Amid the current Delta variant surge, the COVID-19 pandemic has posed unprecedented challenges for health care organizations. No level of planning or preparation could fully inform the scale, longevity or level of impact the virus would have on our organizations, communities and nation. During the last 18 months, hospitals have demonstrated agility and resiliency as new challenges arose throughout the response. As case levels stabilized in spring 2021, hospital operations shifted to monitoring and managing COVID-19 in the long term, to include outbreaks. The Missouri Hospital Association compiled this summative report to share best practices, assist member organizations with assessment and improvement activities, and memorialize all that the state’s hospitals have accomplished during this historic response.
Building on the mid-response assessment published in September 2020, this report follows the chronological progression of the COVID-19 pandemic in Missouri, highlighting key clinical and operational areas of incident management, data collection and analytics, disease surveillance, clinical treatment, health care system surge, vaccine administration, the emergence of variants, and reopening, despite continued outbreaks.
Within each section is a timeline highlighting key events, along with a member hospital spotlight to illustrate varied perspectives and approaches to a given issue. Data insights published throughout the response by MHA and the Hospital Industry Data Institute are included to memorialize key “moments in time” through the surge, vaccination and recovery phases. Finally, the report includes aggregate data from MHA’s annual safety and preparedness program assessment. This assessment, completed in April 2021 by 112 member hospitals, helps inform this publication, future statewide programming and member technical assistance.
A downloadable PDF with complete information, including timelines, graphs and member spotlights, is available.
“COVID-19, while an immense challenge, continues to demonstrate the flexibility and agility built into our organizations, and is prompting many of us to forge stronger and tighter relations with others who serve our communities. With a crisis that is reaching across multiple domains — health care providers, public health and government at all levels — I am proud to note that hospitals’ local leadership remains paramount in response and recovery. I believe that many of us are excited to be ‘better together’ as we leverage those strengthened community and regional relationships to move forward and address future challenges.”
— Jon D. Doolittle, Regional President,
Mosaic Medical Center – Albany
Chair of the MHA Board of Trustees
As hospitals continue to navigate the pandemic, it is important to reflect on all that has been accomplished in Missouri’s hospitals thus far. Doing so will provide a shared sense of achievement, create opportunities to identify areas for improvement and allow for an appropriate strategic vision as organizations move forward through this response.
“The stage for COVID-19 is global, but all response continues to be local. This certainly includes health care providers and public health, but it extends well beyond. Nontraditional partnerships are necessary — including engagement with chambers of commerce from the local to the state level — to first help reduce transmission of the virus and now encourage vaccination. Within the state’s hospitals — through countless acts of compassion and care — every team member continues to play an essential role. The reflections shared here inform our continued response to COVID-19 and future emergencies. However, they also remind us that, despite the difficulty, our mission matters.”
— Herb B. Kuhn, President and CEO,
Missouri Hospital Association
Hospitals activated their emergency operations plan and incident management structures early in the COVID-19 response to identify and effectively communicate response initiatives, monitor resources, and proactively plan for future priorities. In July 2020, 91% of survey respondents reported activating their EOP at the onset of the COVID-19 response. At the time of the survey, 84% still were activated. In April 2021, 63% of respondents reported active incident command structures.
In addition to incident management coordination, EOP activation documents a hospital’s incident response timeline, and supports the application and use of many waivers that were implemented to streamline health care operations and allow for expanded patient care capacity during the pandemic.
As demobilization and evaluation of incident management began, early lessons learned reinforced the need for breadth and depth among executive, clinical and operational leaders to be engaged in emergency preparedness and continuity of operations planning. This ensures a comprehensive “bench” is available to address future incidents that require an organizationwide response.
DATA & ANALYTICS
COVID-19 has proven to be a data-driven response. Beginning in January 2020 as the virus began to spread across Asia and Europe, public health and health care leaders monitored the doubling rate of the then-named novel Coronavirus, as well as the associated ventilated patient and death rates, to project global impact and potential patient surge into the health care delivery system. A key success of Missouri’s response was the collaboration fostered among public and private partners to collect, analyze and deploy data to decision-makers and the public.
On April 6, 2020, MHA formally submitted a request to the DHSS Office of General Counsel to consider waiving state statutes and regulations (sections 192.067 and 192.667, RSMo., and 19 CSR 10-33.010 and 19 CSR 20-20.020), to permit the sharing of critical pandemic response and syndromic surveillance data under the public health emergency declaration issued by Gov. Parson. With these requested waivers executed and appropriate legal agreements signed, HIDI began receiving daily syndromic surveillance and case reporting feeds directly from the state. These data and the integration of MHA and HIDI staff into the COVID-19 Analytics Cell led to the immediate task of helping develop what would become the Local Epidemiological Modeling for Management and Action, or LEMMA model, that the state would use to estimate regional effective reproductive rates and forecasted demand for hospital-level care across the state. After 16 months and 700,000 cases, HIDI has ingested and synthesized nearly 700 gigabytes of near real-time data from DHSS, HHS and Washington University on cases, hospitalizations, testing, deaths, chief emergency room complaints, effective reproductive rates and vaccine administration into 432 consecutive days of refreshed intelligence on the state of COVID-19 in Missouri between March 2020 and June 2021.
As we look forward, opportunities remain to strengthen data interoperability within Missouri and across the nation. Limitations in the various data sources used to guide the state and federal response, and the lack of interoperability underlying these systems, became apparent early on and have persisted throughout the response. Strengthening the interoperability between hospital electronic medical record systems (including staffing and inventory modules) and public health systems would prevent data generation burden during public health emergencies and bolster the validity of reported information to inform accurately targeted responses.
Testing for COVID-19 was an essential and cornerstone component of the pandemic response to identify, mitigate and control the spread of the virus. Early in 2020, access to testing supplies and laboratory equipment was one of the most commonly identified challenges throughout Missouri and the nation. As the testing supply chain opened and health care providers secured localized laboratory capability, COVID-19 testing became routinized — much in part due to the cross-functional teams that health care providers deployed to identify solutions. Successful testing strategies required engagement of hospital laboratories to update or acquire appropriate tools and equipment, materials and supply chain management to secure adequate supplies such as swabs and viral transport media, clinical and operational leads to develop and deploy testing sites, and data analysts to aggregate and distribute test results in a timely manner. These activities occurred concurrent to PPE shortages, preparation for COVID-19 patient surge and managing normal health care operations.
In June 2021, the FDA reported that 384 COVID-19 tests and sample collection devices were available for use under EUA. Testing types and collection methods have expanded to include nasal pharyngeal, saliva and blood tests, and at-home kits that can be submitted by mail.
When COVID-19 emerged and spread in early 2020, little was known about specific patient treatments. Clinicians had to quickly learn about the disease’s impact on the body, as well as evolving treatment options. Clinical guidelines quickly changed as the medical community and researchers learned more about the underlying pathology and clinical presentation of COVID-19. Many early treatments built upon clinical knowledge, treatments and research of other novel coronavirus outbreaks, such as SARS and MERS. In May 2020, remdesivir received EUA approval for the treatment of hospitalized COVID-19 patients. In November 2020, the first monoclonal antibody treatment, bamlanivimab, was approved for nonhospitalized patients. Both therapies initially were limited in supply, and federal allocation was controlled by the state. As a result, not only did hospitals have to keep up with changing clinical guidelines and treatments, but they also had to navigate the allocation process and determine which patients would benefit the most from the treatment options.
Many hospitals in Missouri developed innovative strategies and redesigned spaces to deliver outpatient intravenous monoclonal antibody treatments. Additional treatments were approved under EUA, and science is being conducted at an unprecedented speed with frequent emerging data and updated guidance.
Clinicians also have been faced with the emergence of “COVID-19 long-haul patients.” These patients recover from the acute phase of the disease and no longer test positive for infection, but they continue to experience chronic symptoms for weeks or months following original infection. Going forward, clinicians are faced with determining best practices and treatments for long-haul patients and those with acute COVID-19 infections as the medical community continues to learn more about the impacts from COVID-19.
While a lagging indicator, COVID-19 hospitalizations provided critical insight into the severity of the disease, as well as the impact of transmission at the regional and state level. Monitoring and communicating COVID-19 impact to the health care system provided a necessary perspective to both patients and policymakers.
Locally, hospital leaders across organizations worked proactively, many before receiving their first COVID-19 patient, to expand their surge capacity. Hospitals reported capacity expansions to treat COVID-19 patients throughout the response.
Missouri hospitals played an early and influential role in administering the COVID-19 vaccine, one of the most powerful tools in our fight against the disease. Before the approval of COVID-19 vaccines, hospitals engaged in vaccination plan development to ensure quick administration once vaccine was available in Missouri. Following approval of the first COVID-19 vaccine in December 2020, hospitals were among the first vaccinators in the state to receive vaccine and immediately began vaccinating the state’s front-line health care workers.
Vaccine administration occurred simultaneously with hospitals continuing to provide essential services and managing the peak of hospitalized patients during the pandemic. As additional groups became eligible to receive vaccines, hospitals continued to play an integral part in vaccine administration, and many implemented strategies to identify the most vulnerable patients to ensure responsible use of a scarce resource. Hospitals deployed both in-house clinics and mass vaccination events. Additionally, hospitals provided ongoing medical staff and logistical support to the state’s regional mass vaccination events.
As vaccine administration models shifted from mass vaccination efforts to offering convenience, hospitals continued to create vaccine opportunities for patients through administration during ED visits, before inpatient discharge, and in clinic settings. To date, Missouri hospitals have administered more than 2,093,742 doses of vaccine, which accounts for 37.6% of vaccines administered in Missouri. This highlights the role Missouri hospitals have played throughout this pandemic, as they represent the provider group with the largest number of vaccinations administered.
The emergence of COVID-19 variants has a profound effect on a wide variety of COVID-19 response activities, from clinical treatment to vaccination efforts. Mutations to SARS-CoV-2, the virus that causes COVID-19, have the potential to create variants that are more contagious, cause more severe disease, and are more resistant to treatment or vaccination. The first variant of concern, Alpha (B.1.1.7), was detected in the U.S. in December 2020, and in Missouri in February 2021. Additional variants continue to be detected, including the Delta variant (B.1.617.2), which has been linked to recent outbreaks in all of Missouri’s regions. Current and future variants pose the threat of new surges in cases and hospitalizations, especially among unvaccinated individuals.
As the response to the pandemic continues, hospitals continue to monitor the impact of, and response to, current and new variants.
REOPENING, EVALUATION & NEXT STEPS
Several indicators throughout spring 2021 demonstrated the state’s early emergence from the acute COVID-19 response. Examples include expanding vaccination supply, eligibility and acceptance, declining case rates, suspension of the Fusion Cell, and the CDC’s relaxed masking guidance for vaccinated individuals. Despite these positive signals, hospitals continue to manage a difficult return to “normal” operations given regional outbreaks of COVID-19 variants and resulting hospitalizations.
To aid hospitals with appropriate guidance and technical assistance to support the transition to a new, post-COVID-19 operations model, MHA staff conducted varying methods of member outreach to inform next steps. A listening session during the spring 2021 district council meetings identified key themes related to organizational agility, staff resiliency and stronger relationships with local public health agencies despite a fragile and underfunded infrastructure. Hospital clinical leaders identified the execution of new delivery models — such as testing, surge capacity expansion and the use of telehealth — as best practices to sustain moving forward. Rapidly changing guidance was the most common challenge among clinicians.
Despite the resurgence of COVID-19 cases with the Delta variant, hospital staff recognize the necessity of continued improvement to refine their current and ongoing response activities. Eighteen months into this pandemic, evaluation of hospital planning, response, and resiliency thus far demonstrates the commitment of health care workers to serve their communities. As the pandemic surges on, the following areas must guide future planning and advocacy.
- Changing regulatory landscape in response to COVID-19 lessons learned
- Strategies to enhance supply chain integrity
- Sustaining the demonstrated agility of clinical care teams
- Evaluate continuity of operations for the environment of care/physical environment
- Refine a statewide emergency response data strategy to align with federal directives
- Staff resiliency and mental health resources to support the health care workforce
Many of the effects of the COVID-19 pandemic are yet to be seen — from the impact on future health care operations to COVID-19 “long-haul patients” and long-term impacts on mental health due to prolonged social isolation and disruption to daily life. In the immediate, MHA remains positioned to continue navigating the current environment for Missouri hospitals to address continued case growth, hospitalization surges, ongoing regulatory expectations from CMS, and new proposed rules by the Occupational Health and Safety Administration.
Gatz, J., Reidhead, M. & Porth, L. (2021, August). Missouri’s COVID-19 Response: A Clinical and Operational Reflection for Missouri Hospitals. Missouri Hospital Association. Available at www.mhanet.com
This publication was supported, in part, with funds from the U.S. Department of Health and Human Services, Assistant Secretary of Preparedness and Response Hospital Association COVID-19 Preparedness and Response Cooperative Agreement, CDFA 93.889.