Surge Teams to the Rescue

Surge Teams to the Rescue

An influx of patients both during and after pandemic waves forced physicians and administrators to get creative and provide optimal care.

Even though the COVID-19 outbreak was declared a pandemic in March 2020, the first surge of cases didn’t hit Stanford’s hospitals until July 2020. Residents worked together to create surge teams staffed by volunteer internal medicine residents. Administrators canceled elective surgeries. The parking garage of the newest hospital building became a drive-up testing center.

“Just a few months after they opened the new hospitals, we had the onset of the pandemic. And the pandemic sort of threw everything for a loop,” says Tyler Johnson, MD, clinical assistant professor of oncology. “It was an all-hands-on-deck approach.”

But shortly after it started, the surge subsided, and the surge teams disbanded in early fall.

Then, near the end of the year, COVID came roaring back, with far more cases than before. Doctors from all departments were pulled to take care of COVID patients in the intensive care unit and COVID wards.

Administrators had anticipated that they’d have to pull staff from other departments during the surge, and with the discharging of patients who didn’t absolutely need to be in the hospital, there ended up being enough physicians and other health care providers to take care of the COVID patients. What surprised the health care team, however, was that after the winter holidays, as COVID cases started to wane, hospital admissions for other conditions, such as heart disease and cancer, soared.

“During the pandemic, the internal medicine residents had borne a heroic load, taking care of a huge number of very sick patients, and doing so with great bravery,” says Johnson. “When the pandemic numbers started to fall, however, and the regular numbers started to rise, it quickly became clear that we could not long place the entire burden on house staff — a new care delivery model would be necessary.”

The situation was untenable, and the directors of the Internal Medicine Residency program announced that residents should be more limited in the number of patients they see at a time. “It’s just not reasonable to think that the number of residents, which is fixed, is going to care for an infinitely increasing number of patients,” says Johnson.

“We are extremely proud of our doctors for stepping up, taking on these extra duties, and making sure SHC patients have the very best care possible.”

– Cathy Garzio

“We are extremely proud of our doctors for stepping up, taking on these extra duties, and making sure SHC patients have the very best care possible.”

– Cathy Garzio

It was clear to physician leaders that the Department of Medicine needed a new way to handle the inpatient volume to avoid overburdening the house staff. And so, out of necessity, new surge teams were born. On Jan. 4, 2021, explains Cathy Garzio, vice chair and director of finance and administration, the department launched its three new surge teams.

These surge teams were staffed by attending physicians and fellows from a variety of medical specialties who signed up for shifts to care for up to 10 patients per team without interns or residents. “Then, over time, with volume remaining high and growing, we added four additional teams, plus swing and night shifts,” says Garzio.

All this activity was coordinated by leaders in Hospital Medicine, oncology, and cardiovascular medicine, among others. Jeff Chi, MD, an internal medicine specialist at Stanford Health Care, coordinated the extremely complex schedule with Vicki Parikh, MD, assistant professor of cardiovascular medicine, and Dan Gerber, MD, clinical assistant professor of cardiovascular medicine. “We are extremely proud of our doctors for stepping up, taking on these extra duties, and making sure SHC patients have the very best care possible,” Garzio adds.

How Do Surge Teams Work?

Every new patient who comes to the hospital is assigned to a treatment team. That’s the team that puts orders into the computer, communicates with the nursing staff, and receives pages for urgent issues. “The primary team ends up functioning like the hub at the center of the wheel with all those other spokes feeding into them,” says Johnson. The spokes are the other specialists and staff members with whom the team works.

Because the number of health care providers wasn’t enough to manage the patients coming in during the winter, the department devised a program where they asked doctors from within medicine (including medicine subspecialties) to sign up for shifts working as general hospitalists or internal medicine doctors. “So doctors who would normally be working as nephrologists and pulmonologists and cardiologists and oncologists,” says Johnson, “were able to work temporarily as general hospitalists or internal medicine doctors to take care of these additional patients coming in.”

Administrators started by creating a Google Doc listing shifts during which the hospital needed extra physicians. Doctors signed up for 12-hour shifts, some of which were overnight, and six-hour shifts from 5 p.m. to 11 p.m. to help fill gaps in the treatment teams and provide safe, high-quality patient care.

It was just an enormously complicated logistical undertaking. We’ve often joked that it’s like building a plane while you’re flying it.

– Tyler Johnson, MD

It was just an enormously complicated logistical undertaking. We’ve often joked that it’s like building a plane while you’re flying it.

– Tyler Johnson, MD

The Surge Team’s Players

Initially, only attending physicians were invited to sign up. However, over time, both interest and need grew, and soon residents and fellows were invited to sign up for extra shifts.

Even though the effort started as a stopgap measure, those involved say that it’s been popular. “A lot of faculty that only do clinic work come and cover these surge teams,” says Rita Pandya, MD, clinical assistant professor of medicine, who runs the nocturnist staff in Hospital Medicine. “I was really happy to find out how excited some of these faculty members are to do inpatient work … for them it was like being a resident again.”

Building a Program on the Fly

The first, and biggest, challenge was building the program with so little time. “It was just an enormously complicated logistical undertaking,” says Johnson. “We’ve often joked that it’s like building a plane while you’re flying it.”

To get the system running as quickly as possible, administrators asked physicians to sign up for shifts via Google Docs. “Back in January, if we knew we would still be doing this in June and July,” says Garzio, “I’m not sure we would have organized this via a Google Doc.” The next logistical challenge for Garzio was processing payments. The attendings, residents, and fellows all use different payroll systems.

Lastly, unpredictability has been a major challenge. Pandya runs the nocturnist program and covers all the surge teams overnight. She explains 

From left: Daniel Gerber, MD; Spencer Frost, MD; Victoria Parikh, MD; Alex Wright, MD, MBA; Jeffrey Chi, MD; Tyler Johnson, MD; Lichy Han, MD, PhD; and Charles Liao, MD.

that it’s impossible to predict how many patients will come in overnight and what level of staffing they’ll need. “There have been some nights that have been kind of quiet, and other nights there were over 100 patients in the ER,” she says. “There have been a couple of nights where I’ve even had to help out from home.”

The Future of Stanford’s Surge Teams

During the summer of 2022, there were six surge teams covered by six teams of providers during the day, a nocturnist at night, and a swing shift provider who overlapped with both the day and nocturnist providers. “The patient care has been outstanding, and we’ve taken good care of people,” says Garzio. But the surge teams lasted longer than some staff had anticipated, as COVID spikes, illness among providers, and simple exhaustion exacerbated existing shortages of health care providers.

While some teams may stick around for the longer term, the goal is to phase out all surge teams by January 2023, one year after starting this new care model.

“It’s been quite an experience. I don’t think it’s anything any of us had anticipated and has definitely outgrown what we thought we would need,” says Pandya.