Baltimore convention center field hospital experience

The BCCFH opened in April 2020 as an alternate care site for patients with COVID-19, alleviating Maryland hospitals and emergency departments, particularly during the COVID-19 surges that occurred after the first wave of infections. Such field hospitals, used in a variety of disasters, operate under a sufficiency-of-care model. Sufficiency of care is defined by the Joint Commission as care that is sufficient for need but may not be the same quality of care delivered under normal circumstances. ^{Reference Teck, Baldacchino, el-Guebaly, Carrà, Galanter and Baldacchino7} Although health care providers should ideally have the tools, training, and environment to provide the standard of care, it is permissible to operate under a sufficiency-of-care model in a disaster setting. Because the BCCFH was activated under a sufficiency-of-care model, it was permitted to rapidly hire and credential providers with valid medical licenses from any state in any specialty.

The BCCFH recruited medical doctors, nurse practitioners, and physician assistants from various backgrounds who could care for (with additional support as needed) acutely ill COVID-19 patients with comorbid medical conditions such as diabetes and hypertension. Many of these providers were employed in other, non–acute care settings and worked at the BCCFH because of reduced outpatient demand in these settings or on their days off. Although the physicians and advanced practice providers had the skills necessary to care for patients with COVID-19, many were uncomfortable treating patients with OUD. Patients voluntarily accepted transfer from other hospitals to the BCCFH, and many of these patients had unstable or group housing, limited financial resources, and little or no family support. Patients in these situations also have a higher risk of OUD and require drug withdrawal precautions and initiation or continuation of medication-assisted addiction treatment on admittance. ^{Reference van Draanen, Tsang, Mitra, Karamouzian and Richardson8} The longer the BCCFH has remained open, the better its providers have understood the importance of a focused effort to address this need.

Despite scarce resources compared with those of typical hospitals (e.g., initially the hospital had no consultants), the BCCFH team realized that deferring SUD treatment to outpatient or inpatient specialists would adversely affect care transition and the overall success of COVID-19 care. For example, patients with ongoing medical needs related to COVID-19 may leave against medical advice if their SUD is untreated. The BCCFH leaders also recognized that acute care providers on staff had relatively limited skills in the longitudinal management of SUD. However, the pandemic also motivated primary care doctors with experience in addiction medicine to sign up to provide care for COVID-19 patients at the BCCFH. BCCFH leaders leveraged these providers’ skills, promoted them to leadership roles, and encouraged SUD training opportunities for providers. Although the field hospital was initially designed to solely treat the acute care needs of patients with COVID-19, BCCFH leaders realized a need to reconsider treatment plans and staff training to provide treatment for patients with SUD.

As BCCFH providers were continually adapting to changing COVID-19 protocols, an environment was fostered in which policy and procedure changes were made in response to provider feedback. As a new, temporary site with freedom to initiate novel approaches, the BCCFH had no institutional inertia or “culture of no.” Institutional inertia is an institution’s resistance to change stemming from internal protocols or lack of willing staff. “Culture of no” is the reflexive or almost automatic response given to staff wanting to create change. This collaborative environment contributed to the creation and success of its OUD treatment program. During the first wave of COVID-19 infections in the spring of 2020, BCCFH medical directors established an OUD care plan informed by provider feedback. BCCFH leaders then took advantage of the decline in COVID-19 hospitalizations during summer 2020 to refine the process in anticipation of autumn and winter surges in case volume.

Overview of SUD treatment at the BCCFH

Treatment for patients with SUD at the BCCFH is carried out as follows. Providers at the BCCFH evaluate all patients for SUD before the patients are transferred to the BCCFH. Early identification of SUD allows multidisciplinary teams to proactively meet patient needs by reviewing care plans daily and assessing for adverse reactions to medications. This care coordination enables patients to continue with outpatient counseling via telehealth, ensures patients are discharged with naloxone in hand, and establishes patients with outpatient SUD follow-up.

During the summer and early autumn of 2020, when COVID hospitalization volumes were low, the BCCFH pharmacists and medical directors created an onsite pharmacy that can provide methadone, buprenorphine-naloxone, and medications for acute alcohol withdrawal. This pharmacy has allowed patients taking methadone or buprenorphine-naloxone to continue on their dosage during admission and after discharge, with buprenorphine-naloxone prescribed by a provider with an x-waiver. Additionally, the creation of the pharmacy has enabled the BCCFH to accept patients experiencing acute alcohol or opioid withdrawal or patients whose medication-assisted dosages were inadequate and adjust dosages as needed.

BCCFH’s staff provide targeted SUD training for its providers through informal clinical rounds and formal presentations. Providers with extensive experience with SUD are “on call” for questions or requests to assess patients as needed through a Health Insurance Portability and Accountability Act–secure messaging system. These procedures allow providers to start, titrate, or continue medication-assisted treatment. Initially, only providers who had SUD experience treated patients with SUD. However, this training process has helped providers new to SUD care develop the competency needed to independently and safely initiate and titrate medication dosages for motivated patients

Medication-assisted treatment is one of many therapeutic approaches that have been implemented by the BCCFH. The BCCFH social work department works closely with patients, usually seeing them within 24 hours of admission to address needs such as housing, rehabilitation, and outpatient appointments. This department coordinates telemedicine visits so patients can continue therapy with their outside SUD therapists, providing critical continuity of care. Many patients ask to initiate treatment, and with the leadership of the social work team, BCCFH providers have been able to discharge patients to outpatient and inpatient addiction treatment centers. BCCFH staff use multidisciplinary clinical rounds to discuss patient needs and plan for discharge, considering psychiatric comorbidities, past trauma, family and housing challenges, and ongoing physical therapy needs.

Although the BCCFH is a ‘closed unit,’ the hospital has experienced patients and even staff bringing in contraband, leading to the risk of patient overdose. To address this issue, BCCFH medical directors created rapid response drills and trained staff, including providers, nurses, support staff, and security personnel, to recognize and respond to opioid overdose. ^{Reference Chaudhary, Howell and Ficke9} At discharge, patients with OUD are given a naloxone kit. BCCFH leaders encourage team members to use a confidential reporting system for concerns regarding contraband. Staff supervisors follow up on all concerns. Nurses follow strict protocols for securing and tracking Schedule II medications. Nurses also redirect patient requests for as-needed narcotics and addictive sleeping medications, encouraging use of safer alternatives. Saline locks are removed when remdesivir treatment is completed to reduce opportunities for the use of as-needed intravenous opioids.

As the COVID-19 pandemic continues, providers at the BCCFH will continue addressing the needs of patients with SUD. BCCFH leaders initiated a psychiatric nurse practitioner program which provides care for patients with comorbid mental health conditions. This program provides individual and group therapy, coordinates with outside psychiatry departments for telemedicine consultations, and communicates with patients’ outpatient psychiatric and opioid treatment providers.