Command and Control

Command and Control, U Magazine Fall 2020

How UCLA Health brought together its resources to confront the COVID-19 pandemic and manage an emergency situation in which even the best-case scenarios were daunting.

Well before COVID-19 transformed everyday life in America, William Dunne and his colleagues in UCLA Health’s Offices of Emergency Preparedness, Infectious Diseases and Clinical Epidemiology & Infection Prevention began to closely monitor worrisome reports about a viral disease of unknown origins nearly 7,000 miles away. Since the Ebola scare of 2014, Emergency Preparedness has housed the Emerging Infectious Disease Preparedness team, which is charged with scouring medical intelligence at home and abroad for potential health threats to the community that warrant concern. And by late December, all eyes were focused on a cluster of cases coming out of Wuhan, China.

“We were getting reports of a potential outbreak,” recalls Dunne, administrative director for UCLA Health Emergency Preparedness, Security and Safety Services. After a flurry of emails, phone calls and meetings in early January, Dunne’s group and colleagues convened January 13 on a conference call with officials from Los Angeles International Airport, the Los the Angeles County Department of Public Health, the U.S. State Department and the Centers for Disease Control and Prevention (CDC) to discuss the novel coronavirus known as SARS-CoV-2. Two days later, an email went out from Daniel Uslan, MD, co-chief infection prevention officer for UCLA Health, alerting UCLA’s senior leadership. “Based on our proximity to LAX and international travel to Los Angeles from China, we had to ramp up our preparedness and make sure we had our finger on the pulse of the medical intelligence around the globe,” Dunne says.

As the novel coronavirus outbreak escalated over the next eight weeks into a global pandemic, it became increasingly clear that UCLA Health would need to mount a comprehensive and finely tuned response, with little time to spare. In Italy, a surge of COVID-19 cases overwhelmed hospitals, forcing difficult decisions about how to allocate scarce medical equipment and personnel. With rapid community spread on U.S. shores appearing imminent, a host of vexing issues had to be grappled with simultaneously, and fast: What steps needed to be taken to prepare for a potential surge of critically ill COVID-19 patients that could be just weeks away; how would the health system ensure the safety of thousands of health care workers, as well as patients requiring medical attention for other concerns, against a highly infectious pathogen at a time when the future supply of personal protective equipment (PPE) was uncertain; what was necessary to proceed on these and other fronts, when so much remained unknown about the new virus and when testing to identify infected individuals was scarce?

For a mammoth enterprise such as UCLA Health, a swift and effective response to the rapidly evolving COVID-19 pandemic necessitated a nimble team operating under a fixed command-and-control structure with military-style precision — not something generally associated with a large academic institution. But by March 4 — nine days before the White House declared the coronavirus pandemic a national emergency — that is exactly what occurred when Johnese Spisso, president of UCLA Health and CEO of UCLA Hospitals & Clinics, activated the incident-command center to oversee the health system’s COVID-19 response.

UCLA HEALTH’S CENTRALIZED RESPONSE TO COVID-19 is modeled on the National Incident Management System’s incidentcommand structure — referred to as the hospital incident-command structure (HICS) in its adaptation by health care organizations across the country. The idea is to bring key stakeholders together to efficiently and swiftly make and implement decisions addressing urgent needs. “It’s a model that works for a crisis response,” says Robert Cherry, MD, chief medical and quality officer for UCLA Health and incident commander. “You have a centralized group of leaders within the command center overseeing different branches, with roles designed to be flexible enough to deal with the various external and internal challenges that come up.”

While the day-to-day operations of the command center have wound down, the overall structure and what is known as “code triage” remains in place. Under the HICS system, members of the incident command team fill roles based on their skill sets, and those roles evolve based on need. “In a crisis, we ask people to put aside their normal roles and put on a new hat as we create a specific, hierarchical structure for managing command and control,” Dunne explains.

That structure is designed to ensure that members “stay in their lanes,” with clear lines of authority that discourage freelancing in decisionmaking, while promoting consistency in process and the best allocation of resources. In the case of the COVID-19 team, reporting to the incident commander were the chiefs of four sections: operations, planning, logistics and finance. The core command staff included medical/technical specialists who brought in subject-matter expertise; a public information officer, focused on internal and external communications; a safety officer, focused on incident health and safety of emergencyresponder personnel; and a liaison officer who connected with external entities, such as federal, state and local public health leaders, as well as officials from regulatory agencies and other health care organizations.

All told, about 100 people participated in activities of the command center that typically began with a daily 7 am meeting with the senior executive group to ensure situational awareness inside and outside the organization and set the organizational goals for the day. That was followed by an 8 am direction-setting meeting for the broader command center team; a noontime meeting for communications and policy approvals; and a 3:30 pm debriefing at which section leaders reported accomplishments and provided updates — not to mention smaller-group meetings in between. Additionally, there was a 4:30 pm virtual briefing of all managers throughout the health system to provide them with information and updates to relay to their teams.

This was far from the first time UCLA Health established a command-center response to an emergency, nor a first for many members of the team. To prepare, everyone with a leadership role within the incident-command structure undergoes special training, and there are regularly planned exercises, as well as actual emergencies — devastating wildfires or mass-casualty events like the 2008 train crash in Chatsworth, for example — during which the command center is activated. In addition, there are planned internal events such as UCLA’s move into new hospital facilities in 2008 (Ronald Reagan UCLA Medical Center) and 2011 (UCLA Medical Center, Santa Monica [which now is called UCLA Health-Santa Monica Medical Center]) and unplanned ones such as utility outages.

There also has been plenty of preparation for a potential pandemic, in collaboration with the CDC, California’s state and local health departments and, because of the volume of international travelers who arrive in Los Angeles, LAX. “Ever since the Ebola scare, we have worked to train, review policies and procedures and conduct drills so that, in the unlikely event we ever had a patient with Ebola walk into our emergency department, we are prepared,” Dr. Uslan says. “So, with COVID-19, it was a natural transition for the infrastructure of our existing Emerging Infectious Disease Preparedness Program to support the COVID-19- preparedness efforts.”

But by the first meeting of the COVID-19 command center, on March 4, it was obvious this would be different. “Our program was wellstructured to care for a patient with Ebola, but to scale up that response for the number of patients we were anticipating in this pandemic required a complete rethinking,” Dr. Uslan says.

There was another key difference: Previous command center responses had been for short-term events, typically lasting a day or two; COVID-19 required gearing up for the long haul. “A masscasualty event usually begins with the highest magnitude of affected individuals at the beginning, when you are trying to deal with all the victims at once, and it gets progressively less complicated after that. The COVID pandemic,” says John C. Mazziotta, MD (RES ’81, FEL ’83), PhD, vice chancellor for UCLA Health Sciences and CEO of UCLA Health, “has been a mass-casualty event in reverse, and in slow motion. It also doesn’t have a clear end point.”

The pandemic clearly was not something that would burn itself out over the course of several days or even several weeks. “We needed to make sure we had bench strength — more than one individual for each role, along with a wider range of positions filled and more authority delegated, knowing this is a slow-rolling, long-term response,” Dunne says.

Indeed, the COVID-19 command center leaders commonly define their effort as “a marathon, not a sprint.” Referring to the sustained, constantly evolving nature of the COVID-19 response, one member of that team goes further. “It’s an ultramarathon,” says Annabelle de St. Maurice, MD, co-chief infection prevention officer for UCLA Health.

What’s more, Dr. Cherry adds, “For something like an earthquake, you pretty quickly understand what you’re dealing with. Months into the pandemic, there’s still a degree of uncertainty.”

WHEN THE COMMAND CENTER TEAM HELD ITS FIRST MEETING, it had been just a little more than two months since the discovery of SARS-CoV-2, which was labeled a “novel” coronavirus for good reason. “COVID-19 is an unusual viral disease that can affect multiple organs — and it was brand new,” Dr. Cherry says. “There was still so much we didn’t know about disease transmission, severity and how to treat it. We’ve learned a tremendous amount since then, but even as we learn more, we have more questions.”

While plenty of effort had gone into developing a playbook for responding to a pandemic, no plan could anticipate what would be needed for a new infectious disease, much less one that would become a once-in-a-century pandemic. Over the course of its first 73 days, the incident command team would develop 206 policies and procedures on every facet of health care in the era of COVID-19 — symptom tracking, treatment protocols, testing, visitation rules, use of PPE and return-to-work guidelines, to name a few. The team did so based on the information it had, which often was limited, though expanding with time. Dunne likens the process to trying to assemble a plane while it is in flight.

“We had to stand up policies and guidelines almost immediately as we were entering unknown territory,” says Karen Grimley, PhD, chief nursing executive for UCLA Health, who, with Richard Azar, UCLA Health’s chief operating officer, began preparing the response as soon as the incident-command center was activated. “We didn’t always have the answers. That is not something that we are used to.”

The resources of UCLA’s infectious diseases specialists also had to kick into high gear. “It wasn’t like our division had a written plan that said, ‘When we have a pandemic, this is how we will re-organize our inpatient service, call schedules and treatment plans,’” says Judith Currier, MD, chief of the UCLA Division of Infectious Diseases.”

The greatest urgency in those early days was ensuring enough hospital capacity to safely accommodate an anticipated surge of COVID-19 patients, against the backdrop of warnings that millions of Californians could quickly become infected and overwhelm the health care system. “We didn’t know what to expect, but we could see what was occurring in New York City and in other parts of the world, and we needed to prepare for that possibility here,” Azar says. “We were looking at models for best-case and worstcase scenarios, and even the best-case scenarios were daunting.”

Command center leaders worked with colleagues across the health system to develop a surge plan that detailed ways in which UCLA’s Westwood and Santa Monica hospitals would create additional bed capacity at ascending levels of activation, ranging from Level 0 (normal operations) to Level 3. “Our goal was to maximize all of our physical spaces within the contiguous licensed facilities at our Ronald Reagan UCLA campus and our Santa Monica UCLA campus,” Spisso says. “If fully implemented, our multilevel surge plan would have brought our total capacity to more than 1,100 beds for inpatient care.”

Under a worst-case scenario, non-COVID-19 patients would be redirected to the Navy hospital ship USNS Mercy, docked in the Port of Los Angeles, and/or to UCLA’s affiliate hospitals. Fortunately, this most-dire scenario never materialized, but in anticipation of an influx, the Level 1 plan was activated, which meant engaging with the surgical chiefs of UCLA Health to determine which procedures could safely be postponed for 30-to-45 days in order to free up bed capacity. UCLA’s two main hospitals typically operate at more than 100 percent capacity each day; freeing up beds through these postponements brought them down to the 50-to-60 percent capacity, Azar says.

THE SCARCITY OF COVID-19 TESTING WAS ANOTHER MAJOR EARLY CHALLENGE. “It was clear from the start that we needed to prioritize who would get the tests and to be able to test people in ways that wouldn’t increase the risk of transmission,” says Dr. de St. Maurice. “During the period when testing capacity was limited, we had to prioritize the frontline health care workers and patients who were extremely sick and likely to be positive.”

After relying initially on the limited resources of Los Angeles County, the command center team worked closely with the UCLA Clinical Microbiology Laboratory, under the direction of Associate Professor of Pathology & Laboratory Medicine Omai Garner, PhD (FEL ’12), to quickly build up UCLA’s independent capacity to meet the demand. In relatively short order, UCLA was able to develop the laboratory resources to conduct its own tests — allowing for a dramatic expansion that “became a game changer,” Dr. Cherry says. Within several weeks of standing up the command center, UCLA was able to test every patient entering the hospital, regardless of whether or not they were showing symptoms. This allowed COVID-19 patients to be segregated into certain units, away from those who were disease-free, reducing the risk of transmission to patients and clinicians.

The ramp-up also allowed UCLA to become more strategic in handling the suspected COVID-19 cases among those who didn’t require hospitalization. To divert people away from the hospitals if they didn’t need to be there and reduce the flow of potentially infected individuals bringing the virus to uninfected hospital areas, UCLA Health established drive-through and walk-up testing sites in the community, run by trained personnel equipped with appropriate PPE. Working through the command center and in coordination with the clinical microbiology lab, multidisciplinary teams helped to troubleshoot through ways to ensure safety and efficiency in the operations of these sites.

Given the highly transmissible nature of COVID-19, isolating infected patients always was a priority. At the start, mobile tents went up outside of Ronald Reagan UCLA Medical Center and UCLA Health-Santa Monica Medical Center to prevent the emergency departments from becoming contaminated as incoming patients awaited their diagnosis. Ultimately, all UCLA Health hospitals and clinics instituted safety measures that included universal masking, testing new patients and screening all hospital entrants for temperature and any COVID19-like symptoms. Furniture was rearranged in clinic waiting rooms and cafeterias to promote physical distancing, and visitation for non-COVID-19 patients was curtailed to prevent large gatherings.

“We had to make sure patients with chronic illnesses got the care they needed and wouldn’t avoid coming in because they were worried about going to a hospital or clinic,” says Michael A. Pfeffer, MD (RES ’07), assistant vice chancellor and chief information officer for UCLA Health. “We spent a great amount of time determining how we could provide a safe space, as well as communicating to our patients that it was safe.”

Command center discussions also focused heavily on ensuring a safe working environment for UCLA Health employees, which involved everything from securing sufficient PPE to training thousands of physicians, nurses and other health care professionals in the policies and protocols for the equipment’s proper use

“What is strikingly different about this crisis, as opposed to others, is that a paramount issue has been the safety of health care workers,” Dr. Cherry says. “They are a critical infrastructure, and making sure they are in the fight and able to take care of patients the next day requires that they are disease-free and able to confidently go about keeping patients protected and saving lives.”

When she wasn’t taking part in the command center meetings, Dr. Grimley was spending considerable time on the wards, discussing safety issues with nurses and other health care staff. “In a crisis, you can’t lose sight of the fact that patient care is at the center of our work. We needed boots on the ground to learn firsthand about our team’s issues and concerns so that their voices were represented in our decisions,” she says. “We had to recognize that people were scared, particularly at the beginning, when little was known about the virus, and they were hearing about what was happening to colleagues across the country.”

UCLA HEALTH HAD A STOCKPILE OF PPE stored in a warehouse outside the university, but early on, the rate of depletion, or burn rate, was significantly higher than expected — roughly 3,500 N95 respiratory masks a day, for example, more than tenfold pre-pandemic levels. Meanwhile, the supply chain that all hospitals had relied on to replenish their PPE was significantly disrupted because of the global impact of the pandemic. “If you have 50,000 masks on hand, that sounds like a lot, but if you’re using 3,500 a day and don’t have any more coming in for three weeks, it is a major concern,” Dr. Uslan says.

To keep close tabs on the amount of supplies on hand, the command center team’s IT experts developed dashboards for real-time tracking. The leadership also pursued innovative solutions to cope with the shortage. A sterilization process developed at the University of Nebraska, ultraviolet germicidal irradiation, was already being used at UCLA to sterilize equipment such as wheelchairs. Working with the vendor to repurpose the procedure enabled the sterilization by the end of June of more than 50,000 N95 masks that would have otherwise been discarded, allowing 600 a day to be safely reused.

With much of the entertainment industry shut down, the command center joined forces with the International Alliance of Theatrical Stage Employees union, which summoned volunteers to sew additional masks out of surgical wrap. The command center team also turned inward, drawing on expertise within the UCLA campus community to develop PPE in-house. A collaboration with the schools of engineering and dentistry brought 3D-printed face shields to UCLA health care workers. And, as the command center team was finding new ways to build its PPE stockpile, friends of UCLA Health stepped up to donate additional supplies. “It was really gratifying to see how our broader community came together to support us,” Spisso says. “That brought some light into what to many felt like a very dark time.”

The number of individuals and organizations from the community wanting to support UCLA with PPE and other items was both heartening and, for a time, overwhelming. “It was amazing — we were feeding hospital staff every day with donated meals,” Dr. Grimley says. “Early on, we were getting so many calls and emails from people because they wanted to recognize these frontline and behindthe-scenes heroes.” So many people wanted to help, that responding to all of these offers and vetting the donations became a huge task for the command center’s logistics group. A warehouse in Van Nuys was staffed and used as the receiving center for many of the donated products, and a process was established to determine their feasibility and where they could be put to use.

In an unfolding and ever-evolving crisis, the daily noontime communications meetings among a multidisciplinary group of clinicians, administrators and marketing and media relations experts became essential to meeting the needs of both internal and external audiences for clear, concise and consistent updates and guidance. Externally, the meetings sought to determine what and how to communicate in a unified way to local, state, and federal entities, as well as to the general public, both directly and in response to media requests. Internally, with 30,000 faculty, staff, students and volunteers, and UCLA Health clinics stretching from San Luis Obispo to southern Orange County, the challenge was to ensure information that was pertinent and on target for a wide-ranging audience.

The command center used the meetings as a launching pad for developing and approving daily COVID-19 updates, both clinical and non-clinical, to the entire organization. These included links to new clinical guidance, operating procedures and educational tools, along with other information employees needed to do their jobs. The command center’s logistics team oversaw the development of a testing dashboard (posted and regularly updated on the UCLA Health COVID-19 website, uclahealth. org/coronavirus, it breaks down testing results and daily hospitalized patients, both globally and by county), as well as other dashboards used to inform the team’s daily operations.

One of the major transformations overseen by the command center team was the leveraging of technology to allow patients to be seen over video by doctors and nurses from the safety of their home, either for routine visits not requiring physical contact or to triage patients with COVID-19 symptoms and determine if they needed to be seen in person. “We were able to scale telehealth visits from an average of about 400 a month prior to the pandemic to more than 80,000 a month, which allowed our providers to continue caring for our patients,” Dr. Pfeffer says.

Making that kind of transition was a great feat involving everyone from the informationtechnology and operations personnel to the providers who learned an entirely new health caredelivery method, as well as patients who embraced the change, Dr. Pfeffer notes. Technology also has been used in certain situations for video visits with hospitalized patients as a way of minimizing physical contact between COVID-19 patients and health care workers and to allow family members to see patients when visiting isn’t safe.

The telehealth uptick represents one of many examples of a quick and well-tuned response to a complex need, involving a wide cross-section of a massive organization. While none of the command center team members is about to take a victory lap given the death and despair that was inevitably going to be associated with COVID-19, they know it could have been far worse.

“It’s been gratifying to see everyone operating with a laser-like focus to manage the response,” Dr. Grimley says. “We have drawn from every facet of the organization to get the answers we need, making decisions based on the best evidence. People bring in their own expertise, and that knowledge is respected. That’s what makes UCLA strong, and it has allowed us to keep a level of calm that was essential to being able to ensure the best possible care and safety for our patients and staff.”