# Spectrum

“Doctors don’t
need information overload”

Interview: Swiss emergency medical director Aristomenis Exadaktylos urges better preparations for epidemics.

Professor Aristomenis (Aris) Exadaktylos directs one of Switzerland’s largest emergency medical centers. The facility at Inselspital—the Bern University Hospital—treats more than 50,000 patients a year. Alessandro Della Valle

Professor Exadaktylos, as the director of the department of emergency medicine at Bern University Hospital, you have firsthand experience with the outbreak of the coronavirus pandemic. How well would you say hospitals in Europe have been responding to this crisis?

Aris Exadak­ty­los: We were caught off guard in Feb­ru­ary 2020 because we didn’t think the Covid-19 epi­dem­ic would devel­op into a pan­dem­ic. I would say we were rely­ing too heav­i­ly on expe­ri­ence with pre­vi­ous epi­demics like the avian flu, swine flu, or MERS, which were rel­a­tive­ly mild for us in Europe. When a large-scale out­break appeared in north­ern Italy, some of the hos­pi­tals there were total­ly unpre­pared. You might com­pare it with hav­ing a hand grenade explode in your hands. Other coun­tries at least were able to make use of the head start and pre­pare for the upcom­ing wave of patients. In just a short peri­od of time, we in Bern shift­ed from a con­trolled sys­tem with par­al­lel tracks for elec­tive and emer­gency pro­ce­dures to some­thing resem­bling a wartime sce­nario. But that also meant we had to do a lot of impro­vis­ing

If there’s one department that really needs to be prepared, wouldn’t it be the emergency center?

Exadak­ty­los: Over recent years, emer­gency depart­ments in Switzer­land and the rest of Europe have seen an enor­mous increase in the num­ber of patients. They treat peo­ple with life-threat­en­ing injuries and con­di­tions, and are also vis­it­ed by all man­ner of what we might call com­mu­ni­ty med­ical cases. These include peo­ple with drug issues, or psy­cho­log­i­cal prob­lems, or those who have minor injuries but no gen­er­al prac­ti­tion­er to go toEven under nor­mal cir­cum­stances, the orga­ni­za­tion­al work con­nect­ed with all these cases is a chal­lenge. That’s why all the hos­pi­tals with well-struc­tured emer­gency cen­ters are now in a bet­ter posi­tion to han­dle a pan­dem­ic like the one we’re see­ing. After all, patients with heart attacks or strokes or life-threat­en­ing injuries still have to be treat­ed, just as they were before the coro­n­avirus appeared. 

So what is the best way to handle all this?

Exadak­ty­los: The only way to do it is with a well-func­tion­ing infra­struc­turewhich means every­thing from auto­mat­ic doors to IT sys­tems. The pri­ma­ry con­cern is safe­ty. It’s like having a mod­ern auto­mo­bile that cor­rects for human error. On the one hand, we cre­ate redun­dant sys­tems by installing addi­tion­al back­ground ser­vices that make sure any faulty deci­sions are cor­rect­ed. But on the other hand, we man­age our resources respon­si­bly and only use what we real­ly needMore­over, we want our work envi­ron­ment to look and feel right for its intend­ed pur­pose. If you prac­tice emer­gency med­i­cine in poor­ly lit, cramped room where the air is fraught to begin with, and you don’t have enough staff and the com­put­er sys­tems don’t work, you very quick­ly reach your lim­its in what is already stress­ful sit­u­a­tion. 

The pandemic has subjected hospital workers to enormous additional levels of stress. How are you dealing with them?

Exadak­ty­losWe’re con­fronting a high­ly con­ta­gious dis­ease. A sit­u­a­tion like the one in Italy, where med­ical per­son­nel caught it them­selves and then died, obvi­ous­ly gen­er­ates a high level of psy­cho­log­i­cal stress for any­one work­ing in this fieldIt’s very impor­tant to give every­one, from staff to patients and their rel­a­tives, the sense that they are in a safe and well-man­aged place, and not at the thresh­old to hell. When hos­pi­tal staff have to impro­vise and wear trash bags on their heads or feet, that might be an excit­ing image for social media but it’s enor­mous­ly coun­ter­pro­duc­tive for every part of hos­pi­tal. If your employ­ees don’t have the feel­ing that their insti­tu­tion is pro­tect­ing them, they’ll lose trust. And peo­ple who lose trust are much less like­ly to go the extra mile over the long term. For­tu­nate­ly, that has not been the case for us in Bern. We were well equipped, and were able to give all of our work­ers a sense of being safe and pro­tect­ed. Not because we’re par­tic­u­lar­ly wealthy, but because we had already been con­cern­ing our­selves in peace­time with the pos­si­bil­i­ty of bio­log­i­cal threats, and because we’re also get­ting a huge amount of sup­port from the rest of the uni­ver­si­ty hos­pi­tal. This has been an enor­mous boost to our morale. 

That’s clearly necessary at a time like this. What else motivates your colleagues?

Exadak­ty­los: You start off with a high level of motivation, any­wayNo one is forced to become an emer­gency physi­cian or nurseMy col­leagues work in the emer­gency room because they want to, so a high degree of intrin­sic moti­va­tion is already thereIt’s the same for fire­fight­ers. When a fire breaks out, they have respect instead of fear. They know that’s pre­cise­ly what they have been trained for. If you also know that you’re part of a team, that your lead­ers are set­ting good exam­ples, and that doc­tors from other depart­ments—includ­ing the pro­fes­sors and head physi­cians—are all at the fore­front of help­ing to fight the virus, that too has a moti­vat­ing effect. On top of that, the employ­ees have to see that you’re active­ly tak­ing care of them so all they have to do is focus on their jobs. This includes what some might con­sid­er triv­ial mat­ters such as how meals are brought to their work­sta­tions or the avail­abil­i­ty of staff park­ing and overnight accom­mo­da­tion. 

Professor Aristomenis Exadaktylos, director of the department of emergency medicine at Bern University Hospital Alessandro Della Valle

Digitalization helps us make sure we’re not overlooking anything.

Professor Aristomenis Exadaktylos
Director of the department of emergency medicine at Bern University Hospital

Did you have to modify the processes at your emergency center?

Exadak­ty­los: Yes, quite a bit. We start­ed by form­ing Covid teams that worked only with these patients. In par­al­lel to that we insti­tut­ed a qual­i­ty con­trol sys­tem to make sure our approach was work­ing. After all, we didn’t have any expe­ri­ence with this dis­ease. The report­ing sys­tems were there­fore also very impor­tant, in terms of doc­u­ment­ing and access­ing patient infor­ma­tion. Our emer­gency cock­pit, the foun­da­tions for which we laid sev­er­al years ago togeth­er with Porsche Con­sult­ing, man­ages the data to make it quick­ly acces­si­ble and under­stand­able to our staff. These data visu­al­iza­tions have been enor­mous­ly help­ful to us as we adapt and con­tin­u­ous­ly improve our process­es 

What are some concrete examples of how digitalization helps your everyday operations?

Exadak­ty­los: It helps us make sure we’re not over­look­ing any­thing, and also helps us fil­ter out the rel­e­vant infor­ma­tion we need for each patient. With all the focus on the coro­n­avirus we can’t for­get other cases, like some­one who gets sep­sis from an infect­ed knee, for exam­ple. Our dig­i­tal sys­tems always keep us aware of that type of thing—rather like when a car warns you of a sud­den drop in tire pres­sure. Nowa­days, we are con­front­ed with an ever-increas­ing vol­ume of infor­ma­tion. But it shouldn’t become an over­loadWe’re famil­iar with that prob­lem from anes­the­si­ol­o­gyYou’ve got all these mon­i­tors that are con­stant­ly beep­ing, but if you elim­i­nat­ed the alarm, at some point you wouldn’t notice quick­ly enough if your patient took a sud­den turn for the worse. The bet­ter dig­i­tal sys­tems become, the more pre­cise they are at “under­stand­ing” what infor­ma­tion is rel­e­vant for the doc­tor at that instant. If you don’t have alarm process­es in place, that might work for your emer­gency room under nor­mal cir­cum­stances, but when things get crazy you’d lose con­trol. 

Communication is crucial in emergency rooms, which are often overcrowded because they’re the first place patients go. What guidelines have you instituted to organize it?

Exadak­ty­losWe shift­ed rel­a­tive­ly early on from ver­bal to elec­tron­ic com­mu­ni­ca­tions. Every direc­tive from a doc­tor is entered and trans­mit­ted dig­i­tal­lySome of the staff weren’t very happy about that, but it’s yield­ing enor­mous ben­e­fits right now. For one thing, peo­ple don’t have to move around the emer­gency depart­ment very much because they can all stay at their sta­tions and com­mu­ni­cate from there. The very rapid flow of infor­ma­tion has helped us main­tain social dis­tanc­ing, and work more effi­cient­ly. 

There was a false sense of security.

Professor Aristomenis Exadaktylos
Director of the department of emergency medicine at Bern University Hospital

What long-term conclusions can you draw from the coronavirus pandemic?

Exadak­ty­losWe spent too much time with a false sense of secu­ri­ty. Here in Aus­tria, Switzer­land, and Ger­many, we can deal with the cri­sis because our health sys­tems work and we have enough fund­ing. But there’s no way we can deal with this type of lock­down every year. The health­care sys­tem is not a field that a lot of politi­cians either like or value, so it is fre­quent­ly faced with seri­ous cuts. We real­ly have to think about whether that’s a sus­tain­able model for the future. If we’re now enter­ing a decade of epi­demics, we’ll be grate­ful for every hos­pi­tal bed we have.  

That doesn’t sound terribly encouraging …

Exadak­ty­los: To fight pan­demics, we need a world­wide net­work. Despite all the crit­i­cism, I’m con­vinced the World Health Orga­ni­za­tionthe WHOis the only way to goWe can’t tol­er­ate any more delays in com­mu­ni­cat­ing data or infor­ma­tion in the future. We need trans­paren­cy and glob­al early warn­ing sys­tems, and we have to share infor­ma­tion about treat­mentsEvery extra day of prepa­ra­tion you give to a health­care sys­tem will end up sav­ing lives. Italy is an exam­ple of what hap­pens when that’s not the case. They didn’t have time to pre­pare for the out­break. So we need to strength­en the WHO. A lot of inter­na­tion­al orga­ni­za­tions are tooth­less right now. They can warn coun­tries, but they don’t have any author­i­ty to impose sanc­tions or take other mea­sures. There too we need to mod­i­fy our approach. 

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