Cleveland Clinic Takes Leadership Role in COVID-19 Community Preparedness Planning

Few people could have predicted how quickly life would change when the first U.S. patient was diagnosed with COVID-19 on January 20, 2020. The novel coronavirus’s rapid spread across the country thrust healthcare systems into new public health roles that went well beyond caring for patients within their own facilities.

Cleveland Clinic has played a leading part in planning and executing Ohio’s response to the pandemic, from outfitting a surge hospital in record time to helping ensure that vulnerable populations are protected and that hospitals aren’t overwhelmed by large influxes of patients. The community protection planning was underway before the first patients arrived in the state’s hospitals.

Managing a team response

In March, Ohio Gov. Mike DeWine requested that all hospitals in the state work together to ensure COVID patients received adequate care should a surge occur. Backed by Cleveland Clinic leadership, Chief Medical Operations Officer Robert Wyllie, MD, stepped in to help coordinate efforts.

The difficulties the planners would face with COVID-19 were underscored early in the pandemic during a phone call with hospital colleagues in Italy’s hardest-hit town. “They told us that if we were thinking three days ahead, we were three weeks behind,” Dr. Wyllie recounts. “It was clear that close collaboration would be crucial to prevent hospitals from being overwhelmed, to make sure medical equipment and PPE [personal protective equipment] were available when and where they were needed, and to stop mass outbreaks in group-living facilities.”

Although these goals were straightforward, achieving them would be difficult due to the large number of parties involved. Planning required working with the U.S. Department of Health and Human Services; the Centers for Disease Control and Prevention; the Food and Drug Administration; the National Institutes of Health; state, county and city health departments; and hospitals, hospital systems, physician groups and individual physicians throughout the state.

Moreover, the health departments in Ohio’s 88 counties report to county commissioners, not the state, leaving no single person in charge of those collective operations.

Fortunately, Ohio has long been divided into eight zones for emergency planning purposes. Dr. Wyllie suggested this existing network be used as a basis for coordinating COVID response between hospitals and congregate living facilities in geographic areas. He also suggested that the eight zones be reduced to three, centered on the largest cities: Cleveland, Columbus and Cincinnati. The governor agreed. Dr. Wyllie assumed leadership of Zone 1, which includes Cleveland and 21 northern Ohio counties.

Creating a temporary surge hospital in each of the zones was the first step in the state’s plan. Cleveland Clinic had that responsibility in Zone 1. The International Exposition Center, a large convention and trade show facility on Cleveland’s outskirts, was initially considered, but siting the surge hospital nearer to Cleveland Clinic’s main campus would make staffing and patient transfers much easier.

So in less than a month, Cleveland Clinic converted the Sheila and Eric Samson Pavilion on its Health Education Campus from a medical education building to a 1,006-bed surge hospital for low-acuity COVID-19 patients.

A cascade plan was then developed, outlining where and how COVID patients needing hospitalization would be directed within a region, should an individual hospital reach capacity.

“This helped reassure hospitals, particularly those with small staffs and limited numbers of beds and ventilators, that they wouldn’t be overtaxed or forced to ration care,” says Dr. Wyllie.

To ensure equitable availability of PPE and medical supplies, Dr. Wyllie’s team arranged for a virtual registry to be created on the Ohio Hospital Association’s website. All hospitals in the state list their inventory and update it daily. Facilities that run through their supplies know where to get more.

“We noticed one facility was burning through 400 gowns a day. This rate was unsustainable,” says Dr. Wyllie. “We got them reusable gowns.”

Formalizing triads

The next step was to develop a formal connection among local hospitals, county health departments and congregate-living facilities.

The innovative triad approach was meant to ensure that no hospital would become inundated, that people at greatest risk for COVID-19 infection would be protected and that COVID response activities were coordinated among all government entities.

“This has made a huge difference in terms of calming fears and helping everyone stabilize,” says Dr. Wyllie.

Arranging for hospitals to cooperate proved easier than obtaining information on group-living facilities, a category encompassing providers of skilled nursing, assisted living, mental illness and substance abuse treatment and recovery, youth services and homeless housing.

There are 900 such privately operated facilities in the state, with 60,000 to 70,000 residents and 90,000 employees, many of whom work in more than one facility. No one had a comprehensive list of residents and employees at each site. State- and federally-run facilities, primarily prisons, hold an additional 50,000. The inhabitants and employees of these facilities are vulnerable to COVID due to inherently close living and working conditions and underlying medical conditions.

It fell to Dr. Wyllie and his collaborators to compile a list of these facilities and their occupants and employees. When it was complete, each facility was connected with its local health department and area hospitals, so everyone knew who to contact and which hospital would take their patients who tested positive for the virus.

To date, the cascade plan has proven its value at least twice, for outbreaks in a veterans’ home and a federal correctional facility. Both times, patients were diverted to regional hospitals when small hospitals were inundated. “No regional hospitals got overwhelmed,” says Dr. Wyllie.

Predicting outbreaks

Since the beginning of the pandemic, Dr. Wyllie has been tracking COVID cases to better predict outbreaks. Patterns have become clear. Stay-at-home orders and school closures caused case numbers to drop 12 to 14 days later. Reopening the state in May caused cases to rise. The same thing occurred after the Labor Day holiday.

With the arrival of colder weather driving people indoors, the transmission rate rose. After more than half of students in Ohio’s 612 school districts returned to classrooms, the average number of cases rose 67% in two weeks.

“We think cases will continue to rise through the end of the year,” says Dr. Wyllie. “Hospital admissions follow cases by two to three weeks. Mortality rates follow hospital admissions by another two to three weeks.”

Dr. Wyllie and his counterparts in Zones 2 and 3 hold virtual meetings several times a week to stay on top of COVID preparedness. They adjust their plans as their knowledge and experience grows. “We must double down on our efforts,” he says.

Safety at home

As the Midwest endures the third and highest surge of COVID patients since the pandemic’s start, Ohio is as prepared as possible to care for them. Months of experience managing smaller numbers of COVID patients and learning from colleagues in hot spots is making the job less difficult.

Cleveland Clinic dismantled its surge hospital when it became clear that public health measures had reduced the expected number of COVID-19 patients in Northeast Ohio and that existing hospitals were adequate. Although it can be reassembled on short notice, that is not expected to be necessary.

“We figured out how to stretch our ICU capacity to accommodate up to 2,500, patients and reconfigure our hospital floors to hold 550,” says Dr. Wyllie.

Innovative protocol changes have been implemented throughout the enterprise to protect front-line caregivers and patients. For example, ICU monitoring equipment and intravenous pumps have been moved from the bedside into common areas. This enables caregivers to monitor patients safely without requiring multiple changes of PPE.

Looking ahead

With the statewide COVID response under control, Dr. Wyllie’s attention is focused on arranging for the upcoming distribution of vaccines from Cleveland Clinic — which is one of Ohio’s 10 designated vaccine pre-positioning sites — to regional hospitals for immediate use. He also is advising the state on vaccine distribution and vaccination policies.

He is intrigued by opportunities to use digital technology to prevent outbreaks of COVID-19. His latest project, a collaboration between Cleveland Clinic and University Hospitals of Cleveland, involves the use of business analytics to geolocate micro-outbreaks. The technology allows local health departments and hospitals to be informed when two people with a positive COVID test live within one-third of a mile of each other.

“We were able to predict a micro-outbreak in student housing at Kent State University and alert the university, which interceded,” he says.

The process is far more precise than the zip code-based tracking measures that health departments use to identify looming outbreaks. Dr. Wyllie foresees the potential utility of geolocation in other public health applications after this pandemic passes.

“Think how useful this would be to track opiate addiction or neonatal mortality,” he says. “We would be able to see outbreaks and intercede early.”