Innovations in Fatality Management During the COVID-19 Pandemic.

Abstract

Health SecurityVol. 20, No. S1 CommentaryOpen AccessCreative Commons licenseInnovations in Fatality Management During the COVID-19 PandemicInga Furuness, Madeline M. Tavarez, Meghan D. McGinty, Kim Mendez, Oliver Demree, Charles Aviles, Mohammed Salahuddin, Jennifer Coard, Jenna Mandel-Ricci, Suzanne Bentley, Eric Wei, Christine Flaherty, Manuel Saez, Mahendranath Indar, and Laura IavicoliInga FurunessAddress correspondence to: Inga Furuness, MPA, BSN, RN, Assistant Director of Emergency Management, NYC Health + Hospitals, 50 Water St, 2nd Floor, 206, New York, NY 10004 E-mail Address: furunesi@nychhc.orgInga Furuness, MPA, BSN, RN, is Assistant Director, Emergency Management, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this author, Madeline M. TavarezMadeline M. Tavarez, MPA, CHEP; is Senior Director, Emergency Management Planning and Operations, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this author, Meghan D. McGintyMeghan D. McGinty, PhD, MPH, MBA, was Director, Emergency Management, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this author, Kim MendezKim Mendez, EdD, ANP, RN, is Senior Vice President/Corporate Chief Information Officer, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this author, Oliver DemreeOliver Demree, BSN, is Associate Director, Emergency Management, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this author, Charles AvilesCharles Aviles is Associate Director of Safety Management, NYC H+H/Lincoln, Bronx, NY.Search for more papers by this author, Mohammed SalahuddinMohammed Salahuddin, SSBB, CHEP, is Director, Emergency Management, NYC H+H/Queens, NY.Search for more papers by this author, Jennifer CoardJennifer Coard, LCSW, is Associate Director of Executive Administration, NYC H+H/Queens, NY.Search for more papers by this author, Jenna Mandel-RicciJenna Mandel-Ricci, MPH, MPA, is Senior Vice President, Healthcare Systems Resilience, Greater New York Hospital Association, New York City, NY.Search for more papers by this author, Suzanne BentleySuzanne Bentley, MD, MPH, FACEP, CHSE, is Medical Director of Simulation Center and Attending Physician Emergency Medicine, NYC H+H/Elmhurst, NY.Search for more papers by this author, Eric WeiEric Wei, MD, MBA, is Senior Vice President, Chief Quality Officer, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this author, Christine FlahertyChristine Flaherty is Senior Vice President, Office of Facilities Development, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this author, Manuel SaezManuel Saez is Assistant Vice President, Facilities Administration, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this author, Mahendranath IndarMahendranath Indar is Senior Director, Office of Facilities Development, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this author, and Laura IavicoliLaura Iavicoli, MD, FACEP, is Senior Assistant Vice President, Emergency Management, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this authorPublished Online:31 May 2022https://doi.org/10.1089/hs.2021.0154AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail IntroductionOf the innumerable challenges faced during the first surge of the COVID-19 pandemic, fatality management was among the most widely publicized. COVID-19 led to an unprecedented number of deaths in New York City—both in healthcare facilities and at home—taxing every aspect of the fatality management continuum. Inpatient healthcare facilities, medical examiner offices, and funeral homes faced excessive challenges finding adequate staffing, space, and supplies, which made it impossible to manage the workload with the existing processes. In response, New York City Health + Hospitals (NYC H+H) worked as an integrated healthcare system to develop and implement solutions to challenges related to resource management, staffing, workplace injuries, situational awareness, and the mental health of staff. These innovations can be used by other health systems to develop more robust fatality management capabilities in the future.NYC H + H is the largest municipal healthcare system in the United States, with more than 40,000 staff providing care to more than 1 million New Yorkers across 11 acute care hospitals, 5 postacute long-term care facilities, 7 diagnostic and treatment centers, and more than 70 community-based primary care sites. NYC H + H provides healthcare to a diverse population of patients regardless of insurance, immigration status, or ability to pay. Throughout the COVID-19 pandemic, NYC H + H has worked to provide care to a vulnerable population while navigating complex challenges with acquiring and managing critical resources including staff, space, and supplies.Mass Fatality Management PreparednessThe US Centers for Disease Control and Prevention defines the core capability of fatality management as: the ability to coordinate with other organizations ([eg, public health], law enforcement, healthcare, emergency management, and medical examiner/coroner) to ensure the proper recovery, handling, identification, transportation, tracking, storage, and disposal of human remains and personal effects; certify cause of death; and facilitate access to mental/behavioral health services to the family members, responders, and survivors of an incident.1Prior to the pandemic, coordination and planning efforts took place with key partners such as the New York City Office of the Chief Medical Examiner (OCME), which provided hospitals across New York City with the Biological Incident Fatality Surge Plan for Managing In- and Out-of-Hospital Deaths.2 NYC H + H also collaborated with the New York City Department of Health and Mental Hygiene and the New York City Emergency Management to stockpile essential fatality management supplies and identify infrastructure capabilities for morgue surge space. From December 2018 to March 2019, NYC H + H assembled an internal planning committee of emergency managers, morgue directors, facility managers, security, and clinicians from its 11 hospitals to identify, plan, and coordinate processes for mass fatality operations in accordance with the guidance provided by the OCME Biological Incident Fatality Surge Plan.2 This effort was part of the 2018-2019 Hospital Preparedness Program network initiatives,3 a cooperative agreement funded by the Assistant Secretary for Preparedness and Response. The committee's goals were to: Confirm current morgue capacity within NYC H+H's 11 hospitalsDetermine space and infrastructure resources necessary to accommodate Body Collection Point (BCP) assets at each of the 11 hospitalsUse an electronic data gathering application to document BCP information should these assets need to be deployed across the cityDevelop an incident response guide within the electronic incident command system to reflect the 2016 OCME Biological Incident Fatality Surge Plan2Despite the extensive intra-agency planning that took place prior to COVID-19, the elasticity of the fatality management system across New York City had never been exercised or tested to the magnitude COVID-19 demanded. Since the beginning of the pandemic, NYC H + H has worked with other city agencies to rapidly strengthen the fatality management system to support the ongoing crisis and prepare for future citywide mass fatality incidents.SpaceOne of the most pressing fatality management concerns during COVID-19 pandemic surges has been space. In early March 2020, New York City Emergency Management began deploying BCPs to hospitals and postacute facilities in need of surge morgue space. Although a BCP could be any space where decedents are stored in a mass fatality incident, New York City used refrigerated trailers, which are commonly used to extend mortuary space. On March 21, 2020, New York City Emergency Management deployed the first BCP in New York City.4 Two weeks later, at the height of the pandemic, 83 BCPs were deployed throughout the city, presenting numerous logistical and operational challenges. Fatality management plans developed before COVID-19 had envisioned that hospitals would manage one BCP at a time. Because of delays in citywide systems, some hospitals were forced to house multiple BCPs onsite at once. Determining the location for multiple onsite BCPs proved to be a challenge and emphasized the need to plan for the placement of more than a single BCP, should the need arise. Unlike internal morgues, BCPs do not have predetermined spaces for decedents. For example, fixed morgues have labeled individual spaces. During the first wave of COVID-19, temporary shelves were installed that helped maintain organization. However, the ongoing need to rapidly construct shelves was challenging. An ideal solution would be supplemental morgue space specifically designed as such, akin to the medical ambulance buses emergency medical services use to respond to mass casualty incidents.Situational AwarenessThe paper-based documentation process used in morgues prior to the pandemic was cumbersome and could not provide key situational awareness metrics, such as real-time decedent census, location, and planned disposition. To gain real-time information and simplify mortuary logistics, NYC H+H's systemwide Office of Emergency Management worked with electronic medical record (EMR) information technology leads, site emergency managers, and morgue directors to leverage the electronic medical record system for situational awareness of fixed and surge morgue capacity. The team created an electronic morgue flowsheet in a virtual unit, modeled after a clinical unit (Figure 1). They then developed a dashboard from the flowsheet data that illustrated, among other data points, the decedent location, time in morgue, hours since death, and planned disposition (Figure 2).Figure 1. Mortuary documentation flowsheet in patient electronic medical record. Note: No real patient data were used in this figure; only example data for demonstration.Figure 2. Mortuary Situational Awareness Dashboard. Note: No real patient data were used in this figure; only example data for demonstration. Actual dashboard only viewable by mortuary staff caring for those decedents.Using the EMR for morgue operations solved a number of logistical problems. The fields in the flowsheet autopopulate to the documents required by funeral homes or the medical examiner's office, simplifying paperwork. Death certificates are scanned into the EMR for easy interdepartmental access. Using the EMR especially enhanced situational awareness through a color-coded field denoting time spent in morgue. Where appropriate and possible, fields in the flowsheet have selectable responses instead of free text, so data points are extractable and can generate reports in a dashboard format for enhanced decisionmaking.StaffingBetween March and June 2020, New York City hospitals experienced severe staffing shortages, and fatality management operations were no exception. During this period, morgues at hospitals and postacute care facilities saw a rapid surge in decedents. On March 22, 2020, New York City reported 63 deaths attributed to coronavirus.5 Eight weeks later, that number had risen to 15,888 cumulative deaths (Figure 3). The NYC H + H systemwide logistics section activated emergency contracts to supply temporary mortuary technicians and worked to rapidly cross-train and redeploy staff with transferrable skills. For example, patient transport personnel were reassigned to assist with transporting decedents to BCPs, while doctors whose specialty was not currently impacted by patient surge processed death certificates. One barrier to the effectiveness of reassigning staff was training. During the first surge of COVID-19, just-in-time training took place; to maximize resilience, future planning should preidentify surge staff and build the infrastructure to pretrain or rapidly train staff.Figure 3. Daily confirmed and probable COVID-19-related deaths in New York City from February 29, 2020, to August 5, 2021. Data source: New York City Department of Health and Mental Hygiene.6Mortuary staff also reported an increase in injuries while performing an unprecedented volume of work and the unfamiliar task of moving and handling decedents in BCPs. To address mortuary staff injuries associated with a high volume of heavy lifting in a complex and potentially unfamiliar environment, NYC H + H developed a toolkit to rapidly train staff on ergonomic principles for lifting and moving decedents to and within a BCP. The toolkit includes a training video that demonstrates proper lifting and moving techniques and an educational booklet with an algorithm to help staff determine the safest way to move a decedent given different situations and equipment available. The algorithm has a tiered set of recommendations that includes keeping the heaviest decedents in the fixed morgue if possible, using a lift if available, and using friction-reducing devices like emergency medical service-style slide boards and slip sheets. To develop this toolkit, Emergency Management conducted site visits, talked to staff about the challenges they experienced, and enlisted the help of an ergonomist. Involving mortuary staff and a subject matter expert were key components of this intervention's success, as was ensuring that the content of the training was flexible enough to accommodate different situations mortuary staff might face in a mass fatality incident.SuppliesDuring the pandemic, essential supplies were limited, and processing resource requests promptly was essential to maintain operations. Initially, resource requests were submitted via phone or email and added to an Excel spreadsheet for tracking. This manual process made it difficult to manage, track, and provide status updates on resource requests, particularly those related to fatality management. NYC H + H leveraged our information technology department's day-to-day service delivery platform to create an electronic resource request process (Figure 4) and created user guides that outlined step-by-step processes for entering and managing requests. The logistics section decedent management unit leader oversaw requests. To address supply shortages, resources were balanced and allocated across the health system to meet acute demand. For example, when one acute care hospital ran out of human remains pouches, they placed a request in the service delivery platform, and another hospital with surplus sent over their available supply. Sharing supplies between sites within the system has been a crucial aspect of successful resource management for COVID-19.Figure 4. Digital resource request form on service delivery platform.Mental Health ServicesFamilies of the deceased faced exceptional difficulty navigating the process of putting their loved ones to rest during the first surge of the pandemic. Additionally, those who lost loved ones had limited opportunity to seek social support, an important factor in bereavement.7 Funeral costs skyrocketed, and many families could not afford to have a funeral home burial. Family support teams were assembled to assist families coordinate the burial of their loved one, connect them to funding sources available to decrease the financial burden, and provide psychological support. The teams varied but often consisted of psychiatry, guest relations, and social work staff members whose departments experienced decreased patient volume due to the pandemic. These teams provided key family support and were essential in improving fatality management operations.Fatality management staff faced very stressful conditions as they worked to manage the surge of decedents. In additional to the emotional stress, workers contended with a dramatic increase in work volume and rapidly changing national guidance regarding personal protective equipment. To address the emotional and psychological toll associated with providing such service, NYC H + H significantly expanded its systemwide Helping Healers Heal (H3) program. H3 is a peer support program that was originally initiated to acknowledge the burden healthcare delivery places on healthcare workers themselves and to work to combat “second victim syndrome.”8 This syndrome is the trauma some healthcare providers experience after an adverse patient outcome or practice error, which manifests as psychological (shame, guilt, anxiety, grief, depression), cognitive (compassion dissatisfaction, burnout, secondary traumatic stress), and/or physical reactions. The overarching goal of the program is to provide support and bear witness to, validate, and share experiences. H3 provides a psychological safety net for healthcare workers and has never been as crucial as during the struggles of providing care during the COVID-19 pandemic.The H3 program includes 3 tiers aimed at addressing second victim syndrome. The first tier involves training all staff about second victim syndrome, the stress continuum, and the importance of debriefing after difficult cases or anytime someone is struggling. Debriefing is a reflective, facilitated discussion about an event, in this case inclusive of any and all aspects of the COVID-19 crisis. H3 is led by peer support champions, the second tier of the program, who are trained to provide psychological support, lead individual or group debriefings, and identify stages of the stress continuum. The third tier involves training peer support champions to recognize behavioral cues indicative of mental health issues and make expedited referrals to trained mental health professionals to provide critical and timely intervention. Overall, the H3 program aims to ensure that staff do not feel alone in their unique experiences as healthcare workers, and that all staff have access to crucial mental health resources. Staff found it cathartic to talk to someone about their experiences.ConclusionThe COVID-19 pandemic has tested the ability of healthcare system to manage massive surges in decedents. NYC H + H adapted to this challenge by supplementing fixed morgue space, augmenting and cross-training personnel to expand staffing capacity, sharing supplies across the health system, leveraging information technology systems for resource management and situational awareness, and offering psychological support for involved staff. The innovations that enabled NYC H + H to manage the decedent surge were a result of interdepartmental collaboration, which proved to be a key principle of success that will inform future emergency response efforts.AcknowledgmentsThe authors wish to acknowledge and thank Jose Calderon, Curtis Ritchens, Curtis Ritchens Jr., Dheeraj Mathew, Guillermo Lozada, Melvin Morgan, Nicole Decarmine, David Lowe, Eric Denham, Kenneth Williamson, Michaelo Vega, Mike Montague, Hector Lopez, Lawrence Ohene-Asa, Ramel Simmons, Rashad Smith, Zaire Bowen, Aapri Cummings, Aaron Riley, Alex Guillaume, Alicia Noel, Alix C. Vernet, Andrew Brown, Beatrice Gilles, Breanna Marcus, Carol Mosley, Christopher Giddings, Clena Fleurelus, Dalliant Edouard, Daniel A. Mitchell, Dave Campbell, David Tejada Jr., Dennis Flores, Derrick Weaver, Dilson L. Pichardo, Doanhe Yludora Matthews, Dorian Browne, Edward J. Rodriguez, Eric E. Anderson, Eroline Stewart-Billingy, Estefani Heredia Arana, Eucharia A. Iwuchukwu, Eva Gallimore, Faye Escourse, Genli M. Marte, Haoua Traore, Ikeda Romeo, Jason Shine, Jean M. Edmond, Jeffrey Bradshaw Jr., Jonathan Clemons, Jose Holgun, Jose R. Gonzalez, Joseph Jean Marie, Joseph Reis, Joshua Morgan, Keifer Enniss, Keriesha McDonald, Knolly St. Lewis, Malaika Morris, Marc Arthur, Marcia Moe, Marcos Chavez, Marie Sabine Felix, Marsha Martins, Michere Brittlebank, Mustapha Azeez, Natasha C. Francis, Noel M. Scarlett, Omari Daniels, Raymond Hill, Richard James, Richard Rios, Rita Frederick, Roger De Peza, Ronald Swan, Sabrina De Los Santos, Sagine Laroche, Sandra S. Morency, Shandeka Hunter, Sharis Jn Baptise, Stemela Jean, Tajhare L. Henry, Terell Alexander, Trinity Galindo, Wilbert Harris Jr., Wyane Ingram-Harrison, Alvin Figueora, Sigourney Slocumb-Warlick, Victor Rodriguez, Danielle Coles, Melonee Winter, T'iara-Ruby Damon, Angel Rosario, Ahaila Mohabir, Andres Thomas, Anthony Harper, Anthony Rodriguez, Ashley Digirolamo, Bethsilda Watson, Cachita Smith, Carlos Rios, Charles Perry, Daniel Vaught Jr., Eddie Alicea, Evert Gonzalez, Farooq Mirza, Gabrielle Johnson, Gregory Rios, Hazel Mattei, Jose Nieves, Kymeshia Heyliger, Lakeisha Smith, Marquis Brown, Narobie Jenkins, Neil Singh, Raelle Watts, Royce Stephens, Shruti Dimri, Stephen Jackson, Travis Lynch, Tyler Chan, and Christopher Thompson for their tireless dedication and heroic work in caring for the New Yorkers we lost during the COVID-19 pandemic. We also thank the operations, incident command, admitting, facilities, and H3 teams at all NYC H + H sites. Finally, we thank Andrea Cohen and Catherine Patsos for their insight and review of this article.