Coronavirus: How Dartmouth-Hitchcock Is Reopening Paused Services

Dartmouth-Hitchcock features a 400-bed academic medical center as well as four affiliated critical access and community hospitals in New Hampshire and Vermont.

Safety measures

Dartmouth-Hitchcock has initiated several safety measures, and a key metric shows the efforts have been effective, Merrens says. “We have not had any staff contract coronavirus from a work-related incident.”

The safety measures have included:

• Universal masking: Masks are provided to everyone—employees and patients—who comes into a hospital across the health system.
• Patient encounters: When interacting with patients, staff must wear not only a mask but also a visor. For more sensitive environments—whether it is an operative setting or in a COVID-19 unit—there is the highest level of PPE including gowns and gloves.
• Waiting rooms: Some chairs have been removed from waiting rooms to establish social distancing.
• Appointments: Patient visits to hospital departments and outpatient clinics have been spread out with extended workdays and weekend visits.
• Reduced patient visits: “We have clearly reduced the number of people in the hospital. We have found different ways of getting to people with visiting nurse services to reduce the number of times patients have to come to the hospital. Physical therapy for joint surgery can be done online with videos,” Merrens says.
• Telemedicine: “We were able to pivot many of our visits to telehealth, which has been a big part of our recovery efforts. We already had a very robust telehealth capacity with our Connected Care, which was doing everything from critical care to specialty care before the pandemic,” he says.

Managing the reopening

In early April, Dartmouth-Hitchcock launched the organization’s Clinical Recovery Command Team to manage the reopening of paused services.

“We have tried to look at each area and determine what is needed for patients, what are the barriers, what are the things we are trying to achieve, and how we can implement change across our health system,” Merrens says.

The command team has nine work groups:

• Surgical group focusing on the academic medical center’s main operating rooms and the health system’s outpatient surgical center
• Interventional procedures that are not necessarily operative such as cardiac catheterization, interventional radiology, and electrophysiology
• Endoscopy and minor procedures
• Primary care and pediatrics
• Ambulatory surgical and specialty care
• Radiology
• Lab work
• Community group practice
• Affiliated hospitals

The command team reports directly to the health system’s president and CEO, Joanne Conroy, MD, and includes many of the organization’s senior executives, Merrens says.

The multidisciplinary committee is led by a clinical-administrative dyad: Merrens and Chief Operating Officer Patrick F. Jordan III, MBA. Jeffrey O’Brien, MHA, MS, senior vice president for clinical operations, leads two vice presidents who directly oversee the nine work groups. “The individual work groups have other vice presidents, directors, and line managers who are dedicated to their areas, and they work with clinicians,” he says.

Orthopedics is a good example of how the command team is approaching the reopening of paused clinical services, he says. “We have people thinking about restarting orthopedics, and they are working with our perioperative vice president, the orthopedics director, the department chair, and section chiefs. They are not only working on trauma—which has not changed during the pandemic—but also how we think about elective cases.”

The command team is operating under several guiding principles, Merrens says.

• “The first guiding principle has been assessing our situation. If you look across the country, Seattle, San Francisco, New York City, Boston, Chicago, and New Orleans have all had different experiences in the pandemic,” he says. “We have flattened the curve in our region, so we can plan and think about what comes next. If you are in a situation like New York City, where the ICUs were filled, it can be overwhelming.”
• The command team is committed to simultaneously providing COVID-19 care along with a wide range of other medical services. “What we have been able to do is to think about the pandemic as a long-term process in our region. We have had low levels of infection rates—probably less than 10% of the population. This does not lend itself to herd immunity, but it does lend itself to doing COVID care and regular care at the same time,” Merrens says.
• Ensuring there is an adequate supply of PPE is essential. “We have had tremendous donations from the community. We have been able to source PPE with colleagues across northern New England. We have implemented a process of recycling our N95 masks—we have a hydrogen peroxide vapor system that allows us to reuse masks. Everyone on the staff has their own mask. Once they use the mask, it can be sterilized,” he says.
• Academic activities are a significant element of the recovery process. Dartmouth-Hitchcock has assembled a team of experts in microbiology, epidemiology, and lab services to conduct innovative research such as nearly 30 clinical trials related to the coronavirus pandemic.
• Meeting community needs is a priority, Merrens says. “That could be COVID care. That could be routine screening. That could be childhood immunizations. That could be hip replacements.”

Pandemic’s silver lining

The COVID-19 crisis has been a driver of innovation at Dartmouth-Hitchcock, Merrens says. “The pandemic has allowed us to rapidly adopt different ways of doing things—whether it is telehealth or expanding our workday. It has allowed us to make changes that we might not have made as rapidly before the pandemic. We have been able to use the pandemic as an opportunity for positive change.”

The height of the pandemic and the reopening process will have a lasting impact on the health system, he says. “This will fundamentally change who we are and how we provide care. So, this is not getting back to how we were doing things before—we will always do things differently in the future.”