In the face of a crushing surge of cases that halted elective surgeries, strained resources, and threatened to overwhelm staff, Brigham and Women's Hospital in Boston acted quickly to transform its facility into one of the most efficient and successful COVID-19 programs in the country. Much has changed since the days when its staff had to carefully reuse PPE as it managed an ICU capacity of more than twice its usual number of patients. In early March 2021, Brigham and Women's achieved a 70% vaccination rate among staff and a growing campaign to help educate and vaccinate the community.
Riding the bumps
As COVID-19 gripped the nation in early 2020, the staff at Brigham and Women's began the tenuous work of developing its own strategy for containing the pandemic. The hospital experienced a surge that peaked in late April. According to James P. Rathmell, MD, Executive Editor of Anesthesiology, and Professor and Chair, Department of Anesthesiology, Perioperative and Pain Medicine at Brigham and Women's Hospital, “We went from questioning what we should do with elective surgery on a Friday to completely closing down elective surgery on a Monday, staffing up ICUs, and reducing to 30% of our overall surgical volume very quickly.” The hospital's ICU capacity jumped to more than twice its usual patient volume as the COVID-19 surge went on, requiring the hospital's anesthesiology team to care for a high number of very sick patients with limited PPE resources.
With a growing number of critically ill patients and very little information on the disease, the hospital deployed its emergency response team. Dr. Rathmell explained that they adopted the same hospital incident command structure that would be used for a natural emergency or terrorism situation. A pre-determined hierarchy with an emergency medicine physician as the hospital commander worked quickly to coordinate staff to serve in various roles by redistributing staff from their usual positions into roles that were more critical at the time.
Within a matter of days, the anesthesiologists with intensive care experience were redeployed to open additional units while a COVID response team joined in a daily conference to plan shifts and ICU coverage, line and intubation teams, and telemedicine, which grew rapidly. Dr. Rathmell said a large number of recent graduates and young faculty members familiar with working in ICUs volunteered to help.
Despite the robust staffing, it became obvious in the first few weeks of the April 2020 surge that critical care teams were overworked, so the hospital created three different intubation and line placement teams to work around the clock, allowing critical care teams with a usual load of 8-10 patients to safely care for 15-20 patients in the same period of time. In addition, transport teams relieved respiratory therapists who were overwhelmed with the number of ventilators in use and could no longer move patients to imaging.
A new approach
As the months went on, clinicians at Brigham and Women's became so well-versed at treating COVID-19 patients that when a second surge took hold of the community in December 2020, the ICUs weren't overwhelmed and, in general, patients weren't as sick. By this time, Dr. Rathmell said the hospital's approach to treatment had changed. “We learned with the rest of the world that early intubation was not the best approach and instead found that people are much more comfortable with using medicines such as dexamethasone early,” he explained.
Late in the year, Brigham and Women's COVID-19 program was operating with relative ease. What was once a dramatic shortage of PPE had grown to a healthy supply of resources. Elective surgery returned with some restrictions: patients required a negative COVID-19 test within 48 hours of the surgery and cases were restricted to those that did not require a hospital stay unless postponement would result in probable harm to the patient. Perhaps most important, Brigham and Women's worked closely with other Boston-area hospitals to serve as a transfer destination for other locations that were hit asymmetrically and overwhelmed with patients. Dr. Rathmell explained that comparing notes during the second wave with other hospitals in the health system helped ensure that one location was never overwhelmed by inpatient capacity.
“What was once a dramatic shortage of PPE had grown to a healthy supply of resources.”
Over the last year of battling COVID-19, one thing has remained constant: the partnership between Brigham and Women's and the Boston community. “Masks were donated early on,” said Dr. Rathmell. “And increased production of N95 has allowed us to now have 90 days of supplies in storage with a robust stockpile of masks, gloves, and surgical gowns.” In addition, an outpouring of support from the community allowed the hospital staff to enjoy meals and coffee from local restaurants twice a day for months on end.
In return, the clinicians at Brigham and Women's worked harder than ever to reach out to the community and provide guidance in a time of fear and uncertainty. “People were frightened of coming to the hospital and emergency room, so we stood up mobile testing facilities that went into the community and tested people where they lived,” Dr. Rathmell said. “We are working hard to get out into the community to answer questions and reduce hesitancy to take the vaccine so the people of Boston can take advantage of resources such as the mass vaccination site at Gillette Stadium, which can vaccinate as many as 6,000 people a day.”
Though the care of COVID-19 patients has stabilized at Brigham and Women's hospital, questions linger about the emergence of disease variants from around the world, such as: Are they more infectious? Are they more deadly? Will the vaccine protect against them? As a slow return to normal lingers on the horizon, with a vaccine promising fewer patients and less severe cases, optimism burns strong. “Like many others,” said Dr. Rathmell, “I have some measure of hope that we will find our way through this.”