need information overload”
Interview: Swiss emergency medical director Aristomenis Exadaktylos urges better preparations for epidemics.
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 to. Even 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 infrastructure, which 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 need. Moreover, we want our work environment to look and feel right for its intended purpose. If you practice emergency medicine in a 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 a stressful situation.
The pandemic has subjected hospital workers to enormous additional levels of stress. How are you dealing with them?
Exadaktylos: We’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 field. It’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 a 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, anyway. No one is forced to become an emergency physician or nurse. My colleagues work in the emergency room because they want to, so a high degree of intrinsic motivation is already there. It’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.
Digitalization helps us make sure we’re not overlooking anything.
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 overload. We’re familiar with that problem from anesthesiology. You’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?
Exadaktylos: We shifted relatively early on from verbal to electronic communications. Every directive from a doctor is entered and transmitted digitally. Some 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.
What long-term conclusions can you draw from the coronavirus pandemic?
Exadaktylos: We 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 Organization—the WHO—is the only way to go. We 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 treatments. Every 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.