BY DAYA BAUM
COVID-19 emerged in late 2019 and quickly escalated into a global pandemic, fundamentally transforming daily life and public health systems around the world. The virus has led to widespread illness and significant mortality, yet the complexities of its impact extend beyond immediate health concerns. Governmental responses, including lockdowns, social distancing, and mask mandates, have been widely discussed and analyzed. However, the actions taken by individual hospital administrative groups in navigating the ongoing challenges of the pandemic are less frequently examined. Learning more about the administration may serve to create greater transparency within the community. Dr. Jonathan Siner, former Medical Director of the Medical Intensive Care Unit (MICU) and current tele-ICU director at Yale New Haven Hospital (YNHH) provides valuable insight into the behind-the-scenes administrative efforts that were crucial in managing the crisis as COVID-19 ravaged the Greater New Haven communities and healthcare systems.
Hospitals with universal protocols of care and detailed preparation yielded the lowest mortality rates and the highest level of effective patient care during the pandemic, according to Siner. “You never know how bad it’s going to be, how long it’s going to go on, and if you wait until you’re about to run out of something, it’s too late,” Siner states.
Siner confronted challenges in acquiring physical and personnel resources, shifts in communication among healthcare providers and patients, and personal obstacles. The first major obstacle that YNHH faced was a scarcity of information regarding viral pathogenesis and transmission. This impacted YNHH’s implementation of a new medical protocol in response to the growing crisis. “We didn’t have any data, so it was all what we would call ‘best judgment’ or ‘expert opinion,’” Siner said.
Prior medical knowledge, as well as data from hospitals that were overwhelmed with patients before YNHH, together guided a greater understanding of effective PPE and critical care. Regardless, this lack of control over personal and patient health instilled apprehension in providers, a concern that Siner personally attested to: “I think it became clear after about four weeks of the PPE working, but the first couple of weeks, nobody knew. And people were appropriately pretty anxious every time they went into a room because they wonder, ‘is this stuff actually protecting us, or not?’”
On a more personal level, Siner experienced the pressure of decision-making with a lack of information. Patients and providers alike approached him, sure that they had the solution to solving the pandemic or the intervention that could cure the virus. Siner recounts a physician who suggested putting patients on Heparin, a blood thinner, because patients on the medication at another hospital showed signs of success. While, in Siner’s opinion, there may have been potential medical or physiological reasons why Heparin could help, he had not seen any data as support, and the medication might have caused severe bleeding in older patients. He remembers not having a “sense that it’s correct,” along with similar impressions for several other word-of-mouth interventions. It took some time and reflection for Siner to realize that his and his colleagues’ years of preparation and experience were most important: “I’ve committed to doing what I ordinarily do, which is just provide the best basic care we can. And we kind of have to hope that is enough.”
The intense influx of critical patients initiated a need for more resources and PPE, and even without a great understanding of the virus, the ICU saw a tremendous demand for additional ventilators. Siner spent a major portion of each day coordinating equipment, hospital space, and personnel logistics. The first major shift made by the hospital administration involved relocating the entire Oncology department, floors 12, 14, and 15 of the Smilow Cancer Hospital, to the nearby Saint Raphael Campus. After clinical engineering, including rewiring and installing ICU-level equipment in the new ICU rooms, Siner’s team gained almost one hundred additional critical care beds for COVID patients.
In addition to the obstacles involved in maximizing the beds available for patients, Siner continually worked to resolve issues with PPE availability. “I spent an enormous amount of time on PPE just going around in circles,” Siner said with a resigned chuckle. “There was never enough of it, no matter what you did.” In light of PPE scarcity, providers, nurses especially, used unconventional methods to reuse PPE. For example, they would thumbtack a brown paper bag containing their patient-specific equipment outside the patient room and reuse it over a day. Exposing used PPE to hydrogen peroxide, as long as it did not have lipstick or visible contaminants, additionally allowed the ICU team to reuse equipment. Despite minor solutions, there was no great way to solve the PPE issue, Siner recalls, and looking back, he believes that using polymeric masks more often may have proved more effective.
COVID patients faced severe respiratory distress, a symptom that placed ventilators, in addition to PPE, in high demand. To supply this need, Siner recalls taking an early risk by purchasing sophisticated ventilators without knowing if they were useful for patients and, after finding out they were effective, then “scavenging from outpatient surgical centers…for more monitors.” (When the ICU ran out of typical ventilators, Siner and his team even had to deviate from standard equipment. In a real bind, they even attempted to use operating room ventilators; however, patients generally did not show positive results since these were only intended for short-term use.
Siner’s team instead turned to home ventilators for patients who were improving but still unable to breathe adequately on their own. Having home ventilators—ventilators that were less in demand during the pandemic, however, just as effective—allowed for better distribution of ICU ventilators to critical patients. The in-demand ICU ventilators went to the newer, sicker patients, and the recovering patients were put on the alternative, or less specialized, home ventilators. Purchasing ventilators and deciding to explore new avenues before New Haven was majorly impacted by COVID-19 improved outcomes for most patients who needed assisted breathing. “We never got to the point of saying we’re out of ventilators,” Siner states, “because we planned for backups.”
In addition to resource allocation, Siner’s team implemented personnel systems to manage three times the amount of patients as normal. In this “tiered approach,” core ICU providers needed additional help, so they delegated less expert tasks to hospitalists, doctors responsible for hospital inpatient care, fellows, and physicians in training. Unconventionally, however, Siner’s team let fellows and hospitalists be the “attendings of record”—the on-chart providers most responsible for the care of that patient. Managing personnel in this way avoided “bogging down” specialized physicians with “checkbox” items.
While personnel roles in the hospital shifted during the pandemic, patient-family interactions also greatly changed. Siner recalls initially characterizing equipment and personnel concerns as “primary needs” and slight shifts in communication between providers and patient families as a “secondary need.” Before the pandemic, patients’ families often stayed overnight with full access to the patient’s room, bathroom, and meals at the cafeteria. During rounds, the family had face-to-face contact with the attending physician and additional providers. The pandemic eliminated in-person connection and, in its very early stages, any communication at all. Siner recalled stories of families that did not have a chance to say goodbye to their loved ones who passed away at YNHH and that iPads, Zoom, Alexas, and other forms of telecommunication only quasi-improved the “huge disconnect.” According to Siner, “Once we actually saw the patients, we realized…this is not such a secondary need anymore.”
There were, nevertheless, some positive aspects of electronic methods of communication. Without having to enter a patient’s room, non-intensive care unit attendings (i.e. attendings from other specialties) were able to answer questions on MyChart, YNHH’s online service that allows patients to access and manage their health information, or call family members to deliver information remotely. This greater efficiency—where providers could remain in their offices or at home to interpret charts and call patient families—however, came at the expense of in-person connection.
Siner explained that however important contact between patients and providers may have seemed, healthcare workers took a personal risk each time they entered a patient’s room. Under the ICU’s normal protocol of care, providers deliver CPR when a patient goes into cardiac arrest, or a code blue. COVID-19, which spreads mainly through aerosols from coughing, increases providers’ risk of becoming infected when performing CPR chest compressions on a patient who is not intubated. Providers often felt discomfort when they paused to don PPE before entering a code blue scenario, Siner mentioned. “We’re used to just running in there,” he recalls, “Taking that extra thirty seconds… is not ideal for the patient.”
Siner recalled that during one group code blue, one provider simply did not let PPE hold him back from entering the room quickly to save the patient. According to Siner, another group member said, “I am really proud of you that you went in there…and also totally horrified at the same time.” This altruism additionally came through in the fellows, doctors who have completed medical school and residency training, who were being paid very little to work very difficult, intense ICU shifts. “I don’t think those people were expecting payment,” he acknowledges, “I think a lot of people believed…not doing anything seems a little silly.” Despite Siner’s key argument that laying solid foundations leads to improved patient outcomes, no amount of preparation can completely prevent the risk providers take every time they go to work. That was one they were willing to take.
Not just facing concerns with resource availability and patient care, Dr. Jonathan Siner also hopes that the protocols of care developed by the Yale New Haven Health System Team can “allay a little bit of anxiety,” among the unknowns of the virus and help bridge the knowledge gap between healthcare workers and members of society. On a more personal level, Siner has taken one key management lesson from the pandemic. “As a leader,” he reflects, “I wish I spent more time myself on the units in the ICU and going around Bridgeport and Greenwich hospitals—just to see people. Not every day, but…going down a little earlier on in the pandemic…Sometimes you just need to see people.” Siner serves to demonstrate what type of administrators and healthcare providers embody Yale New Haven Hospital—those who do good, learn, and do better.
Daya Baum is a first-year in Morse College.
Yale Global Health Review 