Ready for the Surge

By Mary Butler

One of the many unsettling aspects of watching the COVID-19 pandemic unfold across the United States was the urgency with which states and cities constructed field hospitals, turning venues that had recently hosted sporting events, concerts, worship services, and comic book conventions into medical facilities designed to treat the influx of patients.

The arrival of the Navy’s hospital ship USNS Comfort in New York Harbor in April drew crowds of spectators willing to risk social distancing fines for a glimpse of the vessel.

While the Army Corp of Engineers worked with remarkable speed to transform convention centers such as Chicago’s McCormick Place and New York City’s Javits Center, hospitals in much smaller communities worked with local officials to stand up alternate care sites (ACSs) for testing, triage, and overflow from hospitals.

According to data provided by the Army Corp of Engineers, work on the 3,000-bed McCormick Place field hospital began on March 29 and was completed by April 24. The first patient was admitted on April 15. Construction of the 1,900-bed Javits Center hospital eclipsed that. The contract to build the field hospital there was awarded on March 26 and construction was deemed complete on April 8.

Thankfully, outside of the New York City metropolitan area, hospitals did not exceed their capacities the way that early models were predicting. As of early May, McCormick Place and the Javits Center began discharging their remaining patients, smaller sites scaled back their efforts, and Navy hospital ships were sent back to their home ports. However, some field hospitals are left standing—particularly in Europe—as anxious public health professionals remain vigilant for signs of resurgence.

As healthcare professionals across the country hold their breath and uncertainty reigns, there’s some solace in knowing how quickly facilities like this can come together.

This speed and adaptability of the work required to get these sites running is due, in part, to the health information management (HIM) and health IT professionals who have been instrumental since the beginning of the crisis. HIM professionals have helped by developing workflows for maintaining medical records in a way that minimizes the spread of infection, ensuring that patients treated in the field have records that can travel with them, and ensuring that the health IT devices and systems in these hospitals stay secure and HIPAA-compliant.

On Paper and PPE

In the early days of the pandemic, the epicenter of the virus outbreak in the US was Washington state. Sally Beahan, MHA, RHIA, senior director of enterprise records and health information at University of Washington Medicine (UW Medicine), participated in discussions about record keeping procedures for the hospital tents set up outside of the emergency departments at every UW Medicine hospital, as well as preparing for the field hospital the Army Corp of Engineers was building in Seattle’s CenturyLink Field. Beahan said the Army field hospital was planning to implement the electronic health record (EHR) that the Veterans Administration uses, but it was collaborating with local providers on continuity of care documentation.

“One of my thoughts was to use an ROI [release of information] vendor to help coordinate that since all of us are on different EHRs in the Seattle area,” Beahan said. “To have the Army contact all these different places and do ROI requests didn’t seem like a very efficient process. They kind of needed an intermediary.”

Beahan isn’t sure if the Army planned to followed her advice since the outbreak in Seattle was contained before the stadium hospital was needed—the facility was open for three days before the Army took it down and moved the supplies elsewhere.

The documentation for UW Med’s own hospital tents was trickier. These tents were intended to isolate ED patients presenting with respiratory symptoms, so the concern was whether it was safer to document on paper or electronic charts.

“We had this whole conversation around, ‘Okay, well, if we’re going to document on paper, then we need to figure out scanning and we need to put scanners in the tents because we don’t want team members to be picking up contaminated paper and spreading the germs around.’ And so they were looking at the possibility of putting scanners into the tents so that the people working on the front lines with the PPE [personal protective equipment] could do the scanning. Our IT department was able to set up the infrastructure within the tents so that we could still use the electronic record, so we didn’t end up needing to do paper,” Beahan said.

In accordance with disaster planning protocols, Beahan and her team had to be prepared to transition to paper records. AHIMA’s Disaster Planning and Recovery Toolkit, for example, outlines scenarios in which reverting to paper records is a best practice.

“Luckily, we have not had to do that yet, but we did create an old-school ICU nursing flow sheet, but it’s this huge three-part form. We had to recreate that electronically because we didn’t have anything like that in our archives to pull from. That was one thing that has been done by our clinical informatics team. So we actually have that now electronically, but we have not moved forward with printing because we’re kind of in this holding pattern and don’t want to print a bunch of unnecessary disaster packets if we don’t need them,” Beahan said.

Charting in the Penalty Box

Toward the end of March, says Sarah Donaldson, MSA, CCS-P, coding and documentation manager at Rutland Regional Medical Center in Rutland, VT, state health officials asked Donaldson’s facility to create an ACS. Local officials settled on the Spartan Arena, a local hockey rink, to house between 120-150 overflow beds for level-two patients—individuals who are not infected with COVID-19 who might otherwise be candidates for skilled nursing care.

Donaldson was involved with the planning for this site from the very beginning. Early on, Donaldson knew she wanted patient records for the site to be kept on paper—partly because the nursing and physician staff was primarily local volunteers, which made training on EHRs more difficult. She was also insistent that the ACS did scanning of records on site, daily.

“My greatest concern was, if the patient was transferred from the alternative care site to another facility, then that chart would go with them. And then if that happened, we would probably never get it back and then we would have nothing to bill from,” Donaldson said. “So I did some training with staff on how to tabletop scan and we set up sort of a routine where we would go to the charts daily and collect the nurses notes, the progress notes, and collect the daily sheets where we would sit and scan and then return them to the patient’s charts. At least we would have what we could if we, by chance, lost the chart.”

Donaldson says this process would help ensure that her remote coding staff would have documentation to code from. She also asked physician volunteers whether they preferred to dictate or handwrite their notes. To her surprise, they asked to handwrite them. And to keep the records from leaving the building, Donaldson asked physicians to finish their documentation on site, where the most convenient—and quiet—spot happened to be the hockey rink’s penalty box.

“One of my concerns was, if we had providers from the community caring for patients, I didn’t want to have to be chasing those community providers after the fact. And I also didn’t want to have to delay any bills going out. So, we had a pretty good process with that daily pickup of those records and ensuring that there was a daily progress note and that notes were dated, timed, and signed,” Donaldson said.

At press time, this field hospital had not yet admitted any patients and state officials were still deciding whether to keep it open.

From Comic Con to COVID-19

Chicagoans watched McCormick Place—the site of AHIMA’s 2019 Health Data and Information Conference—make the transition from top-tier convention site to field hospital with pride as well as nervousness. For Tim Britt, CEO of Synoptek, an IT consulting firm tapped by Salas O’Brien and the Army Corp of Engineers to help design, build, and manage the IT infrastructure of the field hospital, the whole endeavor was astounding. Britt says the Army, local contractors, hospitals, and Illinois and Chicago officials all demonstrated an “unprecedented coordination” in getting the facility built within five weeks.

“If you look at that as the overall project, not just our part… If you look at the overall idea of standing up 30 or 40 or 50 hospitals, or alternative care facilities in a period of four to five weeks, it was pretty extraordinary,” Britt said.

Field hospitals, by their nature, have higher cybersecurity risks than brick and mortar hospitals because they’re built so quickly under higher stakes. Britt says this can be mitigated by setting up sound IT infrastructure. The other challenge, however, is providing adequate training to a workforce with varying levels of cybersecurity training. The clinical staff at McCormick Place consisted of local volunteers, workers from nearby hospitals, and individuals from other parts of the state and country. The state of Illinois was also asking retired nurses and doctors to volunteer in anticipation of caregiver shortages at local hospitals, and Britt didn’t want to assume that this workforce had been trained on social engineering tactics used by cybercriminals.

“There was onboarding training for these individuals if they were coming in on a contract basis, with the medical health folks, they had to train them both on their systems. So, all of our people went through that kind of training as well about…the warm zone, and the hot zone, and the cold zone, and how to navigate between those different areas and the minimum requirements for being in those different areas,” Britt said, referring to the way hazardous or infection environments are designated.

When Synoptek joined the project, an EHR vendor had already been identified and was linked to local medical centers, so Britt didn’t need to deploy the IT professionals with HIM credentials on his staff to the project. However, he did have to identify employees that were willing to do set up in an area where they might be exposed to infected people.

“We had some employees that said, ‘Yeah, I’ll go do it,’ and then they showed up and said, ‘Wait, wait.’ After they went through the training, they’re like, ‘No thanks.’ So we had to change them out. It’s just people have different risk tolerances or perceptions of risk. So it was interesting,” Britt said.

Mary Butler ([email protected]) is senior editor at the Journal of AHIMA.

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