Allina Health, a large health system headquartered in Minneapolis, serves individuals, families, and communities throughout Minnesota and western Wisconsin. As COVID-19 ravaged other states in early 2020, and cases began to appear in Minnesota, Allina Health wanted to be as prepared as possible for the predicted COVID-19 surge.
In late March, Allina Health assembled a cross-disciplinary team to run COVID-19 analytics. Team members used numerous predictive models (University of Pennsylvania Hospital, Qventus, Sg2, and others), as well as took into consideration what other health systems in the region were predicting. A number of variables were factored into the models, including the impact of social distancing measures in the community and the time it would take to double the number of cases.
In early April, the predictive models indicated the need to substantially expand the capacity of Allina's intensive care unit (ICU) and medical-surgical unit (med-surg) to meet the projected demands.
“Our analytics showed that we would run out of capacity within six to eight weeks,” said Nadia Ayoubzadeh, director of health technology management (HTM) and information services for Allina Health. “At the direction of our executive leaders, we quickly created a surge governance structure where key leaders and teams across the organization would work to increase our ICU capacity by 100% and our med-surg capacity by 50%.”
Five workstreams were part of the governance structure: workforce, supplies, capacity/facilities, medical planning/infection prevention, and technology and medical equipment. The technology and medical equipment workstream then was organized into seven teams: information technology (IT) infrastructure and electronic health record (EHR) build, medical equipment inventory and purchasing, medical equipment site implementation, infusion pump implementation, vent and anesthesia planning, remote monitoring, and virtual care implementation.
The initiative was launched with a planning team meeting that involved experts from HTM, capital and supply procurement, clinical advisors in respiratory therapy/pharmacy/imaging/lab, nursing, homecare advisors, IT advisors, equipment room, infection prevention, safety/quality advisors, and improvement system (internal process improvement team).
“We had a large group touch point every morning and afternoon, as well as working sessions with key areas throughout the day, to move the work forward,” said Ayoubzadeh.
Launching the Plan
The mission was clear: to expand capacity by accomplishing months of work within a matter of weeks. The medical equipment planning workstream had daily connections with all project teams and met three times a week with all five workstreams to provide updates and realign as needed, according to the latest details.
Predictive modeling continued to update the numbers for new COVID-19 admissions that were expected each week. Based on assumptions regarding volumes and length of stay, the team determined the number of beds that would be required each week for the next 12 weeks. The team then could subtract the current number of beds available and determine what additional capacity would be necessary to support the projected volumes.
“Once we knew how many additional beds were needed,” said Ayoubzadeh, “our facilities group worked with each site to determine where we could move to double occupancy or change existing departments, such as postanesthesia care units, to ICU spaces.”
Certain supplies and resources were lacking—facts that were made more obvious as models continued to evolve.
“We quickly identified equipment needs and partnered with our supply chain and capital teams to acquire equipment identified for current deficits,” said Michelle McNeill, a manager of clinical equipment services for Allina Health's East Region. “Personnel and roles throughout the organization were redirected to this work as needs dictated.”
The teams continued to monitor the predictive models and adjust goals to the projections. For example, the mathematical models showed that six to eight weeks out, more ICU slots/beds would be needed to support the projected volumes of COVID-19 cases. Another model predicted a shortfall of nearly 50% of the infusion pump inventory.
“Our existing equipment model was unavailable from the manufacturer, so the available model was vetted and a plan developed with clinical and pharmacy leads to place the new model pump in three of our facilities, allowing pumps and servers from those facilities to be redeployed to remaining sites to meet predictions,” said McNeill. “This deployment was planned for a six-week time frame. In comparison, our last full-organization pump replacement took more than six months.”
Allina Health's Improvement System (AIS) department played a key role in guiding the overall process. Its purpose is to improve, accelerate, and stabilize systemwide performance by anticipating improvement opportunities and enabling performance excellence in care delivery and core processes. AIS provided project management and lean thinking expertise to help maximize quality and efficiency. A major goal for AIS is establishing a “one operating system” across all Allina Health sites.
“On an organizational level, AIS deployed daily tiered huddles to lift up safety issues to support our high-reliability goal and cascade communication up, down, and across Allina Health,” said Ayoubzadeh. “This structure proved invaluable in our ability to communicate and cascade information quickly, on a daily basis, across our 30,000 employees.”
When the community implemented social distancing measures, the COVID-19 curve began to flatten, giving the teams a little extra time to perfect and deploy their plans. Each team's lead coordinator/project manager established milestones for each workstream. These plans were monitored and reported to Allina Health executive leaders twice per week.
“We created dashboards that were used by hospital leadership and executive leadership to understand our daily census, non–COVID-19 and COVID-19 patients, COVID-19 testing, and medical usage pertaining to ventilators and infusion pumps,” said Tami Waalen, HTM operation manager. “This allowed us to open up additional floors/departments to handle the surge and ensure each site had the appropriate medical equipment.”
The following key milestones were established:
Inventory gap analysis in the areas identified as potential surge units. This analysis helped determine equipment that was already present and the additional equipment that would be needed based on ICU, med-surg, and emergency department (ED) recipe cards.
After determining what equipment needed to be purchased, HTM wrote situation, background, assessment, recommendation (SBAR) reports to explain the recommendation to top management for funding approval.
The capital and supply chain teams worked with vendors to order products, which were tracked regularly via order dashboards.
Scheduling for the integration and deployment of health technology, including anesthesia and ventilator equipment, was determined.
HTM worked with site teams to perform the transfer, staging, installation, and configuration of equipment.
Infusion pumps were implemented, which included ordering, tracking, and deploying the devices.
“We were very fortunate to have experienced staff within our system who could oversee these tasks and provide the skills we needed to successfully develop and implement our plan,” said Waalen.
Communicate, Communicate, Communicate
As soon as executive leadership gave its approval, “it was all hands on deck,” said Ayoubzadeh. “This work became full-time jobs for many of us, and even more than that. Some days we worked 12 to 15 hours. The other projects and goals we had been working on were put on hold while we worked nonstop to expand our capacity.”
When things move fast and change quickly, with multiple teams involved, it is almost impossible to maintain top communication.
“Although we were operating at a system level and building plans quickly, the local departments at each site were sometimes not aware of all the plans that were going to be implemented,” said Ayoubzadeh. “Although we worked with our internal communications teams to provide regular updates, the details did not always get to the frontline staff. We solved this during our implementation phase, when we told the story of the work that had happened to date and then gathered their input for specific needs and questions they had at the local department level.”
The marketing department, aided by the Hospital Incident Command System, sent daily emails and updates to all involved leaders and employees. "Implementation leaders sent implementation updates twice per week via email to stakeholders at each site,” added Matt Van Donsel, a clinical engineer at Allina Health.
For projects moving at such high speed, Van Donsel recommends using multiple communication modes. For example, teleconferences and team meetings are useful for engaging cross-functional teams and building consensus. Meanwhile, email is useful for communicating simple status updates, as distribution lists can be easily expanded and stakeholders have time to process the information, which may spark questions or raise relevant concerns.
Communication skills also were essential for purchasing, inventory, and managing the supply chain. SBARs were required to justify purchases through capital/executive leadership for approval.
“We constantly followed up through our supply chain/capital team to see when orders would arrive since there were backlogs on certain items,” said Ayoubzadeh.
Allina Heath invested in more than 1,400 new infusion pumps, 76 new anesthesia machines, and numerous vents, point-of-care ultrasounds, and blood gas analyzers—some through creative negotiations with vendors. Whenever possible, efforts were made to push up capital replacement opportunities that were originally scheduled for 2021.
“For example, we had 76 anesthesia machines that were going to be replaced in a few years,” said Jeff Carroll, west region HTM manager. “We tested the anesthesia machines in the ICU setting and confirmed that they would be a viable choice to be used as ICU ventilators if needed, which we thought was an excellent plan. Capital was approved for 76 new anesthesia machines, and instead of trading in the older machines, we negotiated an agreement with the vendor so that we could return our 76 trade-ins at a later time. Thus, we were able to use all of these machines if they were needed in the ICUs.”
Ventilators are another critical piece of equipment for fighting COVID-19. Because of previous influenza outbreaks, the HTM team had stockpiled more than 20 units of an older ventilator model. Using various technicians, HTM was able to thoroughly test and provide respiratory therapy with an additional stockpile of 17 ventilators that could be moved throughout all the campuses and used at a moment's notice.
“This was extremely impressive because of the age of the equipment and sheer tenacity with which our technicians were able to accomplish this feat,” said Carroll.
HTM also formalized its 3D printing service offering and accelerated vent/EHR integration using new middleware technology. 600 tablets were deployed to emergency departments, ICUs, and patient rooms across the system to keep staff safe and give patients access to their families and friends. Allina Health came up with the idea when they were looking for ways to reduce the number of hospital room visits and save on vital personal protective equipment (PPE), such as masks, gloves, and gowns, and still be able to stay close to patients. A virtual visit with a patient using a tablet greatly reduced risk of exposure to medical staff and eliminated the need to wear and then discard PPE.
“Many hours were spent by IT, AIS, and HTM staff to prepare and deploy the technology needed to make social distance communication possible and safer,” said William Cable, manager of clinical engineering services for Allina Health's North Region.
Making It Happen
Allina Health officially closed out the surge governance structure in mid-June. In about eight weeks, the initiative increased ICU capacity by 100% (an extra 150 beds) and med-surg/ED capacity by 50% (270 beds).
“Since we began this undertaking, Minnesota has done such a great job managing the pandemic that the curve flattened substantially and we have not yet needed that level of capacity,” stated Ayoubzadeh. “That said, we now have the capability to flex since we are still living with the pandemic and things can change as the state opens up more.”
For example, as of late July (when this article was written), COVID-19 cases had been steadily rising in Minnesota. At that time, the state had mandated masks in all closed spaces and it was doubtful whether schools would open in the fall.
Unoccupied ICU capacity also can be used for patients flown in from other areas or states that have exceeded their capacities. “We continue to monitor patient census in the Allina system and across the state; a subset of the planning team has remained engaged to help scale our original plans to meet the current need,” explained Van Donsel. “If a large surge begins to occur, we remain ready to add capacity as needed.”
Ayoubzadeh said that the following five attributes were needed to accomplish this ambitious goal in such a short timeline:
Unity of vision and the ability to see the big picture
Collaboration across the system
Commitment to our mission to care for the community
Dedication of every member of the team to achieving our goals
Leveraging talents and strengths to succeed together
“By honoring the diversity of perspectives, talents, and voices in driving toward a common goal, we accomplished a massive project, which would normally take six to 12 months to complete, in eight weeks,” said Ayoubzadeh. “The speed and quality of the work is a testament to the commitment and dedication of the team to put the community well-being before their own comforts.”
“By honoring the diversity of perspectives, talents, and voices in driving toward a common goal, we accomplished a massive project, which would normally take six to 12 months to complete, in eight weeks.”
—Nadia Ayoubzadeh, director of HTM and information services for Allina Health
Mark Crawford is a science/technology writer based in New Mexico and Wisconsin. Contact him at firstname.lastname@example.org.