Showing papers in "Health Affairs in 2020"
TL;DR: The potential danger of exponential spread in the absence of interventions is illustrated, providing relevant information to strategies for restarting economic activity.
Abstract: State and local governments imposed social distancing measures in March and April 2020 to contain the spread of the novel coronavirus disease (COVID-19). These measures included bans on large socia...
689 citations
TL;DR: Evidence from a natural experiment on effects of state government mandates in the US for face mask use in public issued by 15 states plus DC between April 8 and May 15 suggests that requiring face maskUse in public might help in mitigating COVID-19 spread.
Abstract: State policies mandating public or community use of face masks or covers in mitigating the spread of coronavirus disease 2019 (COVID-19) are hotly contested. This study provides evidence from a natural experiment on the effects of state government mandates for face mask use in public issued by fifteen states plus Washington, D.C., between April 8 and May 15, 2020. The research design is an event study examining changes in the daily county-level COVID-19 growth rates between March 31 and May 22, 2020. Mandating face mask use in public is associated with a decline in the daily COVID-19 growth rate by 0.9, 1.1, 1.4, 1.7, and 2.0 percentage points in 1-5, 6-10, 11-15, 16-20, and 21 or more days after state face mask orders were signed, respectively. Estimates suggest that as a result of the implementation of these mandates, more than 200,000 COVID-19 cases were averted by May 22, 2020. The findings suggest that requiring face mask use in public could help in mitigating the spread of COVID-19.
579 citations
TL;DR: This study provides real-world evidence that there are racial and ethnic disparities in the presentation of COVID-19, and observes that, compared with non-Hispanic white patients, African Americans had 2.7 times the odds of hospitalization, after adjusting for age, sex, comorbidities, and income.
Abstract: As the novel coronavirus disease (COVID-19) pandemic spreads throughout the United States, evidence is mounting that racial and ethnic minorities and socioeconomically disadvantaged groups are bearing a disproportionate burden of illness and death. We conducted a retrospective cohort analysis of COVID-19 patients at Sutter Health, a large integrated health system in northern California, to measure potential disparities. We used Sutter's integrated electronic health record to identify adults with suspected and confirmed COVID-19, and we used multivariable logistic regression to assess risk of hospitalization, adjusting for known risk factors, such as race/ethnicity, sex, age, health, and socioeconomic variables. We analyzed 1,052 confirmed cases of COVID-19 from the period January 1-April 8, 2020. Among our findings, we observed that compared with non-Hispanic white patients, non-Hispanic African American patients had 2.7 times the odds of hospitalization, after adjustment for age, sex, comorbidities, and income. We explore possible explanations for this, including societal factors that either result in barriers to timely access to care or create circumstances in which patients view delaying care as the most sensible option. Our study provides real-world evidence of racial and ethnic disparities in the presentation of COVID-19.
462 citations
TL;DR: It is found that declines in non-COVID-19 admissions from February to April 2020 were generally similar across patient demographic subgroups and exceeded 20% for all primary admission diagnoses, and rebounded to 16% below pre-pandemic baseline volume by late June/early July 2020.
Abstract: Hospital admissions in the US fell dramatically with the onset of the coronavirus disease 2019 (COVID-19) pandemic. However, little is known about differences in admissions patterns among patient g...
307 citations
TL;DR: Welsh adults in every age group were more likely than whites to have health risks associated with severe COVID-19 illness, but whites were older on average than blacks, and Asians and Hispanics had much lower overall levels of risk compared to either whites or blacks.
Abstract: We used data from the Medical Expenditure Panel Survey to explore potential explanations for racial/ethnic disparities in coronavirus disease 2019 (COVID-19) hospitalizations and mortality. Black adults in every age group were more likely than White adults to have health risks associated with severe COVID-19 illness. However, Whites were older, on average, than Blacks. Thus, when all factors were considered, Whites tended to be at higher overall risk compared with Blacks, with Asians and Hispanics having much lower overall levels of risk compared with either Whites or Blacks. We explored additional explanations for COVID-19 disparities-namely, differences in job characteristics and how they interact with household composition. Blacks at high risk for severe illness were 1.6 times as likely as Whites to live in households containing health-sector workers. Among Hispanic adults at high risk for severe illness, 64.5 percent lived in households with at least one worker who was unable to work from home, versus 56.5 percent among Black adults and only 46.6 percent among White adults.
300 citations
TL;DR: A Monte Carlo simulation model representing the U.S. population and what can happen to each person who gets infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) is developed to understand the potential economic benefits of reducing the burden of the disease.
Abstract: With the coronavirus disease 2019 (COVID-19) pandemic, one of the major concerns is the direct medical cost and resource use burden imposed on the US health care system. We developed a Monte Carlo simulation model that represented the US population and what could happen to each person who got infected. We estimated resource use and direct medical costs per symptomatic infection and at the national level, with various "attack rates" (infection rates), to understand the potential economic benefits of reducing the burden of the disease. A single symptomatic COVID-19 case could incur a median direct medical cost of $3,045 during the course of the infection alone. If 80 percent of the US population were to get infected, the result could be a median of 44.6 million hospitalizations, 10.7 million intensive care unit (ICU) admissions, 6.5 million patients requiring a ventilator, 249.5 million hospital bed days, and $654.0 billion in direct medical costs over the course of the pandemic. If 20 percent of the US population were to get infected, there could be a median of 11.2 million hospitalizations, 2.7 million ICU admissions, 1.6 million patients requiring a ventilator, 62.3 million hospital bed days, and $163.4 billion in direct medical costs over the course of the pandemic.
252 citations
TL;DR: To reduce harmful emissions, the health care sector should decrease unnecessary consumption of resources, decarbonize power generation, and invest in preventive care, which will likely require mandatory reporting, benchmarking, and regulation of health care organizations.
Abstract: An up-to-date assessment of environmental emissions in the US health care sector is essential to help policy makers hold the health care industry accountable to protect public health. We update nat...
201 citations
TL;DR: This study demonstrates that providing people with assurances for their livelihood during self-quarantine is an important component in compliance with public health regulations.
Abstract: To contain the novel coronavirus disease (COVID-19) pandemic, health and government authorities have imposed sweeping self-quarantine orders for communities worldwide. Health officials assume that the public will have high rates of compliance. However, studies suggest that a major obstacle to compliance for household quarantine is concern about loss of income. A cross-sectional study of the adult population of Israel was conducted in the last week of February 2020 to assess public attitudes toward the COVID-19 outbreak. In particular, public compliance rates with self-quarantine were assessed, depending on whether lost wages would be compensated for. When compensation was assumed, the compliance rate was 94 percent. When compensation was removed, the compliance rate dropped to less than 57 percent. This study demonstrated that providing people with assurances about their livelihoods during self-quarantine is an important component of compliance with public health regulations.
195 citations
TL;DR: It is found that more than 1 in 5 nursing homes report a severe shortage of PPE and any shortage of staff, and rates of both staff and PPE shortages did not meaningfully improve from May to July of 2020.
Abstract: The coronavirus disease 2019 (COVID-19) pandemic continues to devastate US nursing homes. Adequate personal protective equipment (PPE) and staffing levels are critical to protect nursing home residents and staff. Despite the importance of these basic measures, few national data are available concerning the state of nursing homes with respect to these resources. This article presents results from a new national database containing data from 98 percent of US nursing homes. We find that more than one in five nursing homes reports a severe shortage of PPE and any shortage of staff. Rates of both staff and PPE shortages did not meaningfully improve from May to July 2020. Facilities with COVID-19 cases among residents and staff, as well as those serving more Medicaid recipients and those with lower quality scores, were more likely to report shortages. Policies aimed at providing resources to obtain additional direct care staff and PPE for these vulnerable nursing homes, particularly in areas with rising community COVID-19 case rates, are needed to reduce the national COVID-19 death toll.
168 citations
TL;DR: Public health and policy efforts that improve care for foreign born non-citizens, address crowded housing, and protect food-service workers may help mitigate the spread of COVID-19 among minority communities.
Abstract: Massachusetts has one of the highest cumulative incidence rates of coronavirus disease 2019 (COVID-19) cases in the US. Understanding which specific demographic, economic, and occupational factors have contributed to disparities in COVID-19 incidence rates across the state is critical to informing public health strategies. We performed a cross-sectional study of 351 Massachusetts cities and towns from January 1 to May 6, 2020, and found that a 10-percentage-point increase in the Black non-Latino population was associated with an increase of 312.3 COVID-19 cases per 100,000 population, whereas a 10-percentage-point increase in the Latino population was associated with an increase of 258.2 cases per 100,000. Independent predictors of higher COVID-19 rates included the proportion of foreign-born noncitizens living in a community, mean household size, and share of food service workers. After adjustment for these variables, the association between the Latino population and COVID-19 rates was attenuated. In contrast, the association between the Black population and COVID-19 rates persisted but may be explained by other systemic inequities. Public health and policy efforts that improve care for foreign-born noncitizens, address crowded housing, and protect food service workers may help mitigate the spread of COVID-19 among minority communities.
161 citations
TL;DR: Arguments for reduced reliance on incarceration and for related justice reforms both as emergency measures during the present pandemic and as sustained structural changes vital for future pandemic preparedness and public health are supported.
Abstract: Jails and prisons are major sites of novel coronavirus (SARS-CoV-2) infection. Many jurisdictions in the United States have therefore accelerated release of low-risk offenders. Early release, howev...
TL;DR: A statistical model is fit to COVID-19 case fatality rates over time at the US county level to estimate the COVID -19 IFR among symptomatic cases (IFR-S) as time goes to infinity, which can help disease and policy modelers to obtain more accurate predictions for the epidemiology of the disease and the impact of alternative policy levers to contain this pandemic.
Abstract: Knowing the infection fatality rate (IFR) of novel coronavirus (SARS-CoV-2) infections is essential for the fight against the coronavirus disease (COVID-19) pandemic. Using data through April 20, 2020, I fit a statistical model to COVID-19 case fatality rates over time at the US county level to estimate the COVID-19 IFR among symptomatic cases (IFR-S) as time goes to infinity. The IFR-S in the US was estimated to be 1.3 percent. County-specific rates varied from 0.5 percent to 3.6 percent. The overall IFR for COVID-19 should be lower when I account for cases where patients are asymptomatic and recover without symptoms. When used with other estimating approaches, my model and estimates can help disease and policy modelers obtain more accurate predictions for the epidemiology of the disease and the impact of various policy levers to contain the pandemic. The model could also be used with future pandemics to get an early sense of the magnitude of symptomatic infection at the population level before other direct estimates are available. Substantial variation across patient demographics likely exists and should be the focus of future studies.
TL;DR: In the years since the Affordable Care Act went into effect, insurance coverage has increased significantly for all racial/ethnic groups, but coverage increased more for non-Hispanic blacks and Hispanics than fornon-Hispanic whites.
Abstract: Large disparities in health insurance coverage and access to health services have long persisted in the US health care system. We considered how the insurance coverage expansions of the Affordable Care Act have affected disparities related to race and ethnicity. In the years since the law went into effect, insurance coverage has increased significantly for all racial/ethnic groups. Because coverage increased more for non-Hispanic blacks and Hispanics than for non-Hispanic whites, disparities in coverage have decreased. Despite these improvements, a large number of adults remain uninsured, and the uninsurance rate among blacks and Hispanics is substantially higher than the rate among whites.
TL;DR: The 0.4-percentage-point acceleration in overall growth in 2018 was driven by faster growth in both private health insurance and Medicare, which were influenced by the reinstatement of the health insurance tax.
Abstract: US health care spending increased 4.6 percent to reach $3.6 trillion in 2018, a faster growth rate than the rate of 4.2 percent in 2017 but the same rate as in 2016. The share of the economy devote...
TL;DR: A return-on-investment analysis that is based on a randomized controlled trial of Individualized Management for Patient-Centered Targets (IMPaCT), a standardized community health worker intervention that addresses unmet social needs for disadvantaged people found that every dollar invested in the intervention would return $2.47 to an average Medicaid payer within the fiscal year.
Abstract: Interventions that address socioeconomic determinants of health are receiving considerable attention from policy makers and health care executives. The interest is fueled in part by expected returns on investment. However, many current estimates of returns on investment are likely overestimated, because they are based on pre-post study designs that are susceptible to regression to the mean. We present a return-on-investment analysis that is based on a randomized controlled trial of Individualized Management for Patient-Centered Targets (IMPaCT), a standardized community health worker intervention that addresses unmet social needs for disadvantaged people. We found that every dollar invested in the intervention would return $2.47 to an average Medicaid payer within the fiscal year.
TL;DR: A search for all public announcements of new programs involving direct financial investments in social determinants of health by US health systems from January 1, 2017, to November 30, 2019 found seventy-eight unique programs involving fifty-seven health systems that collectively included 917 hospitals.
Abstract: The past decade has seen a growing recognition of the importance of social determinants of health for health outcomes. However, the degree to which US health systems are directly investing in commu...
TL;DR: It is vital that the major regulatory and insurance changes undergirding the COVID-19 telehealth response be sustained to protect access for the most vulnerable patients.
Abstract: New York City Health + Hospitals is the largest safety-net health care delivery system in the United States. Before the coronavirus disease 2019 (COVID-19) pandemic, NYC Health + Hospitals served more than one million patients annually, including the most vulnerable New Yorkers, while billing fewer than five hundred telehealth visits monthly. Once the pandemic struck, we established a strategy to allow us to continue to serve our existing patients while treating the surge of new patients. Starting in March 2020, we were able to transform the system using virtual care platforms through which we conducted almost eighty-three thousand billable televisits in one month, as well as more than thirty thousand behavioral health encounters via telephone and video. Telehealth also enabled us to support patient-family communication, postdischarge follow-up, and palliative care for patients with COVID-19. Expanded Medicaid coverage and insurance reimbursement for telehealth played a pivotal role in this transformation. As we move to a new blend of virtual and in-person care, it is vital that the major regulatory and insurance changes undergirding our COVID-19 telehealth response be sustained to protect access for our most vulnerable patients.
TL;DR: National health expenditures are projected to grow at an average annual rate of 5.4 percent for 2019-28 and to represent 19.7 percent of gross domestic product by the end of the period, compared with 19.1 percent in 2018.
Abstract: National health expenditures are projected to grow at an average annual rate of 5.4 percent for 2019–28 and to represent 19.7 percent of gross domestic product by the end of the period. Price growt...
TL;DR: A systematic review of the impact of three CMS bundled payment programs on spending, utilization, and quality outcomes showed that bundled payment maintains or improves quality while lowering costs for lower extremity joint replacement, but not for other conditions or procedures.
Abstract: The Centers for Medicare and Medicaid Services (CMS) has promoted bundled payment programs nationwide as one of its flagship value-based payment reforms. Under bundled payment, providers assume accountability for the quality and costs of care delivered during an episode of care. We performed a systematic review of the impact of three CMS bundled payment programs on spending, utilization, and quality outcomes. The three programs were the Acute Care Episode Demonstration, the voluntary Bundled Payments for Care Improvement initiative, and the mandatory Comprehensive Care for Joint Replacement model. Twenty studies that we identified through search and screening processes showed that bundled payment maintains or improves quality while lowering costs for lower extremity joint replacement, but not for other conditions or procedures. Our review also suggests that policy makers should account for patient-level heterogeneity and include risk stratification for specific conditions in emerging bundled payment programs.
TL;DR: To improve children's health and well-being, the health sector must move beyond a focus on treating disease or modifying individual behavior to a broader focus on neighborhood conditions and collaborate with other sectors such as housing to execute mobility-based interventions.
Abstract: Neighborhoods influence children’s health, so it is important to have measures of children’s neighborhood environments. Using the Child Opportunity Index 2.0, a composite metric of the neighborhood...
TL;DR: Transformation of the medical device industry to a more circular economy would advance the goal of providing increasingly complex care in a low-emissions future, and complementary policy- and market-driven solutions are needed.
Abstract: A circular economy involves maintaining manufactured products in circulation, distributing resource and environmental costs over time and with repeated use. In a linear supply chain, manufactured products are used once and discarded. In high-income nations, health care systems increasingly rely on linear supply chains composed of single-use disposable medical devices. This has resulted in increased health care expenditures and health care-generated waste and pollution, with associated public health damage. It has also caused the supply chain to be vulnerable to disruption and demand fluctuations. Transformation of the medical device industry to a more circular economy would advance the goal of providing increasingly complex care in a low-emissions future. Barriers to circularity include perceptions regarding infection prevention, behaviors of device consumers and manufacturers, and regulatory structures that encourage the proliferation of disposable medical devices. Complementary policy- and market-driven solutions are needed to encourage systemic transformation.
TL;DR: The pronounced growth in the number of NPs has reduced the size of the registered nurse (RN) workforce by up to 80,000 nationwide, and hospitals must innovate and test creative ideas to replace RNs who have left their positions to become NPs.
Abstract: Concerns about physician shortages have led policy makers in the US public and private sectors to advocate for the greater use of nurse practitioners (NPs). We examined recent changes in demographi...
TL;DR: It is estimated thatPrimary care practices over the course of calendar year 2020 would be expected to lose $67,774 in gross revenue per full time physician and the cost would be $15.1 billion at a national level to neutralize the revenue losses caused by COVID-19 among primary care practices.
Abstract: As a result of the coronavirus disease 2019 (COVID-19) pandemic, virtually all in-person outpatient visits were canceled in many parts of the country between March and May 2020. We sought to estimate the potential impact of COVID-19 on the operating expenses and revenues of primary care practices. Using a microsimulation model incorporating national data on primary care use, staffing, expenditures, and reimbursements, including telemedicine visits, we estimated that over the course of calendar year 2020, primary care practices would be expected to lose 67,774 in gross revenue per full-time-equivalent physician (the difference between 2020 gross revenue with COVID-19 and the anticipated gross revenue if COVID-19 had not occurred). We further estimated that the cost at a national level to neutralize the revenue losses caused by COVID-19 among primary care practices would be $15.1 billion. This could more than double if COVID-19 telemedicine payment policies are not sustained.
TL;DR: Using an equity lens to move beyond incremental to transformational resilience would reduce vulnerability and improve sustainability for all, but substantial additional funding is required for proactive and effective actions by the health system.
Abstract: Climate change has altered global to local weather patterns and increased sea levels, and it will continue to do so. Average temperatures, precipitation amounts, and other variables such as humidity levels are all rising. In addition, weather variability is increasing, causing, for example, a greater number of heat waves, many of which are more intense and last longer, and more floods and droughts. These changes are collectively increasing the number of injuries, illnesses, and deaths from a wide range of climate-sensitive health outcomes. Future health risks will be determined not just by the hazards created by a changing climate but also by the sensitivity of individuals and communities exposed to these hazards and the capacity of health systems to prepare for and effectively manage the attendant risks. These risks include deaths and injuries from extreme events (for example, heat waves, storms, and floods), infectious diseases (including food-, water-, and vectorborne illnesses), and food and water insecurity. These risks are unevenly distributed and both create new inequities and exacerbate those that already exist. Most of these risks are projected to increase with each additional unit of warming. Using an equity lens to move beyond incremental to transformational resilience would reduce vulnerability and improve sustainability for all, but substantial additional funding is required for proactive and effective actions by the health system.
TL;DR: For children in poverty, the risk of obesity declined substantially each year after the act’s implementation, such that obesity prevalence would have been 47 percent higher in 2018 if there had been no legislation.
Abstract: The Healthy, Hunger-Free Kids Act of 2010 strengthened nutrition standards for meals and beverages provided through the National School Lunch, Breakfast, and Smart Snacks Programs, affecting fifty ...
TL;DR: The steps taken by NYC H+H greatly expanded its capacity to provide critical care during an unprecedented surge of COVID-19 cases, along with lessons learned, could inform preparations for other health systems during a primary or secondary surge of cases.
Abstract: New York City has emerged as the global epicenter for the coronavirus disease 2019 (COVID-19) pandemic. The city's public health system, New York City Health + Hospitals, has been key to the city's response because its vulnerable patient population is disproportionately affected by the disease. As the number of cases rose in the city, NYC Health + Hospitals carried out plans to greatly expand critical care capacity. Primary intensive care unit (ICU) spaces were identified and upgraded as needed, and new ICU spaces were created in emergency departments, procedural areas, and other inpatient units. Patients were transferred between hospitals to reduce strain. Critical care staffing was supplemented by temporary recruits, volunteers, and Department of Defense medical personnel. Supplies needed to deliver critical care were monitored closely and replenished to prevent interruptions. An emergency department action team was formed to ensure that the experience of front-line providers was informing network-level decisions. The steps taken by NYC Health + Hospitals greatly expanded its capacity to provide critical care during an unprecedented surge of COVID-19 cases in NYC. These steps, along with lessons learned, could inform preparations for other health systems during a primary or secondary surge of cases.
TL;DR: SIPOs have been effective in reducing the daily growth rates of COVID-19 deaths and hospitalizations, suggesting as many as 250,000-370,000 deaths possibly averted by May 15 in the 42 states plus the District of Columbia with statewide SIPOs.
Abstract: Most states enacted shelter-in-place orders when mitigating the coronavirus disease 2019 (COVID-19) pandemic. Emerging evidence indicates that these orders have reduced COVID-19 cases. Using data starting at different dates in March and going through May 15, 2020, we examined the effects of shelter-in-place orders on daily growth rates of both COVID-19 deaths and hospitalizations, using event study models. We found that shelter-in-place orders reduced both the daily mortality growth rate nearly three weeks after their enactment and the daily growth rate of hospitalizations two weeks after their enactment. After forty-two days from enactment, the daily mortality growth rate declined by up to 6.1 percentage points. Projections suggest that as many as 250,000-370,000 deaths were possibly averted by May 15 in the forty-two states plus Washington, D.C., that had statewide shelter-in-place orders. The daily hospitalization growth rate examined in nineteen states with shelter-in-place orders and three states without them that had data on hospitalizations declined by up to 8.4 percentage points after forty-two days. This evidence suggests that shelter-in-place orders have been effective in reducing the daily growth rates of COVID-19 deaths and hospitalizations.
TL;DR: Compared to physicians in other countries, substantial proportions of US physicians did not routinely receive timely notification or the information needed for managing ongoing care from specialists, after-hours care centers, emergency departments, or hospitals.
Abstract: Primary care physicians in the US, like their colleagues in several other high-income countries, are increasingly tasked with coordinating services delivered not just by specialists and hospitals but also by home care professionals and social service agencies. To inform efforts to improve care coordination, the 2019 Commonwealth Fund International Health Policy Survey of Primary Care Physicians queried primary care physicians in eleven high-income countries about their ability to coordinate patients' medical care with specialists, across settings of care, and with social service providers. Compared to physicians in other countries, substantial proportions of US physicians did not routinely receive timely notification or the information needed for managing ongoing care from specialists, after-hours care centers, emergency departments, or hospitals. Primary care practices in a handful of countries, including the US, are not routinely exchanging information electronically outside the practice. Top-performing countries demonstrate the feasibility of improving two-way communication between primary care and other sites of care. The surveyed countries share the challenge of coordinating with social service providers, and the results call for solutions to support primary care physicians.
TL;DR: This paper found that after expansion, new mothers in Utah experienced higher rates of Medicaid coverage loss and accessed fewer Medicaid-financed outpatient visits during the six months postpartum, relative to their counterparts in Colorado.
Abstract: Timely postpartum care is associated with lower maternal morbidity and mortality, yet fewer than half of Medicaid beneficiaries attend a postpartum visit. Medicaid enrollees are at higher risk of postpartum disruptions in insurance because pregnancy-related Medicaid eligibility ends sixty days after delivery. We used Medicaid claims data for 2013-15 from Colorado, which expanded Medicaid under the Affordable Care Act, and Utah, which did not. We found that after expansion, new mothers in Utah experienced higher rates of Medicaid coverage loss and accessed fewer Medicaid-financed outpatient visits during the six months postpartum, relative to their counterparts in Colorado. The effects of Medicaid expansion on postpartum Medicaid enrollment and outpatient utilization were largest among women who experienced significant maternal morbidity at delivery. These findings provide evidence that expansion may promote the stability of postpartum coverage and increase the use of postpartum outpatient care in the Medicaid program.
TL;DR: Creation of multidisciplinary teams, frequent enterprise-wide communication, willingness to shift direction in response to changing needs, and innovative use of technology were the key factors that enabled the hospital system to meet its goals.
Abstract: Confronted with the coronavirus disease 2019 (COVID-19) pandemic, New York City Health + Hospitals, the city's public health care system, rapidly expanded capacity across its eleven acute care hospitals and three new field hospitals. To meet the unprecedented demand for patient care, NYC Health + Hospitals redeployed staff to the areas of greatest need and redesigned recruiting, onboarding, and training processes. The hospital system engaged private staffing agencies, partnered with the Department of Defense, and recruited volunteers throughout the country. A centralized onboarding team created a single-source portal for medical care providers requiring credentialing and established new staff positions to increase efficiency. Using new educational tools focused on COVID-19 content, the hospital system trained twenty thousand staff members, including nearly nine thousand nurses, within a two-month period. Creation of multidisciplinary teams, frequent enterprisewide communication, willingness to shift direction in response to changing needs, and innovative use of technology were the key factors that enabled the hospital system to meet its goals.