Communicating, Collaborating and Navigating through a 100-year Pandemic

Brooke Army Medical Center, DoD’s only Level 1 Trauma Care Center, was always ready for the contingency that only a 100-yr pandemic could represent.

By Col. Heather Yun and COL Jody Brown

From Combat & Casualty Care , Q4 Winter 2021

How do you prepare for a health crisis that comes around once every century?

Military combat units are well-known for planning and training for myriad contingencies, and the healthcare system is challenged to stay one step ahead in order to keep every service member in the fight. If the readiness level of doctors, nurses, combat medics, etc., is not at its peak, the ultimate sacrifice becomes an unwelcome result. And make no mistake; this 100-year pandemic is a war threatening not only our way of life, but the readiness of the force.

Brook Army Medical Center is the only Level I Trauma Center in the Department of Defense. It has been called the flagship of the military health system in the Defense Health Agency. BAMC’s strength is as a research and training organization. As part of “Military City USA,” better known as San Antonio, Texas, BAMC partners with the Southwest Regional Advisory Council (STRAC), executing regional trauma and emergency healthcare. Alongside University Health System (the only other Level I Trauma Center in the region), BAMC provides lifesaving care to more than 4,000 trauma patients each year, including 750 burn patients, from an area that stretches across 22 counties in Southwest Texas and encompasses 2.2 million people.

Oddly enough, the last city-wide exercise led by STRAC was a scenario based on…a pandemic.

Did that have BAMC and the rest of the city prepared for COVID-19? Not exactly, but the advantage of great communication and collaboration with local hospitals helped all of us navigate the numerous changes seen during this once-in-a-lifetime event.

COMBATING COVID-19

The battle against COVID-19 has taken a concerted, multidisciplinary effort. BAMC relied upon the expertise of infectious disease, critical care, hospital medicine and primary care experts to develop guidance locally every step of the way that then could be disseminated to the rest of the DHA. The virus forced everyone to look at some of our processes and understand how we could do things better in the future, more effectively and cross-leverage resources across the organization.

What the staff learned is a greater appreciation for the role each individual plays in the care of patients and each other. BAMC had to be incredibly agile to stay ahead of the evolving situation, and being able to move on a dime within hours of new guidance. Keeping up with the demand for testing was a challenge.

There were a number of efforts BAMC instituted to maintain a safe and secure environment, while continuing to deliver world-class health care, and assist the community effort against COVID-19. BAMC increased trauma patient throughput, utilized extracorporeal membrane oxygenation (ECMO) for the most severe COVID-19 cases, made changes in pharmacy operations, expanded virtual health, deployed critical staff members to hotspots, isolated testing, and developed a well-thought-out vaccination plan. These are a few areas BAMC helped mitigate the effects of COVID-19.

ADAPTING TO SUPPORT THE COMMUNITY

With local hospitals nearing capacity, BAMC took on additional trauma patients through STRAC to ensure the region’s trauma response remained unaffected by the pandemic. About 85 percent of BAMC’s trauma admissions are community members without military affiliation. BAMC is able to accept civilian trauma patients for care through the DoD’s Secretarial Designee Program and related special authorities.

BAMC increased its ability to care for the area’s most critically ill COVID-19 patients, to include beneficiaries, veterans and civilian patients, through the expanded use ECMO treatment. These efforts helped ease the burden on local healthcare resources and saved lives.

ECMO is a heart-lung bypass system used in the intensive care unit when a patient has heart and/or lung failure. The ECMO machine removes blood from large central vessels in a patient’s body, circulates it through an external artificial lung, oxygenates it, and delivers the blood back into the bloodstream. It essentially does the work of an injured lung and is the last line of defense against respiratory failure caused by the COVID-19 virus.

Patients with severe lung injury can have mortality rates of greater than 50 percent. ECMO has been shown to reduce this mortality down to approximately 30 to 40 percent. Functionally bypassing the lungs with an ECMO machine can provide precious time for patients to receive anti-viral treatments and heal from COVID-19 infection.

ECMO is often the last line of defense for the most critically ill patients with severe pulmonary disease. Whether due to COVID-19 or another condition, ECMO provided a life-support option that could save lives when all other options were exhausted.

With the program in place for nearly a decade, BAMC’s COVID team is accustomed to working closely with local hospitals in the event a patient may be a candidate for ECMO. This collaboration has proven vital in relieving the stress on local hospitals, particularly during COVID surges.

BAMC, provides up to one-third of the ECMO capability for the San Antonio area’s most severely ill community members, veterans and military beneficiaries suffering from the virus. Each life saved is incredibly rewarding and a testament to the importance of this treatment.

CURBSIDE PHARMACY

To help stop the spread of the COVID-19 virus, the San Antonio Military Market implemented curbside drop-off and pick-up pharmacy services at many of its locations. The BAMC Pharmacy team quickly came together on very short notice and successfully implemented a new curbside pharmacy service in less than 48 hours.

Over the course of just two months, BAMC serviced over 89,500 vehicles and dispensed over 162,000 prescriptions. At the peak of operations in June 2020, BAMC processed over 97,500 prescriptions through its drop-off and pick-up in-house services.

VIRTUAL HEALTHCARE

Three years ago, BAMC became an innovation focal point with the launch of the military’s first Virtual Medical Center. The center’s intent is to serve as a testbed for new capabilities and a centralized program structure to advise and oversee global virtual health efforts.
Since that time, virtual health has proven invaluable in supporting troops on the battlefield with real-time health assessments. BAMC providers and specialists also serve in a virtual advisory capacity to their counterparts downrange. Additionally, the center’s Mobile Medic program educates medics around the world, enabling them to conduct medical assessments in the field while communicating with a health care provider via video conferencing.

In response to the COVID-19 pandemic, BAMC and the V-MEDCEN increased virtual health appointments from 16 percent of overall appointments in January 2020 to 52 percent in May 2020.

BAMC also enrolled patients in the new COVID-19 Remote Monitoring Program, a joint effort of the V-MEDCEN. The program equips COVID-19 patients needing additional monitoring with a home healthcare kit and 24/7 over sight from registered nurses to ensure a higher level of post-hospital care.

In effect, the program “bridges the continuum of care” from inpatient to outpatient. The idea for the program was spurred by lessons learned in New York.

BAMC PERSONNEL DEPLOY DOMESTICALLY AND GLOBALLY

Army personnel assigned to BAMC have supported over 40 national and international COVID response efforts with greater than 225 MTOE Assigned Personnel and MEDCOM Soldiers from March 2020 thru November 2021, to include Arkansas, California, Colorado, Florida, Idaho, Kentucky, Mississippi, New Jersey, New York, Ohio, Tennessee, Texas, Washington, Wisconsin, Guam, US Virgin Islands and Iraq.

Support includes Urban Augmentation Medical Task Force (UAMTF) Teams, Medical Care Augmentation Teams (MCAT), Medical Readiness Teams (MRT), and COVID Vaccination Support Teams.

Nearly 40 healthcare professionals from BAMC deployed to New York City from March 27 to May 11, 2020 in support of the Department of Defense COVID-19 response. They joined a team of 800 Army and Navy medical personnel to help transform the Jacob K. Javits Center, a massive convention center in Manhattan, into a medical shelter to treat non-COVID patients.

Seventeen BAMC military healthcare personnel assigned to the 627th Hospital Center deployed to Seattle for about three weeks to set up a 148-bed hospital within the convention center attached to CenturyLink Stadium.

An Infectious Disease physician from BAMC also deployed to Guam in support of the USS Theodore Roosevelt COVID-19 response.
Other BAMC personnel assigned to the 115th Field Hospital supported U.S. Central Command in the fight against COVID-19.

RESEARCH AND STUDIES

BAMC explored every opportunity to participate in local, national and global studies and research efforts in a concerted effort to save lives and ensure the health and welfare of the force.

BAMC has the second largest research portfolio in the Defense Department. Alongside military and civilian organizations, BAMC joined the nation’s first clinical trial to evaluate an experimental treatment for the virus. The Adaptive COVID-19 Treatment Trial, or ACTT, centered on an antiviral drug called remdesivir, formerly touted as a potential Ebola treatment.
The National Institute of Allergy and Infectious Diseases sponsored study enrolled over a thousand people across the nation as it looked to determine if the antiviral drug was effective against COVID-19.

NIAID released promising preliminary results indicating that hospitalized patients with advanced COVID-19 and lung involvement who received remdesivir recovered faster than similar patients who received a placebo, according to a NIAID press release.
Based on preliminary research on the drug, BAMC joined an Army-sponsored force health protection clinical protocol that will enable providers to use remdesivir on a case-by-case, emergency basis to treat military personnel and protect deployed or remote service members as needed.

BAMC and Wilford Hall Ambulatory Surgical Center, Lackland Air Force Base, Texas were two of five Department of Defense locations taking part in the Phase III trial to evaluate the vaccine under development by AstraZeneca. The AstraZeneca vaccine trial was one of many national trials being conducted through then Operation Warp Speed, and the first to encompass the DoD.

We are in a war against the virus, and medical research is the intelligence operation that enables us to stay agile and one step ahead of the enemy. These are the studies that drive innovation, change practice, and ensure that we have all the tools available to provide the best care for our patients, now and in the future.

UNSUNG HEROES

COVID and the expanded ECMO mission transformed units and intermingled staff from other areas to take aim at an obvious priority – manning beds to provide proper care during periods of greatly increased demand. Nurses were shifted from various areas of the hospital to the newly formed COVID wards and ICUs; equipment-laden areas devoid of the chatter of family and friends.

The manpower was a limited pool, particularly as deployments, humanitarian missions and community-based support requirements drew military personnel away, many deployed overseas and stateside.

Hours were long, and emotionally stressful as staff worked, trained, cared for their patients, day in and day out. During all of this, nurses were understandably nervous about contracting the virus – another added stressor.

Aside from the staff, a BAMC-supplied tablet was often a patient’s only link to the outside world and loved ones. Nurses did their best to fill the void with technology, an avenue that has proved vital for patient communication and morale.

COVID testing became the main focus in the laboratory. Lab technicians often run testing for 24 hours, when the number of samples collected necessitates around-the-clock operations. BAMC benefited from support provided by separate commands located on Fort Sam Houston (Public Health Laboratory) and retired Army officers who were reactivated to support the COVID-19 response.”

The laboratory has shown amazing resilience as it has adapted to the evolutionary changes that have come from the (Centers for Disease Control, and Prevention, the Defense Department and other agencies regarding the understanding of COVID-19.

BAMC also provided community support through its drive-thru screening and testing operation. Operational since the earliest days of the COVID response, BAMC eased the burden on the city’s overtaxed testing sites.

Providing on-site testing for military beneficiaries, BAMC helped eliminated the need for them to seek alternative testing locations furnished by state and local health officials. Testing conveniently located on campus produces results within 24 hours.

Drive-thru screening and testing kept thousands of potentially infected patients out of the hospital, minimizing the spread of the virus to other healthcare workers and enabling the BAMC team to continue to see other patients.

The keys to success have been in communication, deference to expertise, and collaboration. Constant communication across the organization ensures that concerns are addressed as early and effectively as possible, before they become safety issues. Relying on subject matter experts to keep up with the science and advances in their field provided counsel and refinement of our responses.

COVID-19 VACCINE ARRIVES AT BAMC

When the Food and Drug Administration is sued an emergency use authorization, or EUA, for the Pfizer BioNTech COVID vaccine on Dec. 11, 2020, BAMC healthcare professionals volunteered to be among the first to receive the shot.

The mentality at BAMC has been one that for every person who steps up to take the vaccine when it’s their turn is another step toward ending the pandemic.
The vaccine was the turning point that many healthcare professionals were waiting for, and was viewed as a necessary step to putting the pandemic in the past.

LOOKING FORWARD

While the war against this unseen enemy continues, BAMC maintains its priority of excellence in healthcare. The American College of Surgeons National Surgical Quality Improvement Program recently recognized BAMC for achieving meritorious outcomes for surgical patient care for three years running, ranking the hospital among the top 10 percent of participating hospitals for surgical care.

Achieving meritorious recognition means that BAMC ranks in the top 10 percent of over 706 hospitals on this composite surgical quality score.
In early October 2021, a Joint Commission (TJC) survey team assessed BAMC for recertification. TJC is a global driver of quality improvement and patient safety in health care. Their collection of leading practices, knowledge and expertise and rigorous standards help lead healthcare organizations to zero harm.

TJC evaluates and accredits more than 21,000 healthcare organizations and programs in the United States and is the nation’s oldest and largest standards-setting and accrediting body in healthcare. To earn and maintain TJC’s Gold Seal of Approval™, an organization must undergo an on-site survey by a Joint Commission survey team at least every three years.

The surveyors frequently noted evidence of demonstrated commitment to becoming a highly reliable organization, emphasizing numerous examples of performance improvement initiatives designed to enhance the quality of care.

To say BAMC has been busy over the past 24 months is a gross understatement. But, the entire workforce remains laser-focused on providing the world-class healthcare its beneficiaries earned and deserve.

Someday, grandchildren of BAMC staff will ask what it was like during the COVID-19 pandemic. We will tell them about how we all worked together so hard and took care of each other.