FEMALE SPEAKER: Welcome to Mayo Clinic COVID-19, Expert Insights and Strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc, and is in accordance with a ACCME guidelines.

JEFF POTERUCHA: All right, welcome everybody from the Midwest. My name is Jeff Poterucha. I'm a Senior Education Specialist with our School of Continuous Professional Development. On behalf of the Mayo Clinic School of Continuous Professional Development, I'd like to introduce you to the Mayo Clinic COVID-19 webinar series. Today's webinar is on critical care planning for the COVID-19 pandemic, preparing for the next wave.

So a few housekeeping things-- today's webinars accredited by the AMA for one credit. There are no relevant disclosures for today's discussion. And of course, we'd like to thank Pfizer for their support of this educational activity.

So before we do jump into the presentation, I'd like to cover a few points. The first is how to claim credit. If you like to claim credit after the webinar, please visit ce.mayo.edu/covid0721. You can see that right on the screen there.

You'll need to be able to log into the site. So if you haven't done that, if it's your first time visiting, you may need to create an account. After you've done this, log in.

You'll see there's an access code box. You'll want to type in today's code, which is COVID0721. This will allow you to access the code, complete a short evaluation, and then you'll be able to access certificate. The link and code will be dropped in the Chat box throughout today's webinar.

So you'll note on this slide that there are two functions at the bottom of your screen. There's a Chat function and there is a Q&A function. So if you have any questions during the webinar for our faculty, our subject matter experts, you'll want to drop those into the Q&A channel rather than the Chat box. This will help ensure that the faculty focused on today's call will be able to see your questions and answer those.

You'll note that when questions start coming in, there's a helpful Upvote button. So be sure to click. Upvote any questions that you would like to see answered. And of course, with the Chat function, that's going to be reserved for any ingredients you'd like to offer out, or if you have any technical issues. You can include those in the Chat function so our support staff can assist you if necessary.

So for today's learning objectives, the first is to describe the core concepts of mass critical care planning and surge capacity, discuss the lessons learned from initial Mayo Clinic Enterprise critical care planning efforts during the COVID-19 pandemic, and compare the differences in critical care planning, preparedness, and the shaping forces in different practice settings across the Mayo Clinic Enterprise.

I'd like to quickly introduce our panel today, starting with our moderator, Dr. Alexander Niven. So Dr. Niven is an Education Chair of the Division of Pulmonology, Critical Care and Sleep Medicine, as well as a Critical Care Independent Multispecialty Practice. He's a consultant within Pulmonary and Critical Care Medicine and an Associate Professor of Medicine.

Dr. Sen is the Chair of the Department of Critical Care in Mayo Clinic in Arizona. He's an Associate Professor of Emergency Medicine and an Assistant Professor of Medicine. Dr. Pablo Moreno Franco is the Chair of the Department of Critical Care in Florida Mayo Clinic. And he's an Assistant Professor of Medicine. Dr. Zurob is the Chair of the Department of Pulmonary Medicine and Critical Care in the Mayo Clinic Health System.

Dr. Brown is the Chair of the Division of Critical Care Anesthesiology and a Professor of Anesthesiology. Dr. Myers is a Senior Associate Consultant within the Intensive and Critical Care Medicine in our Mayo Clinic Health System, as well as an Instructor in Medicine. And Lindsey Lehman is an Operations Administrator, Division of Critical Care Anesthesiology and an Assistant Professor of Health Care Administration. So what I'd like to do is hand over controls to our moderator, Dr. Niven, so we can begin the presentation.

ALEXANDER S. NIVEN: Thank you very much, Jeff. And I want to thank everybody online for joining and participating in what I anticipate is going to be a fantastic discussion. I'm very excited to have the opportunity to participate in this distinguished panel of faculty to really share a little bit about our experience in the Mayo Clinic Enterprise with regards to critical care planning preparedness, and then operations during the COVID-19 pandemic.

And then I think our system is a little bit unique, in that we find ourselves engaged in basically different levels of surge capacity right now between our different locations. But before I get started with that, I'd like to explain a little bit what I mean by the "critical care enterprise." So when many people think about Mayo Clinic, they think about our first campus in Rochester, Minnesota, shown on this slide.

But actually, Mayo has a number of different health care systems that make up our overall health care system enterprise. So Mayo Clinic, Jacksonville and Mayo Clinic, Scottsdale basically represent our two other destination medical center campuses. And we also have an extended network of community-based and rural-access hospitals in southern Minnesota and Wisconsin that we refer to as the Mayo Clinic Health Care System, so the [INAUDIBLE] the health care system per se. Next slide, please.

And that just shows you the Mayo Clinic Health Care System. We also have Mayo Clinic Care Network, which is really a relationship that we have developed with a wide variety of hospitals, really throughout the world, that turns to Mayo Clinic for subject matter expertise, educational and quick reference resources, and a variety of e-consultation services. And so when we talk about the Mayo Clinic Enterprise, this really constitutes sort of the range of services that we have.

What I'd like to do at this point is just move forward to the next slide and introduce a couple of concepts that I think are familiar to many, and certainly used very commonly in the public press, but I think an important thing for us to go through with regards to definitions, so that we can all start off with the same shared mental model. So Critical Care Surge Capacity is something that I think we have heard a lot about, starting with ICU beds and the availability of ventilators and staff to the current active discussions in terms of what the latest uptick in terms of COVID cases will impact in terms of critical care services.

And classically-- and this is actually an adapted table from the CHEST Consensus Statement on mass critical care that was last revised in 2014. We think about four core concepts in terms of critical care surge capacity-- space, staff, supplies, and systems. Now, when we talk about planning for a mass critical care situation or expanding critical care resources to meet a challenge like the COVID-19 pandemic, these planning efforts typically are classified in three main areas.

So we think about conventional critical care operations as, quite honestly, the things that we do every day-- delivering critical care in the usual ICU spaces that we provide care to our patients. If we have a busy day, we call in extra staff who are all trained in critical care. And we have the sufficient resources necessary to deliver usual care services to those individuals. Now, I think many of us over the course of the last six months have found ourselves in situations where we cannot necessarily provide all the usual care and have all the usual resources to deliver that care.

So when we talk about contingency operations, there, we're talking about repurposing spaces for ICU care that are not traditionally used for those spaces, for example, turning a PACU into an ICU. We probably still have enough critical care-trained staff to take care of ICU patients, but perhaps we're extending those staff responsibilities, changing staff to patient ratios, so that we can stretch the resources that we have a little bit further. And there's enough of a strain on our supply chain that we're thinking about ways to conserve supplies or adapt and reuse things like personal protective equipment, which obviously has been a big issue in the press.

And overall, we're still able to deliver the same usual care with minimal impact, just with a little bit more stress. And when we talk about crisis management or crisis contingency planning, this is really when we're faced with situations where we're unable to meet the usual standards of care for critically ill patients because of the volume of those patients and the imbalance between the number of critically ill patients and the resources that we have to bear. So here, we're utilizing non-traditional areas, frequently reaching to staff who are not traditionally ICU trained for help, and recognizing that we are short resources and forced to make sometimes hard decisions to make sure that we're taking the best possible care of the most people.

And obviously, we don't operate in a vacuum, as any hospital in the United States. So as we reach higher levels of stress within our institution, there's all sorts of formal processes that we'll get into in terms of relationships with other regional hospitals, state resources, and even the federal government. So with that, I'd like to take down the slides and move through our panel, and have them introduce a little bit their practice setting as a starting off point, so that you can get a picture of where we started at the beginning of the pandemic, and then how we move forward through the planning process and what we've learned.

So I'd like to start with Dr. Brown, who is really the Director and leader of the Critical Care Enterprise at Mayo, and his administrator Lindsey Lehman. If you could just introduce yourselves, and describe a little bit of what the practice environment is at Mayo Clinic, Rochester.

PABLO MORENO FRANCO: You're muted, Dr. Brown.

DANIEL R. BROWN: Nice pickup. Thank you. As you point out, we have an organization that spans a fair amount of geography. And in an effort to harmonize our approach to care, we have not only departments, we have multidisciplinary groups as well.

And these groups, again, have representation from all of the sites that you noticed, from our Rochester, Florida, Arizona and Health System sites. And we have representation on this call from all of these sites. And thankfully, I am paired with an administrative partner to help facilitate this, Lindsey Lehman, who's joined us here and really has been instrumental in coordinating the activities across campuses and across the regions. I'll leave it at that.

LINDSEY M. LEHMAN: Thanks, Dr. Brown. A brief introduction-- my name is Lindsey Lehman. I do serve as the Operations Administrator based here in Rochester and supporting our community division across the Mayo Clinic Health System. And as Dr. Brown said, we support what we call a "specialty council" here, which is the representatives of our chairs and administrative counterparts across the enterprise. So we really utilize that group and that platform to drive communication and collaboration throughout the COVID-19 response and process.

ALEXANDER S. NIVEN: Pablo, you want to go next?

PABLO MORENO FRANCO: [INAUDIBLE]. So thank you for the opportunity. I'm Pablo Moreno Franco, and I chair the Critical Care Department in Mayo Clinic Florida. So Mayo Clinic Florida is a 304 bed hospital. And we function as a local hub for many destination-type practices, a significant transplant practice.

So about 67% of our volume comes from emergency department places. But the rest of that is part of that elective practice that includes transplantation as a significant part of it. But then, as we have been preparing and thinking about the COVID surge, we've had to extend our typical ICU bed capacity, that is 54 ICU beds, to nearly double that. So we'll talk some more about how we did that coming up.

ALEXANDER S. NIVEN: Ayan. Still muted, Ayan.

AYAN SEN: Good morning, everybody. My name is Ayan Sen, and I'm the Chair of Critical Care Medicine at Mayo Clinic in Phoenix. So Mayo Clinic in Phoenix has two campuses, in Phoenix and Scottsdale. Phoenix is the primary site for the hospital.

And we do have close to about 300 beds, 297 licensed beds. Similar to Florida, we are a destination medical center. And we are a major transplant center, cardiac, liver transplants, kidney transplants, and all that. We are also a major cancer center, neurosciences center, and ECMO center, providing a lot of regional care to the city of Phoenix and Scottsdale.

Obviously, a lot to discuss about how we are dealing with the surge in Arizona. We got some lead time when the pandemic hit the country, and initially, the surge was somewhat muted. But as you all heard in the media and other outlets that we are in the midst of a major surge in the state. And I'm happy to share some of our experiences as this webinar moves forward.

ALEXANDER S. NIVEN: Fantastic. Dr. Zurob, do you want to go next?

ADEL S. ZUROB: Thank you, Adel Zurob in Northwest Wisconsin at Mayo Clinic Health System in Eau Claire. Our hospital is probably the largest health care provider in northwest Wisconsin, out of three different hospitals there. And it's a trauma center, Level Two, as well as having cardiovascular, surgical, and other specialties.

We provide referral services to about three critical access hospitals in the area, as well as several communities. We're fortunate to be about only two hours away from Rochester, so we have access to a world-class destination center. And a lot of our work ends up being coordinated as part of the Midwest practice with Rochester.

ALEXANDER S. NIVEN: Thank you. Dr. Myers.

MELISSA K. MYERS: I'm Melissa Meyers. I am one of the Intensivists at the Mayo La Crosse Hospital within the Mayo Clinic Health System. We're located in southwest Wisconsin, about an hour from Rochester, and are similar in our scope of practice, although a little bit smaller than our colleagues up in Eau Claire. We have a hospital with capacity for about 100 beds and an ICU with 14 beds. But we typically have a census around 40 patients total in the hospital, with four to eight of those being in our ICU-- so much smaller setting than most of the other participants here, which I think has a lot implications for how we've approached planning in anticipating an in-surge of potential patients.

ALEXANDER S. NIVEN: Well, thank you very much to all. What we'd like to do is start by just telling you a little bit about how we coordinated our response to the pandemic as an enterprise and health care system. And for that, I'm going to turn back to Dr. Brown and Ms. Lehman to talk about the initial planning and response, and then have others join in in terms of their experience, and how they translated that experience locally. So Dr. Brown and Ms. Lehman, you want to go ahead?

DANIEL R. BROWN: Sure, thanks. Yeah, I mean, early on, it was pretty clear that there were going to be some commonalities across our practices. And as we'll talk, there are variations from a theme, but basically, it turned into working with our local hospital incident command structure to change our practice, to ramp down our electives and our normal operations in anticipation of this, and then preparing for a wave of cases that we thought we would see at the time, if you think back to it, first overseas, Europe, then on the coasts. And we were following that mantra, trying to anticipate a huge surge in patients.

And we're a town of a little over 100,000 people here. We're an hour and a half from a major metropolitan area. But we have a considerable amount of resources that we can bring to bear if need be.

And really, the local planning in Rochester was hand in hand with planning in other sites, as well as Mayo Health Systems. And I think there was commonality across that. But one of the biggest issues that needed to be addressed right away was a means by which we could communicate across our practices and identify common challenges and ways to work through them with local twists. And I'll let Lindsey speak a little bit to that development of structured communication and adaptability over time.

LINDSEY M. LEHMAN: Thanks, Dr. Brown. We really did take the approach of talking frequently to our colleagues across the enterprise, talking through the common problems that we were identifying, but also really our site-based opportunities and challenges. And as Dr. Brown said, that really relied on a partnership with our site-based HICS or incident command systems in each site, to really talk about the staff that were needed, the resources that were needed.

So really, the communication came down to us communicating as site-based leaders to our colleagues, what we knew, what we didn't know, and continuing this stream of information consistently to talk about our next step in the response, our most immediate concerns and changes. Because there were just a number of things that we felt like they constantly needed to be hearing from us. In addition, again, as I mentioned, we used kind of that specialty council or enterprise group to then also communicate to each other the different approaches that we were taking, and again, getting back to those more enterprise issues that we were identifying, how we would approach those as a group.

We wanted to be consistent in our response. And we wanted our Mayo colleagues across the enterprise to understand that we were in this together. And that we did ultimately have all of these resources, as Dr. Brown said, to bring to bear, not just that our individual sites but as a health system as a whole.

ALEXANDER S. NIVEN: I'll Just to ask before we move on and open it up to the rest of the panel. There was a question that just came in asking about the timing that the Mayo Clinic Enterprise started their mass critical care planning. Was it prior to COVID arriving in the US? And how did it differ from other hospital systems in the United States, such as New York?

DANIEL R. BROWN: Yeah, we had longer lead time. I mean, we still have not really seen what either coast and our southern sites are now seeing, here in the Midwest. So we had-- retrospectively, we wound down our practice in 48 hours. We went from 200-plus procedures a day down to less than 2 a significant downscaling of our practice. And we also recognized that we had considerable work to do.

So I'm pretty sure that everybody on this call was, in a similar fashion, trying to organize in anticipation of this arriving. And frankly, we have yet to be-- we've been impacted, but not to the degree that it is a significant interruption in our normal operations yet, at this point. But clearly, that differs depending on the sites.

ALEXANDER S. NIVEN: The translation of mass critical care and surge planning always has variations based on the setting and the surroundings. So I'll open it up to the rest of the group in terms of their experience on the collaborative end of this planning process.

PABLO MORENO FRANCO: Thank you, Alex. I'm happy to chime in. So I still remember back in February, we were in the Society of Critical Care Medicine Conference with Dr. Brown and Lindsey. And at that time, COVID was something that was coming, but we weren't sure actually what the implications would be for each one of our sites. So I do want to echo their thoughts, that part of the planning, it's really having time together to huddle about which issues each site is having to deal with.

And when I talk about that, the thing that comes to my mind more clearly is, for example, infection prevention and control and personal protective equipment. So how do you handle your staff and their concerns about their own safety in the light of changing HIPAA recommendations, and those recommendations from CDC and local operational control changes so frequently, having to manage that message for our staff, and having to talk about also generating procedures and what implications it would have for their health and exposure. And I think it was because of our enterprise call, because of having experts across the different sites talk about how many liters of flow should we be concerned about something that's aerosol generating or not. Do you handle differently non-invasive ventilation than your basic ventilation in terms of aerosol generation?

And really, the point of that is that it's because frequent huddles, I think at the beginning we were meeting more than once a week for a couple of weeks until we felt we had reached a fairly stable point. And then we could de-escalate the frequency of that meeting. And also, having the flexibility so that it's a meeting that is not with a full-blown agenda and things like that, but just more of a roundtable conversation, each site talking about the issues that they're struggling with, and most importantly, the other sites helping them answer them because of their experience or their perspective. And with that, then, you've also the opportunity to turn around all our local hospital incident command or infection prevention control and say, as a group, as an enterprise group, we have met and this is what we feel should be done.

AYAN SEN: Yeah, this is Ayan from Arizona. I echo Dan and Pablo's comments. I think those of you who are not at Mayo, I think what's important to know is that we have a pretty well-organized command and control system, multiple committees that represent different areas of the practice. We have clinical practice committees, hospital practice committees, and multiple other committees that take care of usual business.

Now, when the pandemic hit the country, the hospital incident command system was activated pretty early in the process, which met every day. And they had a presentation from hospital leadership from key areas, like infection prevention, ethics, and resuscitation. They met at different areas that were part of the decision making process, nursing, respiratory therapy as well, to provide that multidisciplinary flavor to planning and preparedness activities.

We did focus on the key parts that Alex did mention, the space, the staff, the stuff, and the systems aspects of care. The first big thing that we tried to focus on was engineering modifications, working with our facilities and EBS folks, what needed to happen to keep our patients safe and above all, our staff safe so that they could work with psychological safety. It included looking at creation of negative pressure pods, cohorting units, creating surge areas as necessary, as part of our surge plan. We are a small hospital in terms of number of beds and ICUs. But we planned for initially 25% to 50% increase in the number of beds and ICU capability through staffing plans, as required by the governor of the state.

In addition to the hospital incident command system, we mentioned about infection prevention that worked at the enterprise level and local level. We had groups that looked at medical branch staffing solutions. Also, we were lucky to have an enterprise modeling group that was activated at that time, which enabled us to look at the data, what would the sites actually be exposed to.

Because if you'll remember initially, we just don't know what the surge would look like. And as more and more epidemiologic data came through, we were able to do some predictive modeling to say, how many patients are we going to prepare for in the next two weeks, versus four weeks, versus four months? Obviously, it's a dynamic process and we continue to make amendments and changes based on new information and data.

But that was really helpful, so that the planners in critical care, in particular, could make those decisions in order to augment critical care resources. A lot of collaboration communication at the local and regional level-- our hospital medical director and met with CMOs from different institutions in the valley every day. And we wanted to ensure that we had good collaboration communication with other major health systems in the Phoenix valley, so that we were all prepared, and not one hospital was taking care of the surge, and we could distribute and share and allocate some of the pressures that every hospital was going through.

So that's kind of what was primarily our planning and preparedness activities in Arizona. It continues, four months down the line. And we have learned a lot of what to do and what not to do through that process.

ADEL S. ZUROB: I think how you approach this depends very much on the size of your facility and how much resources you have available to you. So for example, when all of this started, and most places probably stood up an incident command roughly end of February, early March, give or take. I think the focus in the first few meetings would have been, or the first week or so would have been on where can I get PPE? Do I have enough PPE? How much am I burning through?

I mean, it's the stuff that is going to impact you right away if you're going to get a surge in the number of patients coming to you. And nobody really knew how much they're going to get next week when they started with this. So there was a lot of on-the-fly, organized chaos, so to speak, where you're having to make sure that these things are secured, and what do I have, what do I not have.

And I think at some point, the next step was where people were looking at different spaces. Where can I shove another bed? If I need another bed, where do I put it?

But then, as this process matures, after the first shock of this, it becomes, what about my staff? How do I staff it? How do I actually transition from this to where my operations don't have to come to zero so that the hospital can still take care of other patients? What other sites can I look at within my system, so to speak, that allow me to take care of some regular operations for patients who might still have to have their surgery done. Or how do I separate them from others?

So I think the planning is dynamic. The issues that you deal with change as the process goes along. And once you kind of get into this, it's very, very important that your meetings, while they have a reasonable cadence so that you can address these things, they also are focused on some issues that you're trying to address, and not just simply meandering, and every day it's a different story that you're trying to pursue. But I think to answer your original question, when did people start, probably around the end of February to early March and in most places, I'd say.

LINDSEY M. LEHMAN: I would agree with that. We also kind of started our planning around that same time. The initial plan at the institutional level in response to an in-surge of patients in these smaller settings was going to be initially to refer them on to our larger centers in Rochester and elsewhere. And I think it was around early March that it was starting to become apparent from what we were seeing happen in some of the sites in Europe that there could conceivably be a situation where there would be enough patients that our large sites wouldn't be able to absorb any and all overflow that might come to us, and that we really needed to have our own plan here in our own setting.

And so I'll echo what Dr. Zurob was saying-- as much as we serve as a referral spot for critical access hospitals, we recognize the resources in them with regard to our planning. And so we started reaching out to them. What sorts of patients would you have the ability to care for? Could we send some of our non-COVID patients to them? Could they basically ramp up their function from serving as a rehab facility for some patients and kind of turn into an acute care hospital to expand our abilities in partnership with them to care for more patients?

ALEXANDER S. NIVEN: So there's a number of questions that are coming in. And I think in the interests of time, I'll ask those questions with our next topic that we wanted to discuss, which is, based on the lessons that we've learned from the first surge, what things are we applying to our daily operations now? And how are we balancing the care of COVID and non-COVID patients in our practice?

And I think there was one other question here asking basically if there was any tension between senior leadership in the organization and clinical planners in terms of shifting operations in directions that perhaps didn't match with expert opinion in terms of care delivery for COVID patients. So I'll just ask that question transparently, and we can comment on it as we go through.

So I think as we discussed and planned this call, we felt that Rochester was a great example of conventional planning or conventional operations right now. Florida was probably in sort of a contingency phase. And Arizona has really been very close to crisis phase over the course of the last several weeks. And of course, the health care system has is reflected more of the Rochester practice.

So I think maybe we can move through those things in order. So it's lessons learned, current operations and how we're applying those lessons learned, and then balancing COVID and non-COVID care. Dan, can I have you start?

DANIEL R. BROWN: Sure, happy to do it. So I can say right up front was that there was never-- there was always agreement in the pursuit of insuring staff safety and preserving our ability to care for our patients. That was the paramount focus throughout all of this. And that was supported from the top on down.

And so I would say that's not been an issue here. We've not been under pressure to try and do something that we didn't believe in or feel was the right thing to do. So thankfully, we have uniform vision of goals here, and so that's not been an issue for us, thankfully.

I will say that right now, this transition into coexisting with COVID is really what our focus is right now. We have ramped back up our practice for the non-COVID patients. And that's really what our focus has been, I would argue, over the past month or. So and Lindsey can comment more to that, but it's how do we maintain the ability to provide care to those patients that are coming to us with health problems?

Now clearly, some of our other sites are on a different trajectory there, but that's really-- I think that's been our focus over the next-- has been our focus recently and moving forward. And what I would say is that we've actually leveraged this opportunity to advance our practice and make change faster than we ever thought possible. I mean, our articulated vision for 2030 is this transition into digital care, et cetera.

And we have accelerated that. We have taken timelines that have been measured in years and we've already accomplished them now. And so many of our service lines are going back and having to redraw where do you see yourself being three, five, 10 years from now? Because we're already there. And so thankfully, there are some positives that have been coming out of this. And those really, again, are our focus at this point.

PABLO MORENO FRANCO: And Alex, if I may elaborate a little further-- I think that question is really good regarding the tension. And I agree with Dr. Brown that really, leadership and the front line, we've always tried to maintain a really good communication and by doing those huddles and participating in a hospital incident command system conversations. But what is also real is that this pandemic has significant financial implications for every industry, but also for the health care industry, in the sense that when you shut down your usual non-COVID practice, when you shut down your surgeries, all of a sudden things start to not do well in the financial aspects.

And we have to react to that. And it's all, as a group, trying to maintain what is called "business continuity." So really, that then created an environment to say, how do we beyond just being prepared and ready for COVID, how do we maintain a non-COVID operation?

And it's a very deliberate conversation that needs to occur, because all of a sudden, you have to have hospital floors that are dedicated for COVID, meanwhile keeping areas for the hospital that are not COVID. And you can then move between those two kind of continuously as spaces, depending on the volume of the surge that you're taking in at any particular time.

The other part of that question, I think, was related to treatments and how do we organize the tension between some providers or some leadership groups trying to push certain treatments down to our patients. And each one of our sites could organize in similar fashion.

I can comment particularly the way we stood up a treatment review panel, because all of a sudden, you have a lot of researchers who are trying to test a particular intervention. Meanwhile, you have the clinical practice trying to do what they're seeing in the literature. So how do you reconcile that and give the patient the best of both worlds?

And the way at least we organized that here was by creating that treatment review panel that meets three times a week. And it's in that setting that a treatment algorithm was created and really modified very frequently, several times a week, actually, as new research opportunities come in line or as new research is developed. So that way, it's a more evidence-driven, research-driven approach, without the political charges that could come from certain interventions.

AYAN SEN: Yeah, we learned a lot of lessons. And we're still learning lessons. And I think we all have to be honest that none of us, not at Mayo, not nationally, internationally, we were prepared for a prolonged public health emergency of this kind. Maybe some southeast Asian countries in times of SARS had experienced that, but really, we never anticipated that we would deal with a pandemic of this magnitude.

And we do table-tops and we have emergency preparedness committees institutions. But the scale and magnitude of what we are encountering is something that's unfathomable, and I think certainly has opened our eyes to what we could do better for the future as COVID's here to stay for the immediate future right now. So a lot of lessons learned.

And I think in terms of the tension and dissent, these are just natural parts of institutional challenges of dealing with something that we are not all prepared for. But what's good about it is that following the signs, and all the literature, all the knowledge that we gained out of encountering and experiencing it, has been worth its weight in gold. Even thinking about what's the best preventive mode, are the aerosol generating procedures, how do we protect our staff-- I think we have learned so much about the opportunities that we need to do and the innovations that we made and we need to continue to make into the future.

As I made a mention of the fact that the engineering modifications, the facilities-related aspects of things, working with EBS, and how do we take care of cleaning our areas and ensuring cleaning checklists are created? Those are things that really made a difference, because we can throw technology at the bedside. We can do all kinds of fancy ventilators, and ECMOs and things like that. But the real aspect of managing this pandemic is preventive care. And I think that's been the biggest lesson thus far.

Certainly, making surge plans-- how to ensure that we care for patients and not just focus on the individual patient, but how do we provide that bigger umbrella of caring for multiple patients with limited resources? How do we ensure nurses are able to deal with the challenges at the bedside and the uncertainty? A respiratory therapist-- I think those have all been learning points and continue to evolve our planning and preparedness activities around a multi-team, multidisciplinary concept.

How do we communicate messages? I think that's been an important learning part of it. Because in situations like these, where there is mass hysteria and concerns amongst especially hospital staff-- if you'll remember, we were hearing about health care providers dying in the front lines. How do we message it appropriately has been an important learning point, not just from critical care, but from the institution as well. Because we need to ensure that we do our best, our absolute level best, to ensure everybody has resources to protect themselves to be able to deal with the challenges in the front lines.

There's so many more. And I think it's a constant process of learning. And you heard about the COVID and the non-COVID balance that we initially thought wouldn't be necessary. It would be an epidemic, a pandemic that would go on for a month or two and go away.

But we have evolved in that domain as well. How do we live in that new normal, where we have to continue to take care of patients with cancers, and need transplants, and MIs and cardiac issues, and care for COVID patients as well, and ensure that staff fatigue in trying to balance these acts appropriately managed, and taken cognizance of, so that we continue to provide the best care for patients in their best interest.

ADEL S. ZUROB: And if I could say I definitely agree, that the biggest thing, our biggest realization, is that this is obviously not something that's going to be over in a month or two. So your plans, whatever they are, have to look at the next year plus, which means parallel planning for maintaining some normal operation as well as taking care of COVID patients. I think PPE is an issue.

So for us, it has been fortunate. We're part of a big organization that can leverage a lot of resources. So we didn't really feel threatened with PPE. But even for us, we had to think about at what point can you actually reuse some of your PPE? Do you have a plan if you have to go that way because of the supply chain being compromised, et cetera.

I think the other part, too, is that unlike when you have a mass event of-- I don't know, a train derailing. It's not just patients who are going to be affected by this. Your staff and their families are going to be affected by this.

And so any planning you're doing needs to also take into account what happens if 10%, or 12%, or 15% of your staff are out because they're sick, or their families are sick, or quarantined, or whatever. And to us, especially in a smaller institution, you really have to think about that. Where do I get extra docs? Where do I get extra nurses? Where do I get extra RTs?

How do I leverage my existing staff, like the providers using technology, so that they're not exposed to every single COVID patient, and then within two weeks, I don't have anybody who can work anymore. How do I extend the intensivists by using technology and using hospitalists, or having plans to draw people from the community, including family practitioners and internists, et cetera. All these plans do not happen in one day.

So if you don't plan for them now, recognizing that this will continue to go on, and as the winter comes and the flu season comes, these strains are going to be even more. This is the time to do it. And I think a lot of our time here, especially in the first few weeks, was focused on where do I get staff from?

It's not easy to kind of say, just send me 20 people. I mean, everybody is going to be going through some sort of a crisis of their own. And so you have to look at your own resources.

Recognize your limitations. What can I do? What can I not do? And then figure out how you're going to leverage your existing staff, and to some degree, shield the ones that are hardest to replace, because that might be all you have.

LINDSEY M. LEHMAN: I'd like to kind of expound on that a little bit, too, if I can, just from a more tangible perspective. I think especially in the smaller community settings, one of our biggest concerns is staff. For example, my current ICU is staffed with one charge nurse and two staff nurses. So even 10 COVID patients could be potentially very overwhelming to us.

And so very early on, one of the things that we started to do is to try and look at where do we have overlapping abilities and how can we leverage that to really support our critical care practice. So for example, if we do get to a situation where we have a lot of patients, we've built teams to support airway placement and central line placement, to help take that stress off of our intensivists. We have brought some of our outpatient family medicine and internal medicine providers into the hospitals already to start learning our electronic medical record, so that if we did get to a point where we had to have them help take care of inpatients, that wouldn't be completely new to them.

And we've done the same thing with our respiratory therapists. We have phlebotomists, and pulled them from our outpatient setting to get them familiar with our inpatient setting, in case we were to run into a situation where we had to leverage their expertise, so that people aren't trying to learn those new roles in the setting of an overwhelmed system, and trying to prepare for that as much ahead of time as we can.

ALEXANDER S. NIVEN: I think we have just about 10 minutes left. And there's a lot of questions with regards to the future and what things that we potentially envisage the future of critical care delivery, what form the future critical care delivery will take as we prepare for the second, third, or perhaps just the new normal environment that we exist in. And so I think I think why don't we just bring up the slides real quick, Jeff, to sort of summarize some of the take-home points that we've been discussing so far.

So I think all of us have developed a true appreciation for the degree of coordination and inter-professional collaboration that's required to provide high-quality mass critical care planning, using the conceptual framework of space, staff, supplies, and systems, and really partnering with both the hospital incident command system but going beyond that, especially as we move from the sprint to the marathon the pandemic has become. One thing that came up in our discussion prior to the start of this call was the importance of simulation and practice, to make sure that the innovations and changes that we have made along the way work and work well before we put it into a busy and stressed practice environment. And the importance of communication, both within a health care system within a specific institution, and also at a unit leadership level, cannot be underestimated.

I think what we've really been looking for is opportunities to leverage this really challenging situation that we face with regards to adapting our whole mentality towards critical care delivery, and leveraging that for system innovation and change. As Dr. Brown had mentioned, I mean, we've really accomplished some of the goals that we've set out for 2030 because of the forcing pressures of this current pandemic. And obviously, the end goal that we have here is to both improve patient care systems, leveraging all sorts of technology with regards to remote monitoring, and then also, at the same time, strengthening our safety processes for staff. Because obviously, if we can keep our staff healthy that solves a big challenge in terms of identifying additional staff who we have to potentially bring to bear.

So striking that balance between COVID and non-COVID in the new normal, I'll just ask if we can advance to the next slide here, and just open it up to the group. Because there's lots of questions still about where we're going and what we see the future being when it comes to critical care delivery in this setting. So I'll perhaps turn to Pablo first, and then open it up to the rest of the group to finish up the conversation.