Strategies in Supporting Deployment during the COVID-19 Pandemic

The ongoing COVID-19 pandemic has strained health systems globally. As of October 2021, there have been more than 45 million cases and 700,000 deaths in the United States.¹ Northwell Health in New York serves Queens County and Long Island, which account for 30.4% of New York state’s more than 2.5 million confirmed cases.²

The initial surge of COVID-19 cases in the adult inpatient units in March-May 2020 strained the supply of medical resources (e.g., ventilators, personal protective equipment [PPE]) and medical personnel. In response to the desperate need for medical personnel to care for adult COVID-19 patients, many health systems mobilized healthcare workers from the adult ambulatory setting and multiple other departments, including pediatrics. At Northwell Health, a large healthcare organization in New York, more than 100 pediatric attending physicians, residents, fellows, and advanced care practitioners were deployed to adult inpatient wards and intensive care units (ICUs).

This article describes our experience in identifying generalizable themes in the deployment process. In response, we rapidly created a multifaceted structure to identify and address needs among deployed pediatric staff. These measures included virtual meetings (2-4 times per week), HIPAA-secure group messaging for resources and real-time peer support, and structured recorded debriefings. This was facilitated by 2 dual-trained internal medicine-pediatrics primary care physicians and a pediatric intensivist who had also been deployed. Most of the clinicians were deployed for 2 to 4 weeks. We conducted one-on-one and group debriefings following their return from deployment. Themes were identified and agreed upon by consensus by the 3 co-authors as facilitators. This study was reviewed by the Northwell IRB and considered exempt.

Identifying Deployment Needs

The evolving needs of pediatric clinicians were identified as each cohort was deployed. These needs varied with each stage of deployment (i.e., prior to, during, and after deployment).

Preparing for (Prior to) Deployment

The role of leadership was essential to the deployment process. Clinicians wanted to understand why they were chosen for deployment, how they would be informed, and the duration of deployment. Transparency in this process from clinical and administrative leadership can help ensure a smooth deployment.

The organizational concerns of clinicians included clarifying their roles in the care team and understanding expectations. Additionally, faculty were concerned about liability, specifically in caring for patients outside of their specialty. The need for orientation around logistics (i.e., deployment timeline, geographic set up of inpatient units, patient assignments, etc.) was clear. This orientation was often facilitated by a non-clinical administrator, but providers preferred a clinician-led orientation.

As clinicians prepared for deployment, they identified gaps in their medical knowledge of COVID-19 management and inpatient adult medicine topics. They found it helpful to review changing COVID-19 guidelines, acute respiratory distress syndrome, and ventilator management (for those deployed to the ICUs). This was done through 60-90-minute recorded video meetings and they reportedly informally that it increased their preparedness.

Lastly, emotional support was invaluable. Clinicians felt anxious about medical incompetence, lack of supervision (especially trainees), and the risk of contracting COVID-19 or exposing family members. Many clinicians isolated from their families in their homes or in hospital-sponsored hotel rooms. All had a “decontamination” process once they arrived home from the hospital. Sharing these practices reduced anxiety and empowered clinicians to manage their own infection control procedures.

During Deployment

New concerns arose during active deployment. Leadership engagement—from the clinicians’ home department and their deployed department—was crucial. Leaders tried to stay aware of what was happening “on the ground” through scheduled conference calls and informal phone/text communication with clinicians. Those who felt unsupported cited lack of leadership involvement and feeling isolated as major contributors.

From an organizational standpoint, the team structure was key. Mixed discipline teams that included clinicians trained in adult medicine or critical care (in the ICUs) paired with pediatric staff helped orient our pediatric clinicians and provided ongoing support around logistics and clinical knowledge.

Deployed clinicians had to confront “learning on the fly” as the prominence of non-COVID-19 related topics increased. However, this did not compare to the challenge of addressing death and dying, compounded by unfamiliarity with end-of-life procedures. Many pediatricians provided more end-of-life care during deployment than they had in their entire careers, discovering they did not know how to pronounce death or complete death certificates. Learning evidence-based techniques to navigate end-of-life conversations with patients and families became a priority. These discussions were particularly difficult given the absence of visitors thereby forcing clinicians to have these conversations through telephone calls and video conferencing, with voices and visual cues obscured by PPE.

Significant emotional support was needed to cope with death and dying. Many clinicians felt helpless and worried (“Did I kill him?”) when patients died under their care. In addition, the public’s view of healthcare workers as heroes juxtaposed against the immense death clinicians were seeing led many to feel their service were not very “heroic.” Additionally, many felt that their family members outside of health care or their non-deployed colleagues could not understand their experiences. Creating a community of support both formally and informally to aid those who are deployed can help this process.

After Deployment

From a leadership standpoint, many received gratitude and moral support from their adult medicine colleagues. They felt appreciated from their home departments as well, often receiving “homecomings.” The question of compensation (both financially or through paid time off) was also raised. We feel that supporting deployed providers in this way is important as a display of institutional support, whenever possible.

The organizational aspects of transitioning from deployment back to normal duties focused on the need for a break before returning to their “day jobs.” This was not always possible with residents and fellows. We urge leaders to give time off to deployed clinicians before resuming their usual responsibilities. Many providers felt 5-7 days off was sufficient and creating a coverage system that enables this relies on leadership.

Deployed clinicians gained knowledge that could be shared with their home department, specifically around end-of-life and palliative care. The need for emotional support was greatest during the post-deployment period. It was only after deployment that clinicians felt they could process their experience emotionally and psychologically. In our program, we reached out to deployed staff 1-2 weeks after their return, informally screening for depression and anxiety, and sharing institutional resources to support their well-being. Health system supports included confidential free counseling services for employees as well as mindfulness and support groups led by colleagues in psychiatry.

Lessons Learned

In our experience, if the process of deployment is handled with care, many would be willing to be deployed again, if needed. As the COVID-19 pandemic continues, we share our lessons learned and recommendations for supporting the workforce during deployment:

• The biggest challenge was dealing with death and dying.
• Many had feelings of helplessness, anxiety, and guilt.
• Do not underestimate the importance of a well-organized deployment process in reducing anxiety and increasing preparedness of deployed clinicians.
• A buddy system that pairs adult inpatient clinicians with deployed clinicians is crucial.
• The period after deployment is a critical time to provide emotional and psychological support.

We believe that these principles can be broadly applied to all deployed clinicians, including internal medicine-trained providers who may not normally practice in the hospitalist medicine or adult critical care setting. It is our hope that by sharing these experiences and themes, we can all be better prepared for the next time that medical personnel must be mobilized.

Acknowledgements: Thank you to Charles Schleien, MD, MBA, Philip Lanzkowsky, MD, chair of pediatrics and SVP of Cohen Children’s Medical Center/Pediatric Services, and Stephen Barone, MD, pediatric program director and vice chairman for education, for their support in this endeavor from the Department of Pediatrics. Thank you also to Joseph Conigliaro, MD, MPH, FACP, division chief of general internal medicine and vice chair of academic affairs in the Department of Medicine of Northwell Health for his support and review of this paper.