How Horizon prepared for and responded to the COVID-19 pandemic

A Q&A with our President and CEO, Karen McGrath  

Q. Tell me how Horizon began planning for the arrival of the COVID-19 virus in New Brunswick. When did that planning begin?

We have been closely watching the spread of the novel coronavirus (COVID-19) in Canada and our province and actively preparing our facilities and workforce for a surge of potential and confirmed Coronavirus patients.

Our virtual Horizon Emergency Operation Centre (EOC) and Local Emergency Operation Centres have been meeting regularly for nearly two months – since early March. And when I say regularly, I mean regularly. It’s every day, for much of the day. Even before then, in February, we had a COVID-19 Task Force that began preparing for when the virus arrived in New Brunswick.

At the Horizon EOC we hear from representatives on our Local EOCs, who report on everything from assessment centre data to Public Health updates to specific concerns in their regions and hospitals. We receive reports from Public Health and review directives from government to ensure their implementation in our facilities.

The work we did leading up to even our first admission was all about protecting and preparing our staff and physicians, as well as our health system’s capacity, to ensure we could manage the impact of this surge – all while relying on our existing health systems.

Q. Planning began in February, and it’s now the end of April. Where are you in the curve today?

As you know, the Public Health measures put in place by the government and our Chief Medical Officer of Health are being followed very well by New Brunswickers.

So, we didn’t see the surge of patients as expected -but I’m happy to talk about the planning and preparations we did within our facilities to prepare for this.

There were things we put in motion right away: testing and swabbing at our new COVID-19 assessment centres, restricting visitors at our hospitals, and screening patients and staff before they come into our hospitals. We started providing procedural masks for staff to wear when physical distancing isn’t possible and encouraged patients to bring with them their own cloth masks to help prevent the spread of the virus in our facilities. And, most recently, we established mobile teams to test those who can’t drive to our assessment centres.

Many of these measures have been in place for a month and a half now, and they really helped ensure we were at the forefront of curbing the spread of the virus and keeping it out of our facilities, where many vulnerable people and health care providers are every day.

And what these measures look like changed weekly … daily … hourly … but they really contributed to the flattening of the curve in this province.

Throughout our facilities, we already had stringent Infection Prevention and Control (IPC) guidelines in place. In response to COVID-19, we established an Infectious Disease and Infection, Prevention and Control (ID-IPC) Committee (a subgroup of our regional IPC committee), to advise the Horizon EOC on matters related to the COVID-19 pandemic and help our local teams implement an organization-wide IPC plan.

This committee is co-chaired by Dr. Gordon Dow, the Regional Infectious Diseases Medical Director at Horizon’s The Moncton Hospital, and Lauza Saulnier, Horizon’s Regional Director of Quality and Patient Safety.

We have delivered numerous training opportunities – in-person and online – on best practices for PPE for staff and physicians, including our Environmental Services (EVS) team.

Speaking of EVS: we’ve also introduced enhanced cleaning protocols during the outbreak, including more frequent cleaning of all public spaces, hand railings, counter tops, cafeteria tables, elevators and other common surfaces.

Q. And you haven’t had many admissions, right? So, let’s go back to looking at Horizon’s proactive actions in early March. What did your emergency preparedness plan look like?

You’re right, we haven’t – but that doesn’t mean we aren’t prepared for them.

Early on, we did a predictive modelling exercise based on other jurisdictions that created three scenarios of potential impact; I’ll speak to the most likely and most extreme here.

We looked at the patient population served by Horizon, and from that determined that we should expect 522 COVID-19 patients within the first 100 days of the virus arriving in New Brunswick.

We took into account that COVID-19 patients would stay in-hospital for two weeks.

The mostly likely scenario would require that, at the peak of the pandemic, we needed to be ready for 99 COVID-19 positive patients, with 26 requiring critical care admissions, and 21 requiring ventilation.

In the most extreme scenario, we’d need to care for 609 COVID-19 patients, with 160 in critical care and 128 requiring ventilation. In the extreme scenario, there’s no doubt our hospitals -our physicians and staff – would be under intense pressure.

Things changed along the way – and so did we. Our non-COVID-19 admissions declined at a rate faster than expected, so we were even more prepared for a surge.

We knew during all this planning that it was more likely that growth rate would not be as high as assumed in these analytics and that the predicted volume of infections will be reached over a longer period of time – a flattened curve.

But still, we planned for the worst as we hoped for the best.

Once we had those models we were able to develop capacity plans in Horizon’s five regional hospitals.

Capacity planning looks at dedicated COVID-19 units, critical care capacity, and supply of critical equipment including ventilators. It also looks at negative pressure environments, seclusion opportunities, and isolation capacity.

Q. Capacity planning. But every day we hear about how Horizon’s hospitals are overcapacity. How did you make room for these potential admissions so quickly? Do your hospitals look different because of these changes?

They certainly look very different than they did a month ago – however, the quality of care and best practices – even better practices – are there.

As part of this planning, we’ve made difficult – but critical – decisions to ensure our health care system is prepared for the influx of severe and critical care patients diagnosed with COVID-19.

When we looked at maximizing the capacity at our five regional hospitals we knew we needed to make beds available. Between the best-case and worst-case scenarios I mentioned earlier, we’d need between 72 and 449 beds for COVID-19 patients, and 962 beds for our non-COVID-19 patients.

It was clear the Alternate Level of Care – ALC – population would be the most appropriate to relocate to make these beds available.

Between mid-March and mid-April we’ve discharged 111 ALC patients to available nursing home beds in the community, as well as to Ridgewood Veterans Wing in Saint John and Veterans Health Unit in Fredericton.

We worked closely with the departments of Health and Social Development, physicians – and families – to make this happen.

We also started cancelling non-urgent surgeries and outpatients services in mid-March. Our hospitals are now treating only the most urgent and critical patient cases, such as emergency traumas and cancer treatments.

We also put into action an aggressive management of length of stay for non-COVID patients, which reduced the overall number of inpatients in our hospitals (hospital census) by 485 inpatients from mid-March to mid-April.

Because of these changes, today we have an average occupancy rate of 71 per cent. As well, the average daily number of inpatients at our regional hospitals is 967 people.

These are numbers I have not seen during my almost 40-year career in health care. They really speak to the detailed preparation and planning by our dedicated staff and physicians, and how seriously New Brunswickers are responding to our plans.

Q. What about  emergency departments? Are you seeing lower numbers there? Are you concerned people that should be coming into emergency aren’t because they’re scared?

Our Emergency Departments (ED) continue to operate 24/7, and New Brunswickers should absolutely still come to the ED if they have a medical emergency.

Our planning takes into account the fact that emergency care will continue throughout our pandemic response.

We are doing a good job of addressing the fact that we want New Brunswickers to only use our emergency departments for emergencies, but to PLEASE visit their emergency department or call 911 if they have an emergency.

We also have protocols in place to pre-screen, segregate and triage all presenting patients to quickly identify suspect COVID-19 patients. All of our facilities have identified transport routes to ensure the safe transfer of admitted patients from our EDs to either a COVID-19 ICU or Nursing Unit. Following each transfer, these routes are cleaned by our EVS staff using enhanced measures.

As well, we’re working with Ambulance New Brunswick to develop a bypass protocol so that COVID-19 patients aren’t brought to community hospitals.

Q. I hear the phrase “COVID Unit” often. What does a COVID-19 unit look like at Horizon?

Horizon’s five regional hospitals – Dr. Everett Chalmers Regional Hospital in Fredericton; Saint John Regional Hospital; The Moncton Hospital; Miramichi Regional Hospital; and Upper River Valley Hospital in Waterville – have designated COVID-19 Intensive Care Units (ICUs) and separate COVID-19 nursing units to care for COVID-19 positive patients who are severely ill.

These hospitals also have the capacity to provide critical care to patients in ICUs, including those patients that may require ventilation.

We have dedicated teams of health care workers who have been identified to provide care to our COVID-19  patients. This allows for our already highly-trained staff to develop expertise in caring for these patients.

These health care workers (with some exceptions of staff/teams who regularly work with many departments in our hospitals) are dedicated to work only with COVID-19 patients, whenever possible. This has allowed us to minimize the number of staff accessing these designated units, which in turn will reduce the risk of transmission of infection.

Here, I need to point out the exceptional work being done by our Facilities Management teams who have swiftly made the changes to these units: in some areas, our Facilities Management staff have been able to work with the hospital ventilation systems to increase the number of negative air pressure rooms. 

In some Operating Rooms (OR) and Labour and Birth units, they’ve constructed COVID-19 OR suites. The OR suite remains under positive pressure and is equipped with an air purifier and a negative pressure ante room has been constructed with an air scrubber which exhausts the air flow away from the centre core through a HEPA filter.

Q. And Horizon just isn’t those five hospitals. There are more than 100 facilities. What did these changes mean for our other facilities, especially our community hospitals?

You’re right. Our community hospitals have changed, too. They are prepared to expand their capacity to care for non-COVID-19 related patients.

Our community hospitals won’t knowingly admit COVID-19 patients because they don’t have some of the equipment and set-up needed – such as intensivists, airborne isolations rooms and other additional Infection Prevention and Control measures.

However, we have prepped our community hospitals to provide isolation space for an inpatient who developed symptoms while there. We have a protocol for transferring these inpatients to a regional hospital.

Q. Tell me about the role of Public Health teams in the community.

The work of our Public Health team is absolutely crucial in tracking and minimizing the spread of COVID-19 in our communities.

As the virus progressed quickly from outbreak to pandemic, our Communicable Disease teams built a planned and coordinated Public Health response.

In fact, for every new case identified in the province, there are members of the Public Health team (medical officers of Health, nurses, inspectors (Public Safety staff), dietitians, administrative support and managers) working actively to identify the origin of an individual’s infection and to contact anyone the person may have come in contact with, to ensure they isolate and receive the appropriate monitoring and follow-up. This is known as contact tracing.

As well, one of Horizon’s regional medical officers of health sits on our Horizon EOC, so we are kept up-to-date on the evolving provincial COVID-19 strategy and response.

Q. How has all of this affected staff and physicians? And what about staffing levels? We know there are many vacancies in the organization, especially in nursing positions.

It’s been challenging for sure. For our staff, for our managers, directors … and senior leaders, too. But I’m really proud of how they’re weathering this storm together.

I’ve heard stories about staff who never worked together before COVID-19 – and now, in such a short time, look to one another as teammates.

We have a Human Resources plan in place to ensure we can staff our essential services.

At the outset, staffing resources was certainly an identified risk. It’s no secret we operate with many nursing vacancies. We expected a pandemic may reduce staffing availability by 20 to 70 per cent, but our continual assessment and adjustment of operational plans made sure we were always in a good place in all of our facilities.

We did this by redeploying staff from their regular jobs into new roles and engaging with the 900 plus retirees and students that have reached out to help us.

We’ve supported our staff with additional training on Personal Protective Equipment – PPE – and increased N95 mask fit testing.  We’ve provided them with mental health resources and support, and timely information and communication about policies that will affect them. We’ve also shared our daily communications with our partners, including unions, the New Brunswick Medical Society and Service New Brunswick; we’ve received really good feedback on this process.

Q. How are you working in collaboration with other health care partners such as the Department of Health, Social Development, Vitalité Health Network, Ambulance New Brunswick and the New Brunswick Extra-Mural Program?

Our partnerships with these organizations have never been stronger. I am in daily meetings with the Deputy Minister of Health, and members of our Executive Leadership Team (ELT) meet with their counterparts often, too.

We also have representation from Horizon on the Pandemic Task Force, which has the decision-making authority about the pandemic response for all aspects of the healthcare system. Their clinical expertise has been a great addition to the planning and response efforts already in place at Horizon. There are also several working groups that have been established by the Department of Health, and many Horizon staff are part of these groups.

We are also working closely with all our partners to make sure our most vulnerable populations, including those in nursing homes, adult residential facilities, and homeless shelters, are protected and safe.

I’ve also heard stories about how these partnerships are really being shown on the frontlines.

You may have heard about the pay-it-forward pizza delivery one of our EDs received from their colleagues at Vitalité. It’s really amazing to see that – despite the changes and challenges our teams staff are going through – they’re still so kind and thoughtful.

Q. Looking ahead, when might you relax these restrictions? Have you started to think through how to re-open our doors to patients who have deferred care?

Well, all patients who have needed emergency or urgent care who came to us during the COVID-19 pandemic have received it.

But, yes, we have begun conversations about how to slowly and appropriately reintroduce elective surgeries, procedures and open up ambulatory care clinics and the like.

To start, we’re looking to jurisdictions and countries like South Korea, where the virus hit earlier than it did here, and where they’ve done a great job in flattening the curve. And we are working closely with the Government of New Brunswick in supporting and implementing their phased recovery plan.

But we need to remain vigilant: COVID-19 will be with us for a long time.

Although we’re looking at how we will slowly re-start elective procedures, how we’ll bring staff back to their pre-COVID positions and how we slowly open our facilities to more visitors we must continue to ensure safety of patients and staff.

Physical distancing, proper infection and prevention protocols, patient and visitor screening -all of these measures will stay with us for the long run. We need to be able to react quickly should there be a resurgence of COVID-19.

Q. Do you have any final lessons or observations you’d like to share? What has shocked or impressed you the most during this crisis? Is there anything you would have done differently across the past several weeks?

I’ve been impressed by the rapid manner in which all of these changes were activated at the ground level in our facilities, and how quickly our systems adapted as we continued to learn more about best practices to treat and contain the spread of this virus.

We had to transform a very complex system in such a short period of time -and we did that so efficiently that we were ready even before we admitted our first COVID-19 patient.

This is due, in large part, to the focused, conscientious and motivated ways our staff embraced our changing requirements for their health and safety, as well as the health and safety of our patients and all New Brunswickers. This includes having to work in new roles through redeployment; through this ever-changing environment they have acted with professionalism and grace. The dedication of Horizon’s staff and physicians has been exemplary.

Our efforts to preserve and manage of PPE stock should also not go unnoticed. Our inventory is good, and our staff and management have played a crucial role in making this so.

Our partnerships with stakeholders, including our Foundations and private businesses who have supported us in many ways, and various levels of government have been outstanding, too. The partnerships between facilities, teams and professionals across our organization deserve recognition too. We have truly been One Horizon in these efforts.

We have much work left to do, but I am hopeful that with continued collaboration, our success will continue.

Q. Anything else?

I think I’ve said it, but I’ll say it again: I would like to assure New Brunswickers, including our staff, that we are confident in our ability to treat a surge of COVID-19 patients – as long as New Brunswickers continue to follow precautions set out by the Chief Medical Officer of Health.

As you’ve heard, our planning has looked at different levels of inpatient volumes, based on models from other jurisdictions. Where we get to within each of those levels depends on the continued work being done by New Brunswickers in terms of physical distancing; staying home; and practicing good hand hygiene.

For the health system, a flattened curve means we may still see a high number of infected patients – but over a longer period time.

If these measures are not followed, our health system is at risk at being overwhelmed. Our staff and physicians are at risk of being overwhelmed. We do not want this to be the case.