Leading the Charge

Special Section: Health Innovation

By the time that Maryland health officials confirmed the state’s first three cases of COVID-19 on Mar. 6, Dr. David Marcozzi was already hard at work developing a multi-pronged response to the pandemic.

Dr. Marcozzi is an associate professor of emergency medicine at the University of Maryland School of Medicine. He also serves as COVID-19 unified incident commander for the University of Maryland Medical System and the University of Maryland, Baltimore.

A member of Gov. Larry Hogan’s COVID-19 Task Force, Dr. Marcozzi has held senior-level positions at the U.S. Department of Health and Human Services; leadership roles with the White House National Security Council; and is a colonel in the U.S. Army Reserve who served in Iraq and Afghanistan.

Jmore recently spoke with Dr. Marcozzi about how the hospital system prepared for and responded to the pandemic.

When did you first realize the seriousness of COVID-19 to Marylanders?

We quickly realized the threat we were facing as the virus initially entered the U.S. prior to having cases in Maryland or Baltimore. At the end of January, we started earnestly looking at what preparation and response was needed to respond to this event and started taking action. UMMS hospitals all performed standardized drills with multiple pandemic scenarios to appreciate our strengths and understand our challenges to improve our readiness for this public health crisis.

Our first confirmed case within the University of Maryland Medical System was on Mar. 8 at UM Upper Chesapeake Medical Center [in Bel Air].

How did you devise the plans for the hospital system’s response?

The key thing was that the response was anchored in an organized approach. Using well established protocols, we set up an incident command system, an organizational structure that allowed us to step outside of the routine decision-making process and prioritize preparedness and response decisions to prepare for the pandemic and assure coordination across our entire health system.

There were six [objectives], each involving a large set of efforts.

1) Protect our staff and faculty so that we could maintain the ability to care for patients.

2) Develop an early ability to recognize patients who were COVID positive through symptoms and testing.

3) Determine the best ways to confirm diagnoses and to evaluate patients.

4) Determine the best treatments for COVID positive patients.

5) Continually plan for what lies ahead and to make sure we were ready for unexpected challenges.

6) Effective communication, internally between staff and administrators, and externally with the press and the public was vital to the effectiveness of what we were doing.

How did you prepare staff?

We started practicing for the arrival of COVID-19 in February before we even had a case in Maryland. We’d get a group of administrators, doctors, nurses and staff in a room and run them through different scenarios. We’d say, ‘OK, we’ve got 20 people coming through the doors with the virus. What do you do?’ Then, we listed all the challenges we identified and worked to find solutions.

There was a clear mission to get our hospitals ready. In February, the entire incident command staff started working 12 hours a day to support our frontline providers. We really didn’t have a day off until Memorial Day.

Every day was like Groundhog Day — morning meetings to set priorities, work throughout the day to solve issues and brief leadership nightly on progress. It was like we were running a marathon at sprint pace.

We had to make sure our system was as ready as possible to care for patients and assure our staff was protected. The team came together. They worked tirelessly in their efforts to realize a model for how health systems could respond to this event.

How did your military background impact the way you organized the hospital system’s response?

Clear lines of authority and responsibility are always helpful in the military, and they were and are helpful with this response. Also, there’s something called the “fog of war,” when you have to respond to an event without having a lot of information. You have to become comfortable with that limitation and realize that decisions must still be made.

There’s a quote by [the late] Supreme Court Justice John Marshall Harlan: “It’s much better to be right than consistent.” You have to be flexible because what you know today might be different than what you know tomorrow.

UMMS has 13 hospitals. How did you ensure that hospitals took a collaborative approach?

We took a system-based approach, establishing a unified command and involved all our hospitals in a coordinated way to leverage the strengths of each and solidify a fully integrated response effort. As a result of this, we seamlessly were able to track stress points and move staff, equipment and patients throughout the system to make sure that patients always had the right bed and the right time for the right treatment.

The cornerstone for this coordination was the Maryland Access Center, our coordinating center, and when many patients presented to one hospital, it found an appropriate bed and coordinated the movement of a patient across the system to enable greater access to the optimal care.

To keep on top of cutting edge developments in the science of this novel virus, we also aligned the hospital system with the University of Maryland School of Medicine. We have some uber-smart clinicians and researchers at the medical school, and we leaned on them to help us understand what was needed and how to deliver the best care.

What were some of the innovative protocols you instituted to respond to COVID-19?

To name a few, there were telemedicine, a clinical practice guideline, a tracker board, personal protective equipment policies and setting up new sites for patient care. Prior to this event, we were moving forward with telemedicine, but the effort was still evolving. As of July, we had more than 120,000 tele-hospital visits over the last four months; this ensured that people who needed to see a doctor were able to without coming to the hospital.

We also developed a COVID-19 clinical practice guideline. The [online] CPG has all of the latest information to effectively deliver the best possible care for patients, and it’s updated in real time. If a doctor is off for a few days and then needs to catch up about COVID-19 when they return to work, all [he or she] has to do is look at the CPG to get the latest information and expert guidance.

Early on, we developed a universal masking policy. You can’t walk through the [hospital] doors if you aren’t wearing a mask. Also, if you’re admitted for any reason besides COVID-19, you are given a COVID-19 test to assure that staff and fellow patients are protected.

Also, early on, we established a robust data effort. We have what’s called a ‘tracker board’ that tells us, in real time across the system, how many patients are presenting at each hospital, how many are admitted, what our supply levels are and are there any concerns regarding staffing. In the fog of war, you’re looking for any germane data to help guide the response. The tracker board continues to be a reliable tool to help us navigate our response.

In terms of COVID-19, what are you seeing in the hospital system now?

In our state, the rolling seven-day percent positive rate and hospitalizations are relatively low in July. Within UMMS, we have under 100 patients [as of the time of this interview] with COVID-19 hospitalized now.

But let’s be clear, we’re entering a mountain range. We recognize that until a vaccine is developed, there will be highs and lows in the number of patients with COVID-19. In Maryland, the governor has done a good job. We have a very successful model in our state. But opening up has some risks. Low-risk is not no-risk. No one is declaring victory. One death is too many.

What innovations do you expect the University of Maryland Medical System will continue to use after the pandemic is under control?

Pre-pandemic, we were moving toward a coordinated care system, but the pandemic has accelerated that development. We will be using the strength of our integrated system to provide greater access to the right care at the right time for all of our patients. We plan on continuing to develop telemedicine for all our patients so they have access to doctors across our system without leaving their homes.

Any final thoughts?

I just want all of us to understand that this isn’t over. This will get more difficult. During this time, it is glaringly evident that we are our brother’s keeper. We are collectively responsible for each other and our future.

Wearing masks, social distancing, telework and other things to slow the spread of this virus are critical actions to take now. If we don’t understand the concept of our shared responsibility for our common good, the next few months will be very challenging.