Hospitals in Wuhan, Hubei, China, experienced a rapid influx of patients presenting with symptoms of severe pneumonia in December 2019; those symptoms included fever, malaise, dry cough, shortness of breath, and respiratory distress. Many of the patients had demonstrated links to the Huanan Seafood Wholesale Market in Wuhan, suggesting an animal reservoir. Respiratory samples were sent to reference laboratories, and the World Health Organization (WHO) was notified of the outbreak on December 31, 2019. The market was closed the following day. As the number of cases increased over the days that followed, many of the patients had no exposure to the market, suggesting person-to-person transmission. Phylogenetic analysis later revealed that the respiratory virus was SARS-CoV-2 (COVID-19), a new strain of coronavirus distinct from SARS-CoV and MERS-CoV.1,2 Early estimates of the basic reproduction number varied between 2.2 and 3.58.3

Related

The State of Ohio declared COVID-19 to be a reportable disease on January 23, 2020. On January 30, 2020, the WHO declared the disease to be a global pandemic. On February 28, 2020, the Ohio Department of Health (ODH) distributed a COVID-19 prevention and preparedness plan to public health organizations and stakeholders. That same day, the Central Ohio Trauma System (COTS) activated the Healthcare Incident Liaison (HIL) system to the 36 counties it serves as the Health Care Coalition (HCC) in Central (Region 4), Southeast Central (Region 7) and Southeast Ohio (Region 8) for the Assistant Secretary for Preparedness and Response’s (ASPR) Hospital Preparedness Program (HPP). The governor combined these regions for the Pandemic Response into Zone 2, and named the Chief Clinical Officer for The Ohio State University Wexner Medical Center as the lead liaison to the state (Figure 1).

Figure 1: COTS Regions/Zone 2 (All tables and graphics provided by the authors.)

The HIL serves to collect and collate regional health information, situational awareness, assists with regional resource allocation and monitoring of healthcare system performance and capacity around the clock. The COTS HIL operates within an Incident Command System (ICS) structure and deploys regional medical assets during emergencies. COTS established the HIL to support Central and SE/SEC Ohio hospitals, coalition members and partnering agencies in the event of a disaster, regardless of its scale. The COTS HIL operates within an Incident Command System (ICS) structure and is able to deploy regional medical assets during emergencies. The COTS HIL is recognized as an integral component of city, county, regional, and state emergency response planning and is seated at the Franklin County Emergency Operations Center under ESF #8- Pubic Health and Medical Services.

COTS was established in 1998 by the Central Oho Health Care Systems to help organize and coordinate trauma care, emergency care, and disaster planning and coordination. Across the regions, COTS serves two adult Level 1 trauma centers, one pediatric Level 1 trauma center, two Level 2 trauma centers, three Level 3 trauma centers, 55 acute care hospitals, free-standing emergency departments and alternative care sites, and 34 public and private emergency medical service (EMS) agencies. Four large health systems provide care in central Ohio, OhioHealth, The Ohio State University Wexner Medical Center, Mount Carmel Health System, and Nationwide Children’s Hospital. Each health system prepares, maintains and evaluates surge plans as a component of the HPP cooperative agreement, and COVID-19 patient census forecasts were made available as part of the State effort to prepare the region for the pandemic.

The decision to establish a joint Alternate Care Site (ACS) at the Greater Columbus Convention Center (GCCC) was made by the chief executive officers (CEO) and the chief medical/clinical officers (CMO/CCO) of the four Franklin County health systems and supported by the Public Health Commissioners of the Cities of Columbus and Worthington and Franklin County. This collaboration allowed the three adult health systems to expand their capacity in response to a surge of COVID-19 patients in Zone 2. Although the pediatric hospital did not anticipate the need to surge their patient population into an ACS, they supported the effort and pledged to participate should the need arise.

Context

While the pivotal role of hospitals during times of sudden, unexpected increases in demand have been recognized by the American Hospital Association (AHA) since 1956, hospital preparedness efforts in the United States redoubled in the wake of the terrorist attacks of September 11, 2001.Hospital preparedness plans developed in coordination with ASPR address the need for hospitals to possess the ability to provide additional resources and staff to accommodate rising waves of patients to minimize morbidity and mortality.4 Key to this ability is the concept of hospital surge capacity, which has been defined as the ability of a hospital to expand rapidly and augment S4 (staff, stuff, space and system) and to manage patients who require specialized interventions.5 While ACS development considerations have been addressed in the research literature,6,7 additional considerations are provided through ASPR in its Federal ACS Toolkit, 2nd Ed.8

Federal guidance provides three ACS models that differ on the basis of eight variables. An ACS that follows the non-acute care model is developed for the purpose of increasing beds, requires minimal structural alteration, and provided ambulatory care and minor acuity care through emergency and mid-level providers. It can be made operational in days, and represents the lowest-cost ACS option. An ACS that follows the hospital care model requires additional resources. The purpose of the hospital care model is to increase beds and ventilators, and provides medical-surgical care. For this reason it may require structural alterations to existing facilities, and can be built at a moderate cost. The acute care model provides step-down care and intensive care unit (ICU) care to patients by ICU and critical care providers, requires significant structural alteration and can be operational in weeks at a much higher cost.

Planning

On March 23, 2020, COTS hosted the initial ACS planning meeting with system level CEOs, CMO/CCOs, and their emergency preparedness directors, city and county public health commissioners, the Franklin County Emergency Management and Homeland Security (FCEM&HS) Director, and the President of the Central Ohio Hospital Council (COHC) to review regional surge plans, identify an ACS option and choose an ACS leadership team. The non-acute care model was chosen on the basis of the health systems’ hospital conventional, contingency and crisis level preparedness plans and COVID-19 patient forecasts. The GCCC was chosen as the option best able to meet the needs as an overflow site for COVID-19 patients from the hospital systems based on its size, central location, proximity to major interstates and hotels, and its extensive history of managing large-scale events.

The Central Ohio Trauma System (COTS) hired a contractor to coordinate the establishment of the ACS and development of the continuity of operations plan (CONOPS). The ACS leadership team included executive leadership from COTS, the three adult health systems, FCEM&HS, COHC, the contracted coordinator, and the Ohio National Guard (ONG). The ACS leadership team toured the GCCC between March 25-27 with the help of ONG and its Army Core of Engineers to assess it for fit.  The decision to approve the GCCC as the regional ACS was made on March 30 and CEOs from the three health systems chose an ACS site administrator (SA) to participate on the ACS leadership team. 

Over the course of the next two weeks, the ACS leadership team met daily to develop the CONOPS plan and advise work teams needed for operationalization. COTS submitted a written request to the FCEM&HS to establish the ACS. A memorandum of understanding (MOU) was executed between the GCCC and the Franklin County Commissioners for use of the GCCC as a temporary hospital for a 30-day period, and they agreed to assume the cost of this operation up to a maximum of $5 million. Zero-cost license agreements were signed by the GCCC and the three health systems. The GCCC was registered as a temporary hospital with the Ohio Department of Health including clinical laboratory improvements amendments (CLIA) and other regulatory filings. 

The ACS could be initiated at the GCCC when a health system exceeded its contingency plan for increasing functionally equivalent patient space due to the increased surge. Only low acuity, convalescing COVID+ inpatients in one of the adult tertiary Franklin County hospitals were eligible for transfer to the ACS. No direct admits, EMS scene transports, walk-ins, or patients younger than 16 years of age would be accepted at the ACS. The ACS could be fully operational within 72 hours of the determination to activate. Each health system established its own organizational triggers for determining when they exceeded surge capacity and timing guidelines for transfer of patients to the ACS. Day one of the 30-day ACS contract would begin upon initial activation. The first hospital requiring expansion to the ACS because of exceeding its in-hospital capacity, would contact the COTS HIL to activate the ACS.

Figure 2: Alert, Notification, and Authority to Activate the ACS

The ACS hospital would be established on the floor of the GCCC (373 thousand sq. ft.) and divided into three separate halls for a total of 1,195 available patient beds (see Figure 3). 

Figure 3: Patient Room Setup

A fourth hall was available, if necessary. A site administrator would be responsible for logistical oversight including situational awareness and information sharing and collaboration with GCCC management and the FCEM&HS without encumbering independent business decision making of any one health system. Each health system would operate its system Hospital Incident Command Structure (HICS) per normal procedures. There would be no separate HICS structure established at the ACS. Communications were streamlined (see Figure 4).

Figure 4: Communication Structure for ACS Oversight

Twenty-two workgroups of subject-matter experts designated by the ACS leadership team, along with the GCCC management team, collaborated daily to coordinate every aspect of logistics and operations within the ACS. Each health system would maintain their own separate and distinct business operations, organizational policies and clinical procedures within their hall. This included electronic medical records (EMR) and associated mobile devices, revenue cycle functions, dietetic services, environmental services, internal hall security and staffing resources. Shared services included staff meals, laundry, hazardous waste, infection prevention and control surveillance, advanced site security, and six short-term ICU beds in the OhioHealth Hall.

The temporary ICU beds would be used for treatment, stabilization and transfer for a two-hour period of time and be managed by the staff of the hospital whose patient deteriorated. OhioHealth supplied the ICU equipment. The managing on-site physician would determine mode of transport and destination. Patient flow into and out of the ACS would be managed by a joint 24/7 transfer center for medical care (see Figure 5). Patient discharges from the ACS to home would be managed by each health system’s case management team.    

Figure 5: Multi Health Center Triage Flow

The FCEM&HS Director would serve as the intermediary for the (MOU) with the GCCC and the Franklin County Commissioners and would interface with the GCCC staff for logistical build out and demobilization, with the Ohio National Guard and the first responders for building code assessment, site security and traffic flow recommendations. The GCCC staff were responsible for information technology infrastructure, electric and power, water and handwashing/sanitizer stations, buildout of patient rooms, logistics and security for docks and parking, patient and staff food services, and environmental services and waste management outside of patient hall areas.  

Seventy-two hours prior to the 30-day end of lease use of the GCCC as a temporary hospital, a joint decision between the three-health system’s incident command, the site administrator, and GCCC general management would be required to determine if a week-to-week extension is needed. This decision would be based on patient census in the ACS and current census in the region. When a system has returned to their routine level of care (conventional) and anticipated surge levels into the tertiary facilities can be accommodated, the FCEM&HS director would deactivate the GCCC. Any remaining patients requiring in-hospital care would be transferred back to the originating facility. Patients able to be discharged home will have arrangements made by system case managers. All supplies and equipment must be off the premises within 72-hours of the announcement to deactivate.

Results

The GCCC infrastructure, electricity, auxiliary generators, plumbing, internet cable, individual command centers, nurse call systems, patient dividers, and cots were stood up by April 8, 2020, nine days after the decision to implement was made. The three adult health systems committed to equip and staff with 72-hours’ notice. One of the authors of this paper was designated as the GCCC ACS spokesperson and fielded multiple interviews to keep the community informed. COTS tracked daily regional census to inform the leadership team of hospital capacity (see Figure 6). 

Figure 6: Zone 2 Adult Med/Surg Bed Availability

The three adult health systems’ call centers established a single portal for COVID-19 destination and triage, with a single call center staffed around the clock by trained nurses and an on-call physician. This team met daily to track COVID-19 hospital census, which peaked at 356 patients on May 7 and has declined since (see Figure 7). These two measures were used by leadership to identify the need for activation or deactivation.

Figure 7: Zone 2 COVID-19 Inpatient Census April 6 – May 18

On May 18,2020, the GCCC Leadership Team decided on a schedule for deactivation. The auxiliary generator cabling was left in place, but the leased generators were released to be returned if needed with 96 hours’ notice, and the hospital systems retrieved their equipment. The leased patient dividers were returned on June 8, and the infrastructure and cots (which were purchased by the State of Ohio) were left in place due to the no-notice protesting occurring at the time of this writing.

The total cost of GCCC ACS stand up and stand down was $2,379,569 ($1,991 per bed). Table 1 provides a breakdown for cost. The in-kind costs of leadership, Ohio National Guard, the Emergency Management Agency, and volunteers to set up and tear down are not included. The costs to hospitals once activated would be borne by patient revenue.

Table 1: Alternative Care Site Stand-up Costs

Discussion

COTS and its members have a long and successful record of cooperating for the public good. The culture of trust developed from years of collaboration on trauma, time sensitive emergencies, and disaster preparedness, response, and recovery allowed the GCCC ACS to happen quickly and efficiently. If this process of collaboration happened de novo, it would have been difficult to achieve these results.

The decision to operate a single space (GCCC) with each health system maintaining their own EMR, pharmacy, nursing and billing infrastructure saved precious time and effort. Naming a single site lead expedited joint decision making. Finally, the County’s willingness to cover the cost of facilities, equipment rental and purchase, and stand up and teardown costs assured rapid standup.

The governor’s decision to cancel the Arnold Sports Festival, close major venues, ask hospitals to defer elective admissions and surgeries allowed the health systems the time to prepare. This leadership and support continued throughout the course of this timeline. The early deployment of the Ohio National Guard provided immeasurable logistic guidance and support. They were instrumental in providing guidance on the initial site assessment, and traffic and security guidance. The FCEM&HS took responsibility for logistics, contracting, leasing and purchasing, standup and stand down. Finally, Franklin County quickly made the decision to bear the cost (up to $5,000,000), which eliminated the concern for financing. All of these processes allowed the GCCC to be stood up in record time and at a favorable cost.

While the total cost of GCCC ACS stand up and stand down was $2,379,569 ($1,991 per bed), other states and cities that chose convention centers as ACS were associated with substantially higher costs (see Table 2). For example, New York developed an ACS at the Javits Center for 1,900 beds (maximum beds under contract) at a cost of $11,364,953 ($5,982 per bed). Chicago stood up an ACS at McCormick Place for 3,000 beds at a cost of $65,526,533 ($21,842 per bed). Detroit developed an ACS with 1,000 beds at the TCF Center for $9,452,813 ($9,453 per bed) (Table 2).9 Many of the facilities will be retained for a possible second wave; others might be repurposed as testing sites or recovery centers.10

Table 2: Comparative Cost of Alternative Care Site Stand Up

Lessons Learned

As a result of the collaborative effort, a number of lessons were learned by COTS and the four health care systems of Central Ohio. First, rapid response requires an established culture of inter-facility trust and a track record of collaboration. Appropriate responses to pandemics require years of planning, partnerships and well-coordinated exercises. Second, combining multiple hospitals as one is difficult; but collaborating on a shared space with separate allocations of a standard field hospital in a single space is fast and efficient. Shared space requires an overarching lead administrator who adjudicates conflicts and assures facility issues are addressed timely. A single, shared facility provides economies of scale and avoids duplication.

The Ohio National Guard and FCEM&HS can bring critical logistic help and advice to the standup of an ACS. Having the assistance of a lead governmental agency partner augments the resources of a state National Guard and county emergency management and homeland security agency. These groups work best when guided by an effective and transformative leadership team. That leadership team and its supporting teams need to meet daily with the authority to address issues and make decisions in a timely manner; a single coordinating body and staff ensures the process keeps moving. In this context, elected leaders are kept in constant communication to ensure that the process does not become political and data is available to provide accountability to the public. Lastly, public relations and media relations should be a coordinated effort with a single, trusted spokesperson to speak from a position of professional authority. Having doctors lead the regional and state effort to address the needs of the public during a pandemic provides assurance to the public that the appropriate steps are being taken to address the health needs of the community.

Conclusion

While the speed of the outbreak in Wuhan, Hubei, China, overwhelmed local government hospital capacity and forced health care providers to establish mobile field hospitals,10 the HCC serving ASPR HPP regions 4, 7, and 8 (Zone 2) were able to adapt their hospital preparedness plans with advanced warning provided by the WHO and the Ohio Department of Health. In accordance with best practices, the ACS was coordinated by the regional HCC in collaboration with health care stakeholders across 36 counties to provide a regional response to the pandemic at a prudent cost.11  

A clear limitation of our experience is that the surge of COVID-19 patients in ASPR HPP regions 4, 7, and 8 (Zone 2) was able to be addressed without the need of member hospitals to trigger the ASC due to the prevention and mitigation interventions imposed by the state including the classical non-pharmaceutical public health interventions to control infectious disease outbreaks isolation and quarantine, social distancing, and community containment. Future research should be directed towards the collection and collation of regional ASC plan development and after-action reports to identify the most effective and efficient ways of providing care during pandemics.

Acknowledgments

Central Ohio Trauma System Staff

Central, Southeast Central and Southeast Healthcare Coalition Members, Central Ohio System Leaders and staff, Franklin County Emergency Management and Homeland Security, the Franklin County Commissioners, City of Columbus leadership, the Ohio National Guard, the Central Ohio Hospital Council, the GCCC leadership and staff, and the Governor of the State Ohio Leadership team, and Public Health (State, County and City). Finally, we wish to thank Andrew Thomas, M.D., Chief Clinical Officer of The Ohio State University Wexner Medical Center for Figure 7 and Olivia Ann Gascon for the production of Figures 2, 4, and 5.

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