Thanks for having me. I will tell you a little bit how we responded in our health system and mostly how the state of Oregon responded to this never-ending demand on ICU on the adult and on the pediatric side. I have nothing to disclose. I want to disclose that our Mission Control Command Center runs on a GE software platform. We will talk about our ICU response in our health center, Kortner Health Center in Oregon, and also then how we pivot to the statewide response. To give you a little bit background about OHSU, it's sort of a mid-size academic center. We have the nice part that we're up on a hill. We are the only academic center I'm aware of in the world who has an aerial tram you can use to get to work, which is kind of fun. We have two community hospitals. We're about 10 miles away from the main campus, one on the east and one on the west side, and we are sort of in this upper northwest Pacific corner here. This is what my team, my department does. We manage the capacity for the health system. We run our system transfer center. We do a lot of the emergency activation. We oversee the virtual hospital, and we prod in a lot of predictive analytics and reporting structure. And so for our journey, we started in 2016. We managed our capacity on a whiteboard. Nurses gathered data. ICU attendings gathered data. It was never congruent. They were always different in opinions. We put it on there. By the time we were done writing, it was outdated, and we kind of realized in 2016 this is not a good way to continue to practice our capacity management. So we invested in technology to get these data in real time. It's automatically updated out of our EMR systems. We have both Epic and Cerner, and it pulls it in there, and it uses other teletracker and kind of wherever it comes from. We can see in real time which beds are occupied, which are planned to be occupied, which are discharging, and that was kind of what we started in 2017. During this pandemic, we then advanced to really get like a forward looking, like the forecasting, like how the next nine days look like. How do we make next Wednesday look better than it is predicted to look? And what we learned is that going from this whiteboard, retro-reactive approach to active problem solving, and then actually incorporating how the future will look and make it better, both from a staffing and from a demand and level loading kind of perspective, was a really interesting journey. And like even today, it's sort of like you have to remind that your executives are used to look at dashboards who give them data from yesterday, but nobody is really well versatile in looking at how tomorrow and next week will look like. We also invested in the people, which is probably the biggest success we had there. Like when I started this, we had two to three people on per shift to run our capacity. They were in multiple departments. There was no org charge who kind of organized that. Now we have eight to nine, sometimes 12 people on. It is one department. Everything is co-organized. I have a nursing dyad who kind of manages that with me. So when we went into this pandemic, like the benefit on the West Coast was that the East Coast got first hit with COVID, and we could see what everybody did there. So the question for us was, how do we do it? And we'd like, we have forecasting tools. We have, and then we kind of use sort of basics of emergency disaster management. We kind of very early on decided, like we need to know thresholds so that we know how bad it is, so that we are not missing out when we have to pivot to that. And we had to update our playbook very regularly. We developed new communication structures. How do we deal with like that? We moved everything to work out that the hospital, unless you are actually providing active clinical care. So we created virtual huddles, which existing today, instead of spending two hours in the morning. Now it's like each huddle is like five to 10 minutes. So that's super helpful. We advanced in Teams chat, which we created for all of our ICU teams. The attendings are connected by a Teams chat with our bed flow system, with our command center. And we can really troubleshoot and manage in real time. And we usually used more and more of a real time data. We also knew we need to be flexible. How can we create more space? And for us, the option was pack your day surgery. And we also advanced into the virtual hospital world, both within hospital at home for acute patients to pull patients out of the acute care units and the emergency room. And we used the federal waiver to upgrade our day surgery center to an inpatient center, which we are still running as such. We did all sorts of things, good thing and bad things. Initially, we did internal reassignment and mandatory labor distribution. That was the worst idea we ever had, like telling a nurse who kind of already decided she wants to go, he or she wants to go out of the ICU, going into our PACU in the eye clinic and just do Monday to Friday work. They didn't like being redistributed. Some of them volunteered, but ultimately, it wasn't a good idea. And from there on, we started to really do it with a voluntary approach. We redistribute workload, we tracked it between the various ICU teams to kind of really level load them better. Up to today, like all of you, we're using travel nurses. But rather than doing as a bag of the napkin calculation how many we may need, we use our advanced analytic to literally say, in eight weeks, I need that number of nurses. And we, on an executive level, decide on how many beds do we want to staff. And then the delta of what we have actually on our crew, how many sick calls and everything have, we kind of use that. And intermittently, we got state-supported crisis staffing, depending what state of emergency was declared. In the operating room, we used all of this knowledge to really manage the up and downs of our demand, which comes really from the surgical schedule. And to whatever reason, in Oregon, surgeons want to do all their cases on Wednesday. And we kind of like, that doesn't work, and we really level load it. So with our thresholds, we decided, you can actually do more cases over the course of the week, but you need to do every day the same number of cases. We don't really care what specialty it does, but it needs to be loaded. And we got to this. We really created that with our data and our partnership with peri-op, using our forecasting and the real-time data to manage anything in that. And with all of this in the background, we also came to is like, can we create a shared vision that the state of Oregon can function as one health system while we historically all compete in this space? And here's just like, this is a map of Oregon. This is the hospitals we have in Oregon. By the way, if you're on the top of the, that's the aerial tram, that's Mount Hood. So this is the morning commute if you work at OHSU. We're looking for anesthesiologists, if you're interested. So Oregon has only 62 hospitals. We are number 50 in per capita hospital beds in the state. And out of the 62, 25 are critical access hospital. If you look at the east part of the state, these are all only critical access hospital. So you can imagine that health inequity, access to higher level of care is a big deal in our state. We have six regional resource hospital, and this is how we kind of organized us. Like we used the trauma concept. Each of them are like, in region one, we are one of two, like OHSU is one of two, level one trauma center. Everything else is like level two or level three trauma center. But we used any of these tertiary centers and made them a regional resource hospital with partnership with the state, with Oregon Health Authority. And like, this is how it's kind of distributed, pretty following where our population is. And these people, like this regional resource hospital is the anchor point. And then we established communication between the regional resource hospital to easily communicate and find like who can take the next ICU patient. We did frequent video conferences. Currently, we do it once a week. During RSV, we did it almost daily, or like three times a week. So we pivoted up and down and we created a coordination center, which I'll share with you. So how do we get to kind of the visibility that we can function as one health center? So in March, 2020, we kind of get on this journey and say, hey, can we track all beds across the entire state? And the answer is yes. And this is sort of the roadmap, depending on size of hospital. We put it in our data warehouse and you can take the output on a desktop. You can pull it up on your smartphone. Like we gave every hospital access to it. There's no HPI data on there. It's just like, is the bed occupied or not? This is how the first version looked like. It's a busy slide, but these are like all the regions we have with the main kind of hub in that area. And it's the areas like from adult ICU down to the different level of neonatal ICU. The color coding here shows you what is full, what is still occupied. As you immediately see, it doesn't show you if the bed is staffed or not. So we had to work on getting some consensus how we manage unstaffed beds. We got to 60 of the 62 hospitals. The two hospitals are not on there are two critical access hospital who are in the process of changing their EMR and it was just not feasible for them to do it. But like we tracking 92% of the hospital beds. Similar like what we encountered in the academic center, it was very clear early on that this is good, but it only works if we have people doing that. So in August 2021, in anticipation and seeing what the Delta wave will show us, we kind of made the commitment between all the health systems that we are building a coordination center for the unmet demand in critical care. Just as a refresher, like in Oregon, probably similar for us, the transfer works like hospital A calls hospital B, which is their business relationship, their normal referral pattern, or the regional resource hospital, which is often the referral in the regional hospital and the wait lists are the same. Then there are three options. Either we have a bed, we say, yes, the patient transfers. Most commonly, we don't have a bed, we still say yes, and the patient goes on a wait list, which doesn't help the critical access hospitals or what became more prominent during this pandemic, we said no, and we also didn't wait list because the wait list was already a couple of pages long. So what we did, and then the critical access hospital, some of them told us we called 50 hospital up and down the West Coast. It was unattainable. People kind of really assigned a nurse to just come into work and call all these transfer centers up and down. And we all know the downsides of this if a patient is not at the right level of care. So what we did with the Oregon Medical Coordination Center, we initially started at a very simple fashion. We just like all the big health system in the city of Portland, the two trauma centers, the VA and everything, we agreed, let's just share if one of us can place at the next transfer center ICU patient, if you need ECMO or CRT or anything like that. So we did this consistently and shared with each other. And initially there was a lot of concern about the politics of that and how we interfere with business relationship, but focusing on the unmet demand really helped us to place. And so this got us through the Delta wave and then we thought it will get us through. Then in September, we made another record, not only having the least amount of beds in the United States per capita, we also got the worst, like we topped the worst air quality in the world. And I couldn't be like, it was really, you opened the door, you went out and you thought you stepped in a fire pit. This is just a picture from my backyard. You could see anything, it was just horrible. This is the fire zone, red is active fire. And as you can see here is a tertiary hospital, like a 300 bed hospital who was in the evacuation zone in the midst of like increasing input of Delta. And we kind of really started like, how can we do that? And like, so the Oregon Medical Coordination Center and via the Regional Resource Hospital kind of really started to evacuate their NICU because that was the most time consuming and we started to evacuate their adult ICU. And fortunately then the next day the weather changed and we didn't really completely evacuate the hospital, but the National Guard was at standby in the airport to kind of receive patients and fly them out. This tool became very helpful in our discussion because it updated in real time and I could actually tell that hospital CMO, you still have two babies in your NICU while they thought they had all accounted for. And like, so it was very helpful. Ultimately we evacuated some other hospitals on the coast because of the fire, critical access hospital and we could track when they were empty because it was updated in real time. This is how it looks today and we added like a substantial part, the EDs like both the sensors and the ED borders, which we define as the patient who needs to be admitted to an inpatient setting, both for adults and pets. And then we also track equipment like ventilators, ECMO circuits and CRT circuits. And this is like how the OMCC2 now functions. We got state funding, it's nursing staff, we do all acute care hospitals, we do the critical care on the adult side, we do all pediatrics, unmet demand and we're building it out for mental health and there's some idea to potentially do it also for post-acute care and redistribution into community to make this one way street to a higher level of care being better working with a load balancing. This is like just sort of a summary how we went through these waves from like February 2020 to March 2023. Like so the last part is our prediction. You can see that our modelers were pretty good. Like our reality actually worked, how the forecast is. Like these are the interventions we did at our academic center and then statewide. Early on, we got the real-time data tracking. We had the regional and statewide connections. We really established operational partnership with everyone. We opened these two centers and then the pediatric RSV response came. And this is sort of the data of the statewide tile and I wanna show you that like Oregon only has 48 pediatric ICU beds in three different units, like two are standalone pediatric hospital and one is attached to an adult hospital. On average, they run about a census of 2022. They can stretch up to 30. This is how they were staffed in all of that. So here is like, this is the previously unstaffed. Like they are fully equipped, but they are not used. So on November 14, like recognizing on Friday that the two critical hospital, the children's hospitals are in a dire distress and we can't flex up. We worked with the state and asked them, please declare a state of emergency. Monday night, the state of emergency was declared, which allowed both children hospitals go into a crisis standard of care, which is required in Oregon whenever you want to go outside your staffing plan. And our nurses were actually asking us, please declare a state of emergency. Please go declare the standard, a crisis standard of care so that we can do what we need to do without risking our licensors. And this allowed us then, like you can see, like over a 24 hour period, we really added 20 to 30 ICU beds. We opened up overflow areas in our pediatric PACU. And like at times we were running 60 PICU patients in that. On this tile, I only looked at the physical patients in the PICU. We also double occupied several of our PICU beds here. So this was really using the playbook from the adult side and the P side. This is the same time. This is the borders in our state. And you can see that from November 14, when the emergency for pediatrics was declared, we got also an uptick on the adult borders. It was really sort of simultaneously with like 10 days behind it. So here we kind of then kind of declare the state of emergency for the adults, which also allowed us to go in crisis standard of care to flex our staffing around that. So the message here is really like having these active real time data allows us to be a vital sign monitor for the state. And like we could message that and got like the disconnected health system really to look at the same data and react in unison and function as one pediatric ICU and also on the adult side as one system. Thank you.

Oregon

ICU

pediatric ICU

COVID-19 pandemic

real-time data