Advancing Pandemic Response Through Focused Contingency Planning

COL Andrew Barr
Walter Reed National Military Medical Center
Bethesda, MD

From Combat & Casualty Care, Summer 2020

As director of Walter Reed National Military Medical Center, COL Andrew Barr leads the world’s largest joint military medical center, Walter Reed National Military Medical Center (WRNMMC), Bethesda, MD. More than 7,000 staff include active duty military, civil service employees, contractors and volunteers. In one day, the WRNMMC staff sees nearly 4,000 outpatients; fills approximately 3,400 prescriptions; and conducts more than 40 operating room procedures, 500 radiological studies and 11,000 lab tests.

In July 2019, COL Barr joined Walter Reed National Military Medical Center after serving as the Command Surgeon, U.S. Forces Korea. COL Barr’s previous military assignments include Commander, Tripler Army Medical Center, Honolulu, Hawaii; Student, U.S. Army War College, Carlisle Barracks, Pennsylvania; Commander, U.S. Army Health Center, Vicenza, Italy; Deputy Commander for Clinical Services, General Leonard Wood Army Community Hospital, Fort Leonard Wood, Missouri; Division Surgeon, 1st Infantry Division, Fort Riley, Kansas, and Basrah, Iraq, in support of Operation Iraqi Freedom and Operation New Dawn; Commander, Craven Army Health Clinic, Fort Monroe, Virginia; Student and Resident, Army-Baylor Graduate Program in Health and Business Administration, Army Medical Department Center and School, Fort Sam Houston, Texas; Brigade Surgeon, 3rd Brigade, 4th Infantry Division, Fort Carson, Colorado, and Balad, Iraq, in support of Operation Iraqi Freedom; Staff Physician, Evans Army Community Hospital, Fort Carson, Colorado; Commander, Katterbach Army Health Clinic, Katterbach, Germany; and Staff Physician, USAMEDDAC, Heidelberg, Germany.

COL Barr received his Bachelor of Science degree in Bioengineering from Texas A&M University in 1990 and was commissioned through the Health Professions Scholarship Program as a second lieutenant in the United States Army. He received his Doctor of Medicine in 1994 from the University of Texas Southwestern Medical School in Dallas, Texas, and completed residency training in Family Medicine at the Texas Tech University Health Sciences Center in Lubbock, Texas, in 1997. He is board certified in Family Medicine. He received a Master’s in Healthcare Administration and a Master’s in Business Administration from Baylor University in 2007 as well as a Master’s in Strategic Studies from the U.S. Army War College in 2016.

COL Barr’s military education includes the Army War College, Army Command and General Staff College, AMEDD Officer Advanced Course, AMEDD Officer Basic Course, Division and Brigade Surgeon Course, and Brigade and Company Command Course.

Combat & Casualty Care was pleased to speak with COL Andrew Barr, WRNMMC Director, regarding some of the medical center’s foremost efforts in the nation’s fight against the COVID-19 pandemic and enhancements to treatment across DoD Joint medicine coming out of a global crisis.

C&CC: Please provide some insight into the evolution of WRNMMC COVID-19 care since initial patients starting presenting for treatment.

COL Barr: Early efforts focused on planning for surge patient capacity, codifying and disseminating guidelines from the CDC and medical literature, and protecting our staff and patients. WRNMMC also implemented its Hospital Command Center to centralize and prioritize operational efforts in support of COVID response.

Multiple planning factors and tools were used to estimate potential patient loads in outpatient, inpatient, and intensive care (ICU) environments. Phased expansion plans for inpatient and ICU operations triggered by patient load were developed and tested. Contingency inpatient clinical space was executed through tent facilities providing space for skill training and testing of contingency plans. Didactic and simulation training programs were developed and implemented to increase critical care skills for over 1,000 doctors, nurses, and respiratory technicians. Early in the pandemic, national shortages negatively affected supply of medical logistics including masks, gloves, hand sanitizer, and culture swabs. WRNMMC’s contingency stockpiles provided adequate supply of medical supplies and cross-leveling across the National Capital Region Market (NCRM) ensured supply for the entire market. WRNMMC developed a list of core logistics pacing items and detailed medical logistics tracking tools that allowed us to better understand stockage levels and burn rates. Innovative approaches to reorder and identification of new vendors allowed us to provide hand sanitizer during nationwide shortages.

A multi-disciplinary approach to problem solving was key to success in all endeavors during the pandemic. This was evidenced through innovative approaches to safety issues. WRNMMC implemented Restricted Access Control Points (RACP) decreasing entry points to the hospital from 84 to 10 each manned by 2-3 personnel who screened patients and staff for COVID symptoms through clinical questions. If identified as a risk for COVID infection, the individual was escorted to the Centralized Screening Area (CSA), a tent structure outside the Emergency Department (ED) where patients undergo a more in-depth screening and receive a swab sampling for analysis through a COVID PCR test. Creating the CSA centralized COVID screening to a group of highly trained personnel physically located outside the facility decreasing the risk of exposure for other patients and staff. The CSA also offered the option of drive-up testing allowing potential patients to remain sequestered in their cars while being screened and tested. Locating the CSA by the ED provided rapid access to increased level of care for patients with unstable or significant symptoms requiring further care. WRNMMC also developed a curbside, drive-up pharmacy delivery program allowing patients to receive prescriptions in their car without entering the facility.

Another area that benefitted from multi-disciplinary collaboration was the interpretation of constantly changing policies and medical guidelines. The multi-disciplinary approach allowed subject matter experts and stakeholders to rapidly review the latest guidelines and develop consensus opinion for recommendations for internal policies. These policies were then rapidly disseminated throughout our organization providing guidance to staff and served as templates for Market policies in the NCRM.

After incidents involving exposure of staff to atypical COVID+ patients, WRNMMC rapidly implemented an aggressive, organization-wide personal protective equipment (PPE) posture to maximally protect our staff. This approach required staff who regularly worked within 6 feet of patients to wear hospital-provided PPE, typically a non-N95 surgical or procedure mask, and required all other staff to wear cloth facemasks. This approach was a best practice and, in conjunction with social distancing and regular handwashing, provided significant protection for our staff for the entire pandemic minimizing the number of staff exposed to COVID at the hospital.

C&CC: As the nature of the virus became more apparent, how has WRNMMC adjusted prioritization protocols to better address patient needs?

COL Barr: Throughout the pandemic, WRNMMC and the NCRM continued to offer face-to-face (F2F) care for patients with acute, urgent, emergent, required routine, and readiness healthcare issues. We evaluated each patient with scheduled surgical cases or medical procedures to assess which cases needed to proceed with caution and which could be safely deferred. WRNMMC rapidly expanded healthcare through virtual health (VH) via phone or video teleconferencing. During the first 3 months of the pandemic, WRNMMC experienced a 35% decrease in outpatient care with 85% of that being delivered in the virtual space. VH efforts were incredibly well received by both patients and healthcare providers especially for routine follow-up care and behavioral healthcare. The popularity of VH will dictate the method of future delivery of care to our patients.

WRNMMC moved to cohorting of COVID+ patients on inpatient and ICU wards early in the pandemic. This approach increased safety of exposure to staff and other patients and developed valued expertise in nursing staff. As COVID PCR lab testing expanded at WRNMMC, COVID screening was expanded from symptomatic patients to all hospital admissions and surgical and medical procedure pre-screening providing additional safety measures for patients and staff as well as appropriate cohorting of asymptomatic patients.

WRNMMC also developed novel communication techniques for command messaging and information sharing including weekly updates from the Hospital Director via Facebook Live…another best practice. Utilization of email, Facebook, secure messaging, Everbridge notifications, and intranet information portals allowed rapid dissemination of information to staff and patients.

C&CC: With signs of national curve flattening, how is WRNMMC expecting to address possible spikes in care need despite general trends?

COL Barr: WRNMMC will continue to build and utilize its lessons learned in preparation for any future increase in COVID-19 cases. Identifying maximal burn rates of hospital supplies, rebuilding stockpiles of PPE and pacing items, rotation of operational and contingency stocks, expansion and improvement of VH platforms and procedures, establishing permanence of CSA and curbside pharmacy operations, improvement of rescheduling techniques for deferred healthcare, maintenance of contingency training programs, and continuation of novel communication techniques will allow WRNMMC to remain ready for any future surge of COVID-19. Maintenance of WRNMMC’s excellent PPE posture and dogged communication of personal responsibility to wear facemasks, maintain social distance, and regularly wash one’s hands will prevent increased prevalence of COVID-19 at WRNMMC.

C&CC: In meeting out-patient ongoing health monitoring needs, what are some ways WRNMMC is bringing expertise to bear?

COL Barr: WRNMMC is proud to serve as a leader in readiness, research, training, and medical treatment of COVID-19. WRNMMC will continue to share best practices and lessons learned across the NCRM, DHA, and DoD.