How to Support Hospitals During The COVID-19 Pandemic: Lessons from Maryland

The global COVID-19 pandemic, declared in March 2020 with the spread of the severe acute respiratory syndrome coronavirus 2019 (SARS-CoV2) virus, overwhelmed hospital systems, clinics, and emergency departments across the United States. As COVID-19 initially spread across the country, hospitals were thrust into an uncertain infection prevention and control environment with a multitude of operational challenges. Hospital systems responded to rapidly evolving science with questions about virus transmission, symptoms for COVID-19, appropriate quarantine and isolation protocols, and COVID-19 testing protocols.

As hospitals dealt with an unpredictable pandemic, they required a consistent and trustworthy mechanism to receive guidance from experts and learn from each other. Recognizing this need, the Maryland Statewide Prevention and Reduction Collaborative (SPARC) for COVID-19 created a virtual forum for staff from 43 acute care hospitals in which participants engaged in real-time discussions about how to manage current issues regarding the pandemic. As we grapple with the Delta variant and return to high rates of COVID-19 community transmission, the SPARC model may help other public health departments understand how to best support infection prevention programs in hospitals in their state.

In particular, the SPARC experience highlights the:

• Value of a dedicated forum to disseminate complex information during public health emergencies;
• Role of public health-academic partnerships in translating general guidance into specific practice;
• Importance of peer-to-peer learning to validate practices when national guidance is not yet developed; and
• Need to consider variation in hospitals’ capabilities when providing support.

The SPARC For COVID-19 Model

In 2018, the Maryland Department of Health (MDH) recognized the need for quality improvement support and coordination between the MDH and hospitals statewide. Using the expertise and resources through the Centers for Disease Control and Prevention (CDC) Prevention Epicenters in Maryland at the University of Maryland School of Medicine and Johns Hopkins University School of Medicine, the three organizations developed the Maryland Statewide Prevention and Reduction for C. difficile Collaborative to prevent and reduce infections with this bacterium that can cause severe illness. SPARC developed a broad and well-resourced learning collaborative that leveraged a model where subject matter experts worked in collaboration with the MDH to support hospitals and facilitate peer-to-peer learning. The first iteration of SPARC was well received by its 13 participating hospitals, which saw a significant decrease in their C. difficile rates compared to hospitals that did not participate. 

With the onset of the pandemic, SPARC shifted focus to COVID-19 as hospitals’ priorities and support needs changed to controlling the SARS-CoV-2 virus. Since October 2020, SPARC for COVID-19 has leveraged the relationships built during its C. difficile collaborative to provide relevant information to Maryland acute care hospitals on weekly webinars hosted by the MDH. With the support of additional subject matter experts recruited by the SPARC team, SPARC facilitated expert-led presentations and discussions, town hall sessions, and peer-to-peer learning opportunities during the weekly webinars. With up to 180 attendees per webinar—consisting of infection preventionists, clinicians, hospital administrators, and epidemiologists—the collaborative has had a wide reach across the state of Maryland.

Lessons Learned From SPARC For COVID-19

In May 2021, SPARC initiated an assessment of its activities. Our findings—gleaned from survey responses from 31 webinar participants, five key informant interviews, and a group feedback session with 53 MDH webinar attendees—indicated that SPARC for COVID-19 successfully fostered an expert facilitated peer-to-peer learning network amongst hospitals. Below, we present four lessons learned based on our findings that can inform future state-based quality improvement collaboratives for COVID-19 and other public health emergencies.

Lesson 1: Dedicated Forums For Information Sharing Are Vital In The Face Of Rapidly Evolving Evidence

The goal of SPARC-led discussions was first and foremost to provide well-informed and trustworthy information to hospitals. We found that a regular forum for hospitals to receive information was critical; hospitals were responding to the current state of the pandemic while anticipating future needs and needed real-time support. Information needs changed quickly on a monthly to weekly basis. In the fall and early winter of 2020, webinar participants were particularly interested in topics related to COVID-19 testing, diagnosis, and clinical care, including health care worker safety. This soon shifted to questions regarding vaccine efficacy and distribution in late 2020 and early 2021, followed by variants and long COVID-19 (also known as post-COVID-19 condition).

SPARC created a nimble approach to addressing hospital information needs as the pandemic continuously evolved. Discussion topics were selected based on current happenings of the pandemic or direct requests from participants. Ultimately, SPARC-led discussions covered a range of topics including COVID-19 testing, personal protective equipment (PPE) practices, policies regarding health care worker quarantine post-COVID-19 exposure, long COVID-19 syndrome, visitor policies, pediatric COVID-19, health care worker vaccination, and the impact of new variants on disease severity and vaccine efficacy. Some topics were revisited over multiple months. For example, questions about PPE (for example, which mask type or respirator to use in different situations, mask re-use, implementing universal eye protection) were consistent throughout SPARC discussions as hospitals considered how to use and conserve PPE during surges—and then whether to modify PPE use as COVID-19 cases decreased.

SPARC participants reported disseminating information from the SPARC webinars to their incident command teams and hospital leadership, reflecting the broad reach of the information shared. This was a key hallmark of success, as knowledge of COVID-19 was continuously evolving, and hospitals were seeking a reliable, convenient information source. As one SPARC participant shared: “There was so much information that [you] gave us … to help us navigate all the different changes in the beginning of this whole pandemic when we didn’t know exactly what to do. I felt that the information … that SPARC provided us along the way helped us to get better….”

Lesson 2: Collaborative Partnerships Between Public Health And Academia Support The Translation Of Guidance And Recommendations Into Practice

The partnership between the MDH and academics at the two CDC Prevention Epicenters—University of Maryland School of Medicine and Johns Hopkins University School of Medicine—allowed for a rapid synthesis of new COVID-19 guidance during webinars. The MDH could speak to a topic from the state’s perspective, specifically providing context on state- and county-level epidemiology for COVID-19 and other respiratory infections, variants and sequencing data, and risk factors from contact tracing. Academic partners shared how they were operationalizing guidance based on current evidence and facilitated further peer-to-peer discussions about the topic.

The SPARC for COVID-19 model was particularly impactful in helping hospitals navigate evolving guidance as COVID-19 case rates increased and decreased. For example, as the pandemic evolved hospitals had to revise and update visitor policies, consider how to manage PPE usage and supplies, and consider practices for health care worker quarantine and testing. While federal and state guidance was available, there was uncertainty regarding how to translate guidance into real-world practice. SPARC provided hospitals with a regular forum to ask members of Johns Hopkins Health System and the University of Maryland Medical System—the two largest hospital systems in the state—critical questions, including:

• How are you adjusting your patient visiting policy because of increased positivity rates?
• Are you allowing visitors in shared rooms?
• What are your recommendations regarding double masks for hospital staff?
• What PPE (including mask and eye protection) are you recommending your health care workers wear while caring for patients known or suspected to have COVID-19 infection, and other patients?
• For which procedures should you be using N95 respirators?
• How are you determining when to send staff for testing if they have mild, vague symptoms?
• How do you handle vaccinated health care workers with respect to post-exposure quarantine and testing in the face of increasing cases in the community and surge in the hospital?

One participant shared: “I would take the information back to our Executive Team, and this would help guide our decision making. We are a smaller hospital, so we always look to what the larger facilities were doing…. We did change our protocols based on the information provided….” Without these discussions, it is possible that hospitals—especially those with fewer resources—would have struggled with how to operationalize new information and implement rapidly changing guidance.

Lesson 3: Peer-To-Peer Learning Is A Critical Tool, Allowing Hospitals To Validate Practices

Opportunities for hospitals to share information and draw on others’ experiences are critical to infection control and prevention. While hospitals received guidance from the CDC and state and local health departments throughout the pandemic, they found it valuable to understand how their peers were implementing and operationalizing the guidance. SPARC facilitated these discussions in two ways:

• First, informal peer-to-peer interactions in the chat forum and in the discussion portion of the webinars were invaluable to allow facilities to ask their own questions of their peers.
• Second, SPARC leveraged the expertise from the peer group to invite speakers and panelists to share their experiences more formally. For example, when facilities expressed concern about implementing infection control practices in the behavioral health unit, SPARC invited the medical director of one of the state psychiatric hospitals to share successes and challenges in that setting.

SPARC provided an essential mechanism for hospitals to address uncertainty and validate their policies and practices. One key informant shared: “Peer-to-peer learning situations are vital. We need to see what others are doing, what works, and doesn’t work. Early in the pandemic, facilities were very isolated and were not reaching out to other entities for support because they were so internally focused.” State and local public health departments should consider how they can form partnerships that help remove silos between hospitals and facilitate peer-to-peer discussions.

Lesson 4: Statewide Quality Improvement Collaboratives Must Consider Variation Across Hospitals

While participants represented perspectives from a range of hospitals in terms of size and setting (for example, urban and rural), the members of the SPARC collaborative represent two of the largest hospital systems in Maryland. One key informant noted that the guidance shared from SPARC sometimes reflected the capabilities of larger hospitals in urban settings and needed to be adapted for smaller hospitals in other settings to implement. They shared: “If I’m just listening to the big people talk, I may not interact with them…if I’m listening to a hospital that I know is about my size, probably in my same situation, I may get more out of it; I may participate more.” A dedicated partner from a community-based hospital may have helped better provide practical implementation guidance for different types of hospitals, as well as elicit perspectives from participants at smaller hospitals.

A Model To Support Hospitals In Public Health Response 

The COVID-19 pandemic has demonstrated the importance of collaboration, knowledge transfer, and information sharing in public health response. SPARC for COVID-19 provides a model for other state-based quality improvement collaboratives seeking to support hospitals during COVID-19 and other public health emergencies. The relationships and collaborative structure developed during the previous iteration of this collaborative were invaluable to quickly develop a new program to fit the needs of facilities during a public health emergency. Participants reported that the collaborative was very effective in providing guidance useful for effectively managing the COVID-19 pandemic beyond what was provided in national guidelines. Other states may want to mirror the SPARC model to facilitate expert-led discussions and vital peer-to-peer learning opportunities between hospitals.

Authors’ Note

This collaborative was supported by Centers for Disease Control and Prevention Epidemiology and Laboratory Capacity funding.