How close did the region come to “crisis standards of care?”
I consistently felt that we were always a step ahead of the significant issues that arose during the November – January surge. Through our weekly calls with hospital executives, I felt that we understood how impacted the hospitals were. As the number of hospitalized COVID-positive patients increased, several hospitals were on the verge of implementing crisis care due to personnel shortage (illness or quarantine due to COVID), medical oxygen issues (delivery capacity limitations and lack of portable tanks), ventilator, and high flow oxygen equipment shortage, and limited bed availability. These issues impacted emergency departments’ ability to offload ambulance patients and led to significant wait times before ambulances could transfer care to the ED.
It is very difficult for us to think of hospitals having to implement “crisis care” in the United States. The public certainly is not able to accept the concept. This idea was validated when the EMS Agency issued directives like limiting the use of oxygen in the prehospital setting. As the EMS Agency and MHOAC, we have consistent communication with our hospitals and HASC. This allowed us to identify which hospitals were struggling during the surge. Our disaster resource center program and systems of regional care were a natural fit for the MHOAC program to reach out to our larger hospital systems and request a more regionalized approach to assist all hospitals on the verge of crisis care.
Once the state assigned personnel to assist the MHOAC in supporting hospitals that were identified as being on the verge of crisis care implementation, we had significant progress in stabilizing heavily- impacted hospitals. The EMS Authority, CDPH, Cal-OES, L.A. County Department of Public Health, and Office of Emergency Management assigned staff to our Department Operations Center. The L.A. County Coroner also provide a dedicated team to assist with fatality management.
The Regional Hospital Leadership Group assisted us by identifying barriers to their ability to care for patients, being aware of struggling hospitals and reaching out to offer assistance. Prior to this leadership group, hospitals felt they were on their own and did not have an effective way to move patients to Skilled Nursing Facilities, higher level of care, or patient repatriation. This group brought everyone together, working on the same goals.
L.A. County EMS is the largest, multi-jurisdictional EMS agency in the nation. And the region includes close to 90 acute-care hospitals. Does that raise the level of complexity during a crisis or perhaps provide ways to spread the pressure out?
Indeed, the number of acute care hospitals within L.A. County increases the complexity of the response to any disaster — but even more so when responding to a pandemic that affected every hospital, the entire county, and the whole state. During the height of the surge, attempting to “load balance” between hospitals was impossible because every hospital was working beyond its normal capacity.
The large volume of hospitals and EMS providers to coordinate makes it challenging and complicated, but it also helps spread the impact of the surge. We needed every EMS and hospital resource during the fall/winter surge, plus outside support from our state and federal partners.
What was most helpful for L.A.County during November – January was that this was not the first surge of patients during this pandemic. We had a moderate surge during the summer months, so our hospitals implemented surge strategies at that time. When the fall/winter surge occurred, hospitals had time to evaluate their disaster plans and refine their surge strategies. Additionally, the Medical Health Operational Area Coordinator (MHOAC) Department Operations Center had been activated since March 2020 and developed efficient and effective processes to support the health care delivery system.
Lastly, the L.A. County EMS Agency and MHOAC programs have been actively engaged and have personal relationships with hospitals and prehospital care providers for years. The EMS Agency has managed the Hospital Preparedness Program (HPP) since its inception in 2002. Thus, we had established our disaster preparedness program and Disaster Resource Centers, along with our warehouse for distribution of medical equipment and supplies.
In December, news reports focused on impacted emergency departments and a handful of facilities that diverted ambulances from their EDs. What did you learn that you can pass on to hospital managers?
There are counties in the state that do not allow hospitals to go on diversion. We use the ReddiNet system for our various levels of diversion. If the hospital does not meet the criteria for a type of diversion or is requesting what we call “Internal Disaster,” they call our Medical Alert Center, or MAC. We also have an Administrator on Duty (AOD) for unusual situations. It is through these processes and notification to the AOD from the field ambulances and hospitals that we were able to monitor how impacted our system was and how much trouble individual hospitals were in. This led us to change some policies and add EMS Agency directives to better manage the impact on the EMS system. Also, through the CEO Leadership Group, we encouraged hospitals to hire Emergency Medical Technicians (EMTs) and paramedics to assist in the emergency departments to monitor patients and allow the ambulance personnel to get back to the field.
Other counties use various mechanisms to monitor their systems. I felt the ReddiNet system, diversion policies, and AOD notification were instrumental in allowing us to effectively monitor our EMS system and be proactive with our hospitals. I am encouraged that hospitals will continue to utilize staffing models to decrease our ambulance patient offload times (APOT).
We will be conducting an After-Action Report of the MHOAC response soon to identify lessons learned to improve our disaster response plans.
What’s your impression of the threat posed by variants and the overall stubbornness on the pandemic? How prepared should hospitals remain for additional surges?
I try to think positive about our future ability to live with COVID-19. With the vaccines, people may get infected with the virus but most likely will not need hospitalization in the numbers that we saw last year. That being said, remember that I am not a doctor. So this is just my opinion and hope based on the data that we analyze.
Through the Hospital Preparedness Program and our recent experience, I know that our hospitals are better prepared. We have more surge beds available, and hospitals that had issues with their oxygen delivery system have completed retrofitting.
The availability of clinical personnel was our biggest challenge, and I think the vaccine has significantly addressed that issue.
From the beginning, I have advocated for increased federal funding to the HPP grant. This program was instrumental in laying the foundation to get us through the surges caused by the pandemic. I hope that, with advocacy and education, the federal funding is significantly increased.
HASC’s ReddiNet® emergency communications service played a prominent role during the surge. How has ReddiNet grown over the past dozen years? What might it do to refine its role?
Our EMS Agency and Medical Alert Center (MAC) take great pride that ReddiNet started out as a pilot program with us. Someone at HASC had the foresight to recognize the benefit of a program that allows all hospitals and now prehospital providers to communicate critical information in a disaster. We have always supported the ReddiNet system, and I hope that our input as to the various new uses has assisted in its development.
ReddiNet has significantly changed and expanded since its inception. Due to their leadership and “how can we help” attitude, their function/capabilities and areas for use are endless. As I mentioned previously, ReddiNet functions and reports were instrumental in allowing us to recognize and respond quickly to any significant changes and issues that arose in our EMS system.
Anything else you’d like to mention?
Throughout the pandemic, everyone was trying to come up with a number that our hospitals could surge to. I referred to this as a “unicorn.” I believe the first guess was about 4,000 patients across all hospitals in the county but our health care system started to buckle when we had 7,000 hospitalized COVID-positive patients in mid-December. We peaked at 8,098 hospitalized COVID-positive patients on Jan. 6, and we were only able to manage the surge with additional personnel from the state — and with surge tents.
I stress this because we did a surge bed survey in March 2020, and our hospitals responded that they could surge about 10,000 additional beds. Surge strategies call for space, stuff and staff. L.A. County was able to create space (space conversion within the hospital and surge tents). We got more stuff (ventilators, high-flow oxygen devices, medications, PPE). We were unable to obtain sufficient staff.
Based on our experience with Alternate Care Sites, Federal Medical System, USN Mercy, L.A. County Surge Hospitals, I strongly believe that patients need to be within or on the grounds of a hospital. Resources and funds need to be directed to the hospitals and not diverted to set up facilities outside of hospitals.
Contact HASC Publications Director Erik Skindrud with comments or ideas for future In the Spotlight interviews.