The Covid-19 pandemic has forced healthcare leaders across the country and the world to adopt tools in crisis management, quickly organizing and adapting responses to rapidly evolving patient volumes and needs. Through trial by fire, emergency and hospital leadership across the US has needed to build new capacity, re-invent workflows and create novel algorithms to address the disruptive challenges posed by the pandemic. Interviews with division chiefs and disaster leads of six major adult emergency centers, most of which have been at one time or another in the hotspot of the first wave of the epidemic, elucidate three core leadership principles of crisis management that can guide ongoing and future efforts within and beyond the emergency room setting.

As best described by Leonard et al., a routine emergency – such as a house fire – is characterized by familiarity and, based on prior experiences, has in place standard operating procedures, equipment and staff that is optimized for effectiveness and efficiency (Leonard 2020). In stark contrast, there is no direct precedent for the scale and severity of Covid-19, and in the early days, very little scientific information available to guide even medical decisions. Given these challenges and that no one is in a position to offer complete answers, Leonard et al. emphasize the importance for leaders to enable a process that team members will trust to generate the best available answer. The three core leadership principles derived from interviews of emergency medicine leaders at the frontlines of the initial Covid-19 wave follow this directive.

1. Create a core management team with the authority and resources to coordinate across units and act quickly:

Key decisions around capacity building and flow through the emergency department requires close collaboration across many units, many of whom previously did not typically need to work closely together. To this end, the creation of a core team in the hospital with both the authority and resources to coordinate across units and act quickly was crucial for solution fast-tracking and implementation. Such a team included “not too many people but only the right people,” as Dr. Christopher Freer at St. Barnabas describes, including not only physician and nursing leaders, but also representatives from engineering and logistics. Such command centers often have access to real time data and have a process in place wherein multiple units can be activated quickly with appropriate allocation of resources.

A prime example of this is in the case of University of California San Francisco (UCSF) emergency department being able to secure military grade surge tents and have them up and running within six days of arrival, long before a surge had been predicted. The decision to purchase these tents was made within hours after its initial proposal, with strong backing and sense of urgency from the core team; this enabled the bypassing of a much longer financial approval process. The implementation of the surge tents was a multifaceted project that required interdisciplinary support from facilities management, radiology and pharmacy.

A different type of cross unit collaboration is in the creative repurposing of resources to the emergency department from other teams as needs and situations evolved. As ED volumes escalated and elective procedures were put on hold, non-ED providers were able to step in to help. At University Hospital Newark, orthopedics teams came to the emergency room to safely prone intubated patients, becoming the designated “proning team.” Interventional radiologists and surgical providers took over central line placements. This redeployment of essential skills and services across units was made possible by a command center, which helped to coordinate and facilitate work load balancing.

2. Maintain consistent on-the-ground presence, communication and channel for feedback:

 In such a highly unpredictable and tense crisis environment, where frontline staff are facing dangers to their own health and safety, open communication and trust is essential. At the same time, there is a balance between transparency and information overburden. In initial stages of the pandemic, fears around shortage in personal protective equipment and escalating staffing needs ran rampant. Across all six emergency departments interviewed, there were consistent schedules and structures in place to deliver updates and solicit immediate feedback. At University of Southern California, in the first few months of the initial surge, there were open calls with leadership daily at 4PM, when specific issues around protective equipment and other pressing needs were addressed and discussed. At St. Barnabas, COVID leaders and nursing managers rounded every day in the COVID areas of the emergency department, maintaining an open line of communication with frontline staff and evaluating the immediate intended and unintended effects of evolving changes. At UCSF, physician and nursing leadership were present for both the 7AM and 7PM huddles, keeping messaging uniform across shifts.

3. Execute decisions with the understanding that most will be tentative and experimental, maintaining flexibility while focusing on core values:

Given this crisis is profoundly different from routine emergencies confronted in the past, with circumstances changing from day to day, it is reasonable to accept that most decisions will not be perfect and will need to change as well. As Leonard et al. describes, the more important expectation is that the team will maintain focus on its core values and goals throughout its entire decision-making process, while staying nimble and flexible. The early stages of the pandemic saw extreme uncertainty in PPE guidelines and Covid testing capacities. National guidelines seemed to change on a weekly if not daily basis, on the method of transmission, on whether to wear full PPE, and on safe intubation practices; often, different sources would even have conflicting information. In such a tumultuous environment, it is even more imperative for staff to be guided firmly by core priorities rather than transient guidelines. The team at University of California Los Angeles (UCLA), for example, measures every decision by its degree of patient and staff centricity, balancing against other potential negative impacts. Many of its early decisions negatively affected the degree of educational exposure for residents, while improving staff and patient safety, which was a trade-off they were willing to make under these circumstances. Dr. Lynn McCullough of UCLA describes her mindset of being “anticipatory instead of reactionary” in pursuit of patient and staff safety, and her team was first within the hospital to implement universal masking even with initial resistance.

Author

Yongtian Tina Tan

Yongtian Tina Tan MD MBA is a pediatric emergency medicine fellow at Seattle Children’s Hospital in Seattle, Washington. She has a strong interest in healthcare innovation, clinical operations, and applying business principles towards improving patient care.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.