July 24, 2020

Pandemic Preparedness and Response: A Tale of Two States

When a new disease morphs into a pandemic, public and private health leaders are often caught off guard, especially in regions that are first to be flooded with infected patients. Such was the case with COVID-19, which began its U.S. rampage through a handful of states, leaving little time to prepare and respond. Meanwhile, officials in other states watched and learned from the difficult lessons of their peers in the hardest hit areas.


Perhaps no two states better portray the contrast in pandemic preparedness and response than New York and Arizona.


NEW YORK: Grappling with the onset of a national crisis

New York had the highest number of confirmed COVID-19 cases in the country from the start of the outbreak until July 22, 2020, when it was surpassed by California and Florida. It  also was among the earliest states to be overwhelmed by the virus. As of July 22, New York’s confirmed cases totaled 409,697, and 25,081 individuals had died from the disease. To put these statistics into context, New York at its peak had more COVID-19 hospitalizations than 46 other states combined.


On March 16, just two weeks after confirmation of New York’s first case, the number of COVID-19 hospital patients in the state had increased tenfold, according to The New York Times. Needless to say, many hospitals were quickly stretched to the limit and beyond. The situation in New York City was especially dire, with hospitalizations skyrocketing 40% in a single day  (March 25-26).


At one Queens hospital, an influx of hundreds of COVID-19 patients far exceeded what the facility could provide. On March 25, several outlets reported that the hospital was at its “breaking point” following the deaths of 13 patients within a 24-hour period. One medical resident described the conditions as “apocalyptic,” according to The New York Times.2 Meanwhile, 3,500 beds — some within 20 minutes of the Queens hospital — were available at other New York facilities.


Responding to the sudden spike in COVID-19 admissions, another hospital in Manhattan converted its lobbies into supplemental patient rooms. The hospital also created capacity by setting up a 68-bed COVID-19 respiratory care unit in nearby Central Park.


Other extraordinary measures implemented during the early stages of the pandemic ranged from splitting ventilators for simultaneous use by two patients, to the deployment of the U.S. Navy hospital ship Comfort in the New York Harbor. Ultimately, the state cobbled together a “dashboard” that provided limited visibility to hospital capacity; scouts in the field would react to this data by trying to arrange patient transfers to less crowded facilities. But this initiative was far from a comprehensive approach to region-wide load balancing.


Notably — and tragically — the state’s hospitals possessed the capacity to care for all COVID-19 patients, even during the pandemic’s early peak stages. “It wasn’t that every hospital was full,” an aide to Governor Andrew Cuomo explained to The Times. “It was a problem that a handful of hospitals were nearing capacity, while hospitals within a 15- to 20-mile radius had plenty of space.”


To its credit, New York implemented tough measures to limit the spread of COVID-19 and lessen the strain on healthcare providers. By early June, the rate of increase in new cases had fallen to less than 0.25% per day, and as of late July, New York had not experienced a spike, or second wave, in daily new case rates. Even so, as one of the early COVID-19 epicenters, New York learned many painful lessons, including the consequences of not having a centralized system for efficiently transferring COVID-19 patients from overwhelmed hospitals to facilities that had available staffing, beds, and equipment.


ARIZONA: Learning and taking proactive steps

Although Arizona logged one of the nation’s first COVID-19 cases (Jan. 26, 2020), rapid community transmission didn’t occur in the state until after New York’s initial surge of patients. One thing was certain: Arizona’s leaders were determined to avoid the trauma they witnessed in other states, and they had time on their side — but only to a point, as the virus was spreading quickly in many areas of the country.


Arizona differs from New York in several key regards, most obviously in its smaller, less dense population. But Arizona also faced a number of similar challenges in responding to COVID-19, including uneven geographic concentrations of hospitals with advanced COVID-19 care capabilities.


Despite the potential obstacles, public health and health system leaders moved forward with their plan to establish the Arizona Surge Line, a centralized hub designed to facilitate the load-balancing of patients with confirmed or suspected COVID-19 across the state’s 100-plus hospitals. Never before had Arizona undertaken such an ambitious community health project.


To make it work, and to expedite deployment of the Surge Line, Arizona Department of Health Services (ADHS) leaders understood they needed two key elements: 1) people with exceptional talent and experience; and 2) technology that could provide real-time visibility into bed capacity and resource availability to support transfers of patients to the right level of care, to or from virtually anywhere in the state, as swiftly as possible.


ADHS recruited Charles Larsen, MSN-L, MBA, RN, NEBC, Senior Director of Transfer Services at Phoenix-based Banner Health, to lead the Surge Line implementation team. He came to the project with extensive experience managing Banner’s transfer center, which serves 20 hospitals in the state. Besides getting a highly capable project leader, the state benefited from Larsen’s work with the access center solution used at Banner Health.


“When the state contacted me to stand up the Surge Line, I said ‘yes’ — as long as we can use the proven access center technology we’re using at Banner, because I know it will work, and we can quickly make it happen on a statewide level,” he says.


True to his word, Larsen and his team scaled up the access center technology to serve the entire state — and they did it in less than two weeks. Equally impressive, they won support and cooperation from the state’s normally competing health systems, assuring them that the Surge Line would complement, not replace, their individual transfer centers.


Following a successful implementation, Larsen returned to Banner Health, and Luke Smith, DNP, RN, NE-BC, assumed oversight of Surge Line operations. Smith is a member of the Clinical Operations team at Central Logic, which provides technology and clinical consulting to help power the Surge Line.


The first order of business for Smith, who possesses a rich clinical background, was to connect with health system and hospital leaders across the state. “This was a brand new initiative — nothing like it was ever done anywhere else. I had to do a lot of outreach, developing relationships so that when healthcare organizations started experiencing COVID-19 patient surges, they would feel comfortable calling the Surge Line,” he explains.


Northern Arizona became the state’s first COVID-19 hotspot, and the Surge Line was ready. “The Navajo Nation was hit really hard,” says Smith. “We had daily communications with hospitals serving that area and were able to work with them to get patients transferred quickly to facilities in other parts of the state where they could receive a higher level of care.”


As the spread of COVID-19 continued, similar scenarios played out in other areas of the state, including Yuma on the Southern border. “Through daily conversations with Yuma healthcare leaders, we could see the start of a surge, even before the state’s data showed what was happening. Early intervention helped prevent catastrophic events in Yuma and northern Arizona.”


Virtually all of Arizona has benefited from the Surge Line as COVID-19 cases peaked in late June and early July, and many areas of the state continue to experience high infection rates. Even larger hospitals in the most densely populated areas are using the Surge Line, according to Smith. “Certain hospitals in Phoenix have been hit harder than others. Some of the larger organizations are able to transfer patients within their health system, but other smaller systems have requested our help with load balancing. So we’re not just assisting hospitals in outlying rural areas, but any hospital that doesn’t have adequate resources or has become a hotspot for COVID-19 patients.”


In addition to having daily conversations with healthcare leaders across the state, Smith points to statewide, real-time visibility as a key to the Surge Line’s success. “We have a global picture of the entire state’s available beds, clinicians, equipment and other resources, which enables patients to be transferred promptly to the appropriate level of care, regardless of where they live. This includes the transfer of recovering patients back to the sending facilities, when appropriate, to free up ICU beds for critically ill individuals.”


Ultimately, the Surge Line has helped ensure that no Arizona hospital is overwhelmed by COVID-19, allowing caregivers to focus on achieving the optimal outcome for every patient.


Helping to shape future readiness and response

Sharply contrasting stories from places like New York and Arizona have prompted leaders in other states to take a hard look at their response to COVID-19 — and to consider how they can improve their preparedness for future patient surges, whether caused by a pandemic or another crisis. Important lessons gleaned from the Arizona experience include:


  • It’s possible to quickly stand up a state or regional transfer center with the right leadership and team, including individuals with transfer/access center experience.
  • Also essential is technology that can be scaled up to provide real-time visibility of clinicians, beds, and equipment across a large geographic area, coupled with an efficient means to promptly transfer patients to the right level of care.
  • Prior to go-live, representatives of the state or regional transfer center need to reach out to health system leaders, explaining how it will work and how it will benefit them.
  • Competing health systems will buy into a centralized transfer center once they understand that it benefits everyone and it won’t supplant their own transfer/access centers.
  • A state or regional transfer center should be designed with a long-term view — that is, it can be rapidly re-deployed in response to future crises.


For more information or assistance with standing up a state or regional transfer center, contact us.