Nuvance Health—a seven-hospital system serving 1.5 million individuals across the mid-Hudson Valley and western Connecticut—is on the front lines of the COVID-19 battle. Only an hour from New York City and JFK airport, Nuvance hospitals are facing COVID-19 cases that are increasing at triple-digit rates. President and CEO John Murphy, MD, took some valuable time from the battle to tell us the specific measures his system is putting in place and the toll the virus is taking on system resources.
In all Kaufman Hall interviews, the expert opinions expressed are those of the interviewees and should not be considered opinions of Kaufman Hall. This interview was conducted on March 16, 2020.
Q: What volume of patients are you treating who have COVID-19, and how quickly is that population growing?
A: We have throughout our health system at least a dozen patients who have tested positive and are inpatients. We also have a fair number who have come through our system in one way or another but are at home now under self-quarantine.
The rate of growth and the number of cases over the past 48 hours has been substantial. In New York, cases have increased by about 50 percent. In Connecticut, cases have increased about 100 percent. And in New Jersey, cases have increased by about 200 percent.
We expect to see a significant continued increase, especially as testing becomes more widely available. At that point, I believe the growth rate will become nonlinear, as happened in at least 12 western countries that didn’t have access to some of the isolation strategies that China has used.
This morning we just opened an outpatient testing facility. I’m sitting in my office looking at a line of cars waiting to get in. The police have actually had to come out and close off surrounding streets. Even with that demand—mind you, these are people who have called to schedule tests—it’s still going to be three to five days to get the results back.
So we really don’t know how many people are infected in this community. I suspect based on the French and the Spanish experience, that the number of patients who are actually infected in our communities is probably one to two orders of magnitude greater than we think.
Q: How is your hospital dealing with the need for capacity to treat such a rapidly growing population?
A: One way we are trying to create capacity is by working to get people out of the hospital as quickly as possible and as appropriate. This is something like reverse triage. Triage is typically thought of as identifying who is sickest and needs our attention first, and expediting their access to treatment. The flip side of that is taking a look at who’s in the hospital and who’s the least sick and whether those patients can be discharged.
The problem with that strategy at the moment is that the nursing homes in the area are refusing to take patients discharged from our hospitals because its widely known we have COVID-infected patients. I’m speaking with the Governor to see if there is some regulatory or legislative remedy. We clearly don’t want to put sick or infected patients in a nursing home, but we are trying to get people who we can appropriately discharge out of our hospitals.
In addition, we just canceled all elective procedures of any kind. We did that for two reasons. First, we are trying to slow the number of admitted patients and reduce the number of occupied beds. Second, when those patients go into the operating room there is a certain consumption of isolation resources. We want to preserve all of that protective equipment, all those masks and gowns, for a real surge that we think is coming.
Supplies have been a headache for everybody. It’s a national issue. A lot of our supplies unfortunately were coming from China; now we have to live with that.
Q: What level of capacity and resources do you think you’ll need?
A: Nationally, somewhere between 15 and 20 percent of the population who are infected will need hospitalization. In our geography I think that number will probably be closer to 20 percent given that we’re an older population than a typical U.S. city. Worldwide, between 5 and 10 percent of individuals who are infected will need an ICU.
We are actively doing scenario planning, which involves looking at the population we serve, looking at some of the epidemiologic surveys from 12 or 15 other countries, and making some assumptions about the rate of rise and how many people can we expect in our population to get infected. From there, we are making assumptions in the models about accessing necessary capacity and equipment. We are mapping out locations of the negative pressure rooms and ventilators in each hospital, and how much protective equipment we have. We are looking at what scenarios would overwhelm our capacity and resources.
We have begun to identify sites where we would try to cohort patients, creating a ward-like environment in which you could have an entry point for properly attired staff, who would work a six-hour shift. We think that the best way to approach this is to create one ward for patients who don’t need critical care, and one for patients who do need critical care, particularly ventilator support.
We’re also looking at monitoring and meeting the needs of patients after they’ve been ventilated. For example, based on the experience from China, South Korea, and Italy, these patients may have cardiac issues.
We’re trying to map all of that out, looking at what sites we can create, and then creating them. The real issue for us, in addition to where you put these patients, is how to ensure we have enough supplies, including ventilators, and enough staff.
Q: Tell us more about the staffing issues.
A: We furloughed approximately 200 employees who had come in contact with individuals who subsequently tested positive for COVID-19. Based on what you read in the lay press, you would think that individuals infected with the virus present with a fairly predictable set of symptoms—fever, cough, sore throat, not typically runny nose, not typically any GI symptoms—and then of course travel history used to be a clue. Not any longer. There are people coming in with some pretty atypical presentations that were considered very low risk; therefore, the staff was not always fully and properly protected, or patients didn’t disclose their symptoms.
Once you identify a positive patient, you have to trace back and find out what staff person had close contact for a prolonged period of time with that patient, and then off that person goes to home. So we’ve furloughed lots of people, including many critical providers.
If we were to have, say, 150 patients on ventilators, who is going to manage those ventilators? Typically you have intensivists managing a tenth of that census. We want the anesthesiologists and CRNAs who are in the OR to be available to help with the ventilator management, which is another reason we are canceling the elective procedures that might expose an anesthesiologist to a person who was infected but we didn’t know it. We lost eight anesthesiologists in one exposure. We want to anticipate staffing needs and plan for who can manage the ventilators for our sickest patients. We’re getting help from not only intensivists, but also anesthesiologists, CRNAs, cardiologists, and others. That’s a real concern.
Also, we’re in the process of retraining and reestablishing competencies for nurses who have left the bedside. We now need them back and to be prepared to provide care. I was just at our medical staff office looking for recently retired physicians to see if we can put them to work on telehealth offerings, because we have a real spike in demand for virtual visits.
You have to be sensitive to how stressful and difficult it is to care for infected patients. The protective gear is heavy to wear, it gets warm, you can’t take a sip of water, you can’t use the bathroom, it’s very time-consuming to get in and out of the gear, and you’re in it for the duration of the shift. So the shifts need to be shorter. The level of anxiety is higher than I’ve ever seen it. I saw a nurse the other day who was literally trembling before going into one of the patient rooms in her gown. You have to calm the anxiety of the staff, which is very real. I am proud of the tremendous job they are doing.
Q: How did you structure your response to the virus?
A: The first thing we did is we open a command center at every hospital and the medical group. They were the same structure, the same reporting cadence and sequence throughout the day, so that systemwide command could meet twice a day. There are clinical work groups, infection control work groups, intensive care work groups, and others that all report in to—and get delegated from—incident command.
Q: How to you track the financial implications?
A: We have someone from finance to sit in on these work group meetings and create a very easy system for us to track the financial implications. I review that every day along with the CFO. We have had millions and millions of dollars of unbudgeted expenses. We track these so that, to the extent the federal government and potentially state government release dollars, we can figure out how to legitimately access those dollars for relief.
We have an understanding board. Some of the decisions we’ve made within the last 24 hours are going to have significant effects on our revenue. We’re also working with the payers to try to enlist their support, particularly to pay for virtual visits. It is the right thing to do.
Q: What words of advice do you have for other senior health system executives?
A: This is a frightening experience, a tough experience for young CEOs, for new physicians, and for staff who haven’t been through something like this before.
This is an extraordinary stress test for a health system. It’s very hard even to finish a thought or finish a sentence. It’s easy to get distracted by all the incoming issues. But there is a certain list of things that you need to attend to. I will list some of them.
You have to know who is going to do the contact tracings. You need to be able to put together in rapid order who came in contact with each person who tests positive, with help of state dept of public health. You have to do it quickly.
You have to have your facilities staff up their game They have to do deep terminal cleanings in places where infected patients have been. We have 165 outpatient facilities; those are typically cleaned by smaller cleaning services. You need to instruct them on what it actually means to kill this virus and what agents can be used and can’t be used.
Infection control becomes terribly important. You have to know when to use masks, when to gown up, how to isolate persons who are under investigation, what do you do with an employee who has bad cough—all those sorts of things.
You have to develop human resources policies quickly. Who gets furloughed. Who gets paid for furloughs. Can you screen employees, and have them not come into work before they answer some questions and we take their temperature. You have to deal with the labor unions on that. Some of the HR issues seem small but are very important. The N95 mask, which can filter out small microbes, droplets, and virus particles, must be carefully fitted on staff. That means men who have beards need to shave them. And you don’t have time to listen to someone to say, “I really love my beard.”
Information technology is another critical area. We sent a third of our workforce to work from home. You have to have the IT capabilities and the policies for that.
You also need a clinical playbook. We have a global health program of sites in nine countries around the world including China and Russia, and we have a very sophisticated clinical playbook that reflects the clinical learnings from other countries.
A lot of people are figuring this out as they go. And if you have read about the great flu pandemic, you know that we’re not going to be on the other side of this anytime soon. This is probably just the beginning.
Q: How are you communicating with various constituencies?
A: Communications is a huge issue. Telephone operators in the hospital are overwhelmed with anxious phone calls. We now have a dedicated hotline for the community and another for employees. We also have daily video conference calls that thousands of employees attend.
Communications with public health and our community leaders is ongoing. For instance, we are in contact with Mayor, who just closed schools, and what that means for our employees. And we have to communicate with the board regularly.
I have call with the Governor in a couple of hours because we will need relief from certain laws in order to create testing facilities in standalone triage tents. We also need to allow clinical staff to cross state borders to fill in gaps.
We have homeless people coming in for testing and the shelters have been closed. How do you isolate those people who actually have nowhere to go? I’ll ask the Governor and his staff and other agencies for their advice and assistance.
And you have surgeons who are saying, this is affecting my income, I can’t operate and I’m paid on RVUs, what is your plan for that?
Q: How do you view your role beyond your own health system?
A: I look horizontally. We are trying to get the state hospital association to plan collectively for a surge, not simply limit our thinking to the boundaries of our system. We need to look at other hospitals and health systems that may have excess capacity to work collectively across at least two states.
We’ve got to plan for the long game.
Q: Any final thoughts?
A: I want people to know that this is all about being ready. And being open no matter what comes our way. We are going to deal with it. We are going to put patients first. We are going to put the community first.
We have reached out to a number of our donors and said, this is really an extraordinary moment, and a number of our donors have stepped up to help us get the ventilators, masks, and medications we need and are now using for our critically ill patients.
I am so proud of our community. We’re working as hard as we can, and our community is helping. We’re deeply appreciative of that.