The covid-19 pandemic has precipitated many changes in the NHS in order to deal with large numbers of people in need of treatment. Temporary Nightingale hospitals have been built in large cities to cope with the critical care overflow. I offer 30 years of leadership in crisis experience within field hospitals to identify transferable lessons.
Defence has a structure to analyse the requirements of a new “capability”, in this case a temporary hospital, remembered as TEPID OIL—Training, Equipment, People, Infrastructure, Doctrine (meaning plans and guidelines), Organisation, Information and Logistics. For medicine there’s one missing, “Clinical”, because everything we do is (or should be) focused on improving patient outcome or experience, or safety (of both patients and our healthcare staff): that gives us TEPID COIL.
The Clinical imperative therefore drives every other aspect of a capability. Do we have the right People to treat the predicted casualty profile within an Infrastructure that is clinically appropriate? Have we created the Doctrine that states who we will treat, and if necessary set the ethical bar for boundaries of treatment (including experimental interventions and ceilings of treatment) and adjusted our clinical guidelines? How do we deliver just in time Training against new Equipment with which staff are unfamiliar? How do we Organise to optimise casualty flow for the predicted principal illness/injury pattern, and what daily “battle rhythm” is needed for maximal staff utility and optimal clinical care? What must we anticipate are our vulnerabilities in Logistics—what consumables might we run out of, what equipment will likely fail, and how will we adapt, improvise and overcome this? Do we have Information systems that support our battle rhythm, provide clinical management support, and contribute to rapid organisational learning and continuously improved patient care?
Under People I will start with leadership. You can’t direct a field hospital from behind a desk. Capture problems by visiting every department at known times to reset your situational awareness to respond to the next challenges. You can fix and troubleshoot in the intervening period (remembering to sleep and eat when you can!). It’s not just about the direct patient care areas: remember the lab, x-ray and pharmacy. They are all critical to the running of the hospital—and often where trip hazards lay to hospital performance. Anticipation and foresight are key. You’re the one that needs the headspace to think to the next bound, before you run out of a key supply.
People are your key asset. Most will excel, but the experience will break some. People will not necessarily be well prepared to deal with seriously ill colleagues: in conflict we treat soldiers, wearing the same uniform, and it feels like treating someone from your extended family. Considering the psychological wellbeing of staff is essential. There is no preparation, however deep your experience, for death at scale. Now is the time to discuss ethical dilemmas that standard practice would never demand, not over future patients. Think carefully about who needs to be exposed to the most traumatic experiences. I have banned junior doctors from the temporary mortuary in war and taken that responsibility entirely myself. Nothing to learn there. If you take on similar responsibility, who do you have to support you as a clinical leader? Whether you’re religious or not, remember the hospital chaplain as an empathetic and confidential ear.
Some other people will do silly things—in my experience releasing inappropriate clinical material onto social media—and a swift response is needed. Don’t be afraid to remove someone who is ineffective or disruptive: the performance and welfare of the whole team is more important. Your leadership style will almost certainly be emergent. Initially people will look to you for direction, but as experience grows you can step back into a mentoring role. With practice at tempo, you’ll achieve self-managing teams. In a field hospital this transition can take as little as a week.
The observation “Amateurs talk tactics, but professionals talk Logistics” is attributed to General Omar Bradley and is highly apposite. The initial focus has been on ventilator availability. It is logical to expect forethought into supply of ventilator ancillaries and the availability of medical gases. But where has a field hospital fallen down? I’ve experienced fragility of the supply chain for laboratory reagents; vulnerability of mobile x-ray equipment to excessive use; and exhausted pharmaceuticals. Without lab, imaging and specialist drugs, it’s not really a hospital. Pay attention to building in resilience and being alert to early warnings and indicators. Raise your horizon and anticipate what you might run short of. Request early. Don’t let a challenge become a crisis. Improvise if you must—you are only limited by your imagination.
Organisation of the temporary facility will probably be guided by conventional wisdom. But it doesn’t have to be. What are the elements that you actually want to cluster together? If you are heavily reliant on the laboratory to support the mega-ICU, have you placed them adjacent to each other, or even with the lab in the centre? Be bold. If something isn’t working, re-organise. If it’s a temporary Infrastructure, change it. In a crisis, the most valuable quality is decisiveness (at least, according to Napoleon). General Colin Powell’s leadership principles include the “40:70” principle. [1] If you don’t have 40% of the information you probably can’t make a safe decision, but if you’ve waited for over 70% of the information then the ‘enemy’ may have acted. Having the moral courage to make difficult choices based on incomplete information epitomises leadership in crisis.
The most important factor in transforming clinical outcomes during recent combat operations was aggressive exploitation of the data and Information to drive continuous clinical quality improvement.[2] This methodology was adapted for use to support the British military response to the Ebola crisis in Sierra Leone. [3] At the heart of this is a weekly clinical telephone conference where lessons are shared between all deployed hospitals: learning takes place and practice changes in near real-time.[4] How can this be replicated to promote standardisation and inter-hospital learning during this crisis?
Medicine advances in war. That’s a recurring historical fact. The conditions for innovation are exactly the same in this covid-19 crisis. I predict the paradigm norms and expectations when dealing with casualties at scale will reset.
Brigadier Tim Hodgetts, Senior Health Adviser (Army) & Head Army Medical Services | Honorary Professor of Emergency Medicine, Commissioner Royal Hospital Chelsea @ArmyHealthAdv
Competing interests: None declared
References:
[1] Oren Harari (2005). The Powell Principles. McGraw Hill Professional.
[2] Smith J, Hodgetts T, Mahoney P et al. Trauma Governance in the UK Defence Medical Services. J Roy Army Med Corps 2007; 153(4): 239-242.
[3] Dickson S, Clay K, Adam M et al. Enhanced case management can be delivered for patients with EVD in Africa. J Infect 2018; 76(4): 383-392.
[4] Wildridge D, Hodgetts T, Mahoney P et al. The Joint Theatre Clinical Case Conference: clinical governance in action. J Roy Army Med Corps 2010; 156(2): 79-83.