote about crisis recognition and defined it as being ill prepared for managing the situation. There’s not a lot of crises in our world. We are the crisis experts within the hospital. But when it comes to a once a century global pandemic, I’m willing to bet most of us don’t have the best game plan for that. Early on, we discussed COVID with our local health department and our emergency preparedness committee. But at some point, it was time to bring it to my C suite. I didn’t know what to expect but thought it was my job to raise the warning flag, and then push to broaden the conversation to include the other specialists.
The decision to raise the warning flag shouldn’t come lightly, but it is ultimately the leader’s job to decide how and when to escalate the situation. Timing is important, so for my situation, early January would be too early — and wouldn’t get the attention of hospital leadership. The means of notifying our leadership is also important. An email or text to the CMO could be missed and based on your timing, getting COVID on their radar may not be critical enough to schedule an emergency meeting.
I’d recommend against using a public forum like MEC. Ultimately, I did a “fly by” through the C-suite and caught the CMO at his desk, which was the goal. I suspect each EM medical director had a somewhat different approach, but the bottom line comes back to us recognizing that we might be ill-prepared in the ED and the hospital to manage a pandemic.
If you’re not at the table, you’re on the menu
The above statement has been a running joke with a few friends of mine for years and speaks to the importance of attending every hospital quality meeting, MEC, etc… Never has it been as important as during a pandemic when the ED is among the star players. Given our clinical schedule, it’s not possible to attend every meeting, so this is the time to coordinate messaging with your nurse leaders or other docs who can represent the ED. The task force meeting topics typically include things like volume trends, PPE needs, staffing and roadblocks for testing.
It’s critical that we, as leaders, do everything in our power to attend. The same lesson about attendance and delivering common messages should be played out anytime someone from the physician and nurse ED leadership team is meeting with key hospital personnel, whether it’s the C-suite or other clinical leaders.
COVID led to the creation of numerous meetings and committees. Sometimes I think hospital leaders try to protect the physicians by not asking them to join additional committees. But I think COVID taught me that we all have an obligation to speak up and invite ourselves to meetings if we have the time and think we can help.
Ask for what your need
As a contracted physician, the last thing I ever want to do is appear needy or unreasonable to the C-suite. And long before we knew ED volume was going to decline, we wanted to be prepared for the surge of COVID patients coming our way. My nursing leadership and I spent a lot of time considering space requirements both for patient care and waiting areas and we stressed a lot deciding whether we were going to ask for it. Typically, business decisions are based on a clear return on investment argument. But this was a pandemic and we were trying to think outside the box. As you’re making your plan for any new purchase, do your homework which likely includes speaking with other chairs in surrounding EDs.
Ultimately, we brought it up, made our case, got approval, and had a tent up and running, complete with power and three heaters, pretty quickly. We used it as a waiting area for low acuity patients for a couple of months. When I asked for a scrub vending machine, my nursing director told me I was crazy. It was a big ask, would involve a lot of dollars, but worth spending some of my own political capital since I knew it was important enough to all of the ED physicians and nurses. Ultimately, we got scrubs delivered to us, so staff didn’t have to bring COVID infested scrubs home to their house if they didn’t want to.
I don’t expect to get everything I ask for, but putting together a clear argument and how it benefits the staff and patients gives you a leg up. Fortunately, our executive team was also thinking outside the box for ways to keep patients and staff safe. And if you don’t ask, you don’t have a chance of getting it.
Staff safety comes first
We’ve all lived by the saying “put the patient first.” This has helped me in admission (and discharge) decisions, in getting consults, and as a guiding principle for administrative projects and ED purchases. But with COVID, where we all thought we were going to get infected and even die, it was critical to think about staff safety as the top priority. In my mind, if we wanted staff to show up for every shift, we needed to not only keep them, but make them feel safe.
While there were a few people we might never make feel safe, most just needed their questions answered and a few wanted to experiment with different devices to protect them. We offered face shields, goggles and respirators among different options. I realize every hospital couldn’t finance multiple safety options, but part of our responsibility is to represent the concerns and best interests of our staff. This may be in scrubs or it might be in allowing people to purchase their own respirators.
My nursing leadership team made clear to me to make sure that docs, nurses and other support staff were treated equally based on the patient risk and that we needed to be prepared to defend differences in equipment. At my facility, ER docs and anesthesiologists got access to our limited supply of PAPRs, but as our BiPap use increased, it became clear that our respiratory therapists needed PAPRs as well. Be fair with items in limited supply, but be sure to protect your staff. As we develop priorities for ongoing projects, we should also be focusing on other staff safety initiatives such as how our policies for psychiatric and violent patients put our staff at risk.
Not everything belongs at the large multidiscipline meetings
Although I think we had a lot of excellent discussions at our COVID task force meetings, what I learned early on was that disagreements between physician specialties is best discussed outside of a multidiscipline meeting. It was critical to have discussions about obtaining code status, how long to run codes, or the creation or dissolving an airway/procedures team. These meetings were best held outside the task force so that we could report an outcome or plan. Inter-department bickering is best kept out of the public view of hospital leadership.
The success of these behind the scenes meetings is often based on how well you nurtured relationships ahead of time. I’ve often said that I meet with key department/division leaders regularly even when there’s nothing significant to review. These meetings, even if brief, allow a relationship to get built so when you do need something, you have a strong foundation of working together.
It’s impactful to tell a clinical story
As COVID started, my calendar had about 20 hours of meetings added to it each week. I suspect every ED chair around the country, and certainly in early hot spots, had similar changes to their meeting schedule, if not more than me. I know some chairs stopped working clinically so they could manage their hospital’s COVID response. There was clearly no right answer, but I did find it useful to work my clinical shifts. Not only did I experience the same stress and anxiety that my team was feeling, experience the same end of life discussions with family, experience the same drop in productivity as my team, and to also see firsthand how our processes work (PPE stations, equipment cleaning stations, high and low acuity COVID sections, translator phones, etc.).
There were a couple of times I was pretty overwhelmed and was very appreciative when a couple of people offered to pick up shifts for me, but generally, I kept my clinical responsibility. Our COVID task force consisted of a lot of hospital leaders, but only a few physicians and nurses who worked clinically, so I believe I had added credibility and certainly had more “firsthand” stories when I was able to share my experience or issue from my shift “over the weekend” or ”yesterday.”
Next month I will share more lessons that I learned resolving around communication, including the importance of networking, social media and working with your PR team.
I am a Director of an Emergency Department in India.
Never before was able leadership more required than during this ongoing pandemic.
ED has become the cornerstone of Covid care in my hospital.
We have started a fever clinic to isolate the mild diseased from the moderately and severely ill patients
.Attrition has fortunately been less and the staff has risen to the occasion.
How do we deal with burnout?
Reduce the number of working hours and provide enough rest and time to recuperate between night shifts.