Arizona develops surge line for load-balancing COVID-19 cases
As Arizona began preparing for an anticipated surge of COVID-19 patients, the state realized that coordination between hospitals to balance patient loads and provide access to high-demand resources such as ventilators was only occurring among a few health systems in the Phoenix and Tucson areas.
This left out large portions of the state, especially in rural northern communities – which include an Indian Health Services area – that would likely be inundated with COVID-19 patients. This scenario would have forced physicians and their teams in these areas to call numerous health systems in hopes of finding the right level of care for patients when they needed it most, which would not have been an ideal situation.
Officials from the Arizona Department of Health Services (ADHS) recognized that a statewide patient load-balancing system could ensure that no hospital would be overwhelmed with COVID-19 patients while others had empty beds – whether those hospitals were across town from each other or in distant parts of the state.
Ideally, the state wanted to create a statewide hub with one central hotline that any Arizona hospital could call to access the right level of care for patients with suspected or confirmed COVID-19. To do this, technology was also needed that could provide real-time visibility into bed capacity and specialist and ventilator availability across the state’s 100-plus hospitals. This was a significant undertaking, given that a statewide hub like this had never been attempted before.
"In Phase 1, we are concentrating on triaging the highest-acuity patients to critical care units."
Charley Larsen, RN, Arizona Department of Health Services
“After speaking with ADHS, they requested that I temporarily step aside from my duties as senior director of Banner Health Transfer Services to lead this initiative and help implement the workflows and the information technology tools to manage COVID-19 patient flow across the state,” said Charley Larsen, RN, senior director of Banner Health Transfer Services, who also is serving in a temporary role as RN program director for the COVID-19 response team at the Arizona Department of Health Services. “Banner generously enabled me to do this, and has given my time and expertise to the initiative as an in-kind donation.”
Eighteen months ago, Banner Health engaged with vendor Central Logic to improve the transfer process. Included in this work was the consolidation of several transfer centers located in Arizona down to two, as well as the establishment of a new transfer center in the region of Northern Colorado and the Eastern Plains.
Through these two redefined access centers, Banner Health Transfer Services manages more than 70,000 incoming patient referrals annually across the southwestern United States. Banner Health Transfer Services directly services transfers into 20 Banner Health facilities, including 17 in Arizona alone. Banner manages all aspects of system-wide resource visibility, access and transfers using software and strategic support provided by Central Logic.
“The platform provides real-time visibility into bed capacity in all Banner’s hospitals, the availability of specialists for consults and admissions, and numerous other key metrics needed to manage transfer traffic and trends,” Larsen explained.
“Importantly, referring physicians can reach Banner’s access centers by calling a single phone number for the entire health system, and the transfer and admission process is typically handled in one call. That was the type of process and visibility we wanted to replicate on a statewide level.”
Larsen contacted Central Logic and they both agreed that a statewide version of what was implemented at Banner was the best strategy to offer visibility into beds, ventilators and specialist availability for the dozen or so health systems in the state.
Since the COVID-19 curve has been so unpredictable, they wanted to get this centralized access center – which the state refers to as the Arizona Surge Line – operational as soon as possible, with an initial focus on the highest-acuity patients and facilities. The vendor, Larsen noted, had the technology needed to support this initiative that enabled the organizations to get it up and running in only a few days.
MEETING THE CHALLENGE
“Shortly after my initial call with ADHS about creating the Arizona Surge Line, we were on the phone with every major health system and hospital in the state explaining our plan and why we needed to combine our resources to benefit patients,” Larsen recalled. “Through this collaboration, we were able to soft-launch the program just two weeks after the initial conceptual conversations. Under normal circumstances, a stand-up of a transfer center of this magnitude would take more than four months.”
Surprisingly, there was little concern about competitive or financial issues due to patients transferring from one system to another, even though most healthcare providers in the state have been financially devastated by the required shutdown of elective procedures and the major downturn in non-COVID-19-related medical visits.
“This has been the most rewarding aspect of my role in leading the stand-up of the Arizona Surge Line,” Larsen said. “It has been truly inspiring to see competing health systems put aside competitive considerations to work together and best serve the citizens of the state of Arizona.”
This collective support for implementing the Surge Line was crucial because the effort required the cooperation, coordination and collaboration of healthcare provider organizations across the state, as well as technology vendors.
To deliver real-time visibility into the availability of critical care beds and other key resources, the Surge Line is built on Central Logic’s vendor-agnostic, secure, Microsoft Azure-based platform, which pulls data from Arizona’s Health Current statewide health information exchange.
Fortunately, over the past 10 years, the HIE had already integrated with 95% of the hospitals in the state, which made creating that level of visibility for the Surge Line much faster. In the Surge Line headquarters, transfer agents field calls from community hospitals around the state to transfer COVID-19 patients to an available health system with specialist care.
Central Logic gives the transfer agent a complete view of critical care availability for each hospital in the state. Because of the vendor’s reporting capabilities, staff also can share a daily activity report with ADHS officials.
“We launched Phase 1 of the Arizona Surge Line on April 21,” Larsen noted. “In Phase 1, three transfer agents work on the Surge Line during the day to assist referring physicians in identifying the right level of care for their patients around the state; two agents manage the line overnight. If we need to accelerate to Phase 2 or 3 in the future based on Arizona’s surge level, the line can easily scale up to include more agents.”
Of course, the best-case scenario is that the state will not see a surge in cases that will require that acceleration. It’s important to note that while the Surge Line was built for COVID-19, it can be used for any future unexpected surges in statewide patient admissions that might occur for any reason, such as another pandemic, a natural disaster or a mass shooting.
“We are hoping for the best while planning for the worst,” Larsen added.
After the soft-launch on April 21, the organizations were transferring only two or three patients a day. Soon after, ADHS and Central Logic each issued announcements about the Surge Line, which generated awareness across the state. Since the initial soft launch, the organizations have pushed out additional communications and further developed processes and protocols to elevate patient transfers to well over 100 per day.
“The Central Logic platform offers us complete visibility into bed capacity and specialist and ventilator availability, so the transfers have been going smoothly,” Larsen reported.
“To date, we have been able to accommodate patient or family requests for a particular health system. While we are trying our best to predict future volumes of patient referrals, the early success of the Surge Line, combined with opportunities to expand services offered and the general unpredictability of the course of the COVID-19 virus, we simply do not know when or where our service offering will peak.”
Regardless of where that volume lands, with the continued strong partnership with vendors, the organizations are confident that they will be able to manage the workload without concern, he added.
“In Phase 1, we are concentrating on triaging the highest-acuity patients to critical care units,” he said. “As the crisis continues, we plan to have the Surge Line help us load-balance patients from critical care to lower-acuity settings such as skilled nursing facilities, and to coordinate transportation if resources are scarce. We also plan to offer Surge Line callers access to physician consults if they do not intend to transfer a patient but still need clinical assistance from a specialist for critical or palliative care when on-call physicians are not available.”
ADVICE FOR OTHERS
“For states that are anticipating a first or second peak of COVID-19 cases, I would urge them to consider implementing a similar statewide collaborative load-balancing initiative to prevent any single health system or community from being overwhelmed with patients,” Larsen advised.
“Don’t wait,” he said. “Putting competitive concerns aside, combining resources, and working together to protect patients and frontline clinicians is the only ethical choice during this type of public health emergency.”
Even if the COVID-19 activity for any particular state is beginning to subside, Larsen still would strongly urge consideration of the establishment of a surge line for future needs. It would be much easier to stand up this type of initiative under controlled and less urgent circumstances, he said.
“For real-time visibility into bed, specialist and ventilator visibility, a statewide surge line will need platform-agnostic access center technology that can be rapidly scaled up to accommodate the large amount of incoming data and transfer request activity that will occur,” he concluded. “In addition to providing visibility into critical resources, the technology also needs to be able to inform reporting to identify geographic trends and patterns among different health systems or hospitals, which is valuable information for state health officials overseeing the initiative.”