How a Carolina Healthcare Team Built a COVID Hospital From Scratch

Bret S. Stetka, MD


July 28, 2020

At the moment, North Carolina is reporting its highest daily rates of COVID-19 cases and hospitalizations yet. It's a surge that critical care physician Douglas Brent McQuaid, MD, saw coming and prepared for. Alongside colleagues at Cone Health Medical Group, McQuaid helped take over a recently closed hospital in Greensboro, North Carolina, and turned it into an acute facility for the exclusive treatment of patients with COVID-19.

Medscape spoke with McQuaid about the rationale for repurposing a shuttered facility — newly christened as Green Valley Hospital — and lessons learned from working amid a pandemic.

Douglas Brent McQuaid, MD

When did you realize that your hospital needed to prepare for COVID-19?

I work for the Pulmonary and Critical Care Division, so we were getting nervous based on what was happening in Seattle and in northern Italy, and we realized we'd better start planning before we even had any cases. We knew that it had the potential to overwhelm our health system.

So I went to the literature to try to find out what on earth to do. A couple of my partners and I found a really nice resource published in Chest in 2014. It discussed how to work with your health system to plan for a surge and a pandemic if you're a pulmonary and critical care physician. We went through that thing line by line and came up with a plan.

At the same time, the people I work for here at Cone Health realized that this has the potential to overwhelm us. Our analytics folks started to create models to show what it would look like once COVID hit Greensboro, which made us quickly realize that we're not going to have enough beds.

We initially rolled out plans based on our current infrastructure, knowing that we were limited by things like the number of negative-pressure rooms for staff protection and intensive care unit (ICU) beds. At that point we began upfitting several ICUs to have negative pressure.

How did that planning change once you started to see your first cases?

In March it really became clear that using our current infrastructure, we could care for our patients with COVID, but it was certainly not the best care that we could provide. The reason for that was that these poor folks would come in and they would get really sick really quickly.

We were operating in kind of a pre-COVID mindset, that if your 02 saturations dropped to a certain point, depending on how much oxygen you're on, we need to intubate you and put you on a ventilator. Yet, in order to do that, I have to don and doff the personal protective equipment (PPE) right outside your room, and I need to bring a crew with me, like a nurse and respiratory therapist, and all the equipment. We would also have to do things like figure out how to set up IV poles outside the room so the nurses could change them without donning and doffing every time. This was at a point when everybody in the country was terrified that we were going to run out of gloves and gowns, masks, and everything else, so we were trying to be really conservative.

And then the cases started building and building. There was one day that my partners and I intubated 13 patients, all with COVID, and then the same thing happened the next day. Before you know it, you've got 30 some-odd patients who are intubated in your ICU, and every single one of them is in an individual room, where people are kind of nervous to go in there. It consumes a lot of PPE to go in and out of the rooms.

And somehow, amid the chaos, you managed to open a hospital?

Yes, I know. I almost can't believe it. There was a hospital in the area that was the main obstetric and gynecologic hospital for Greensboro and for Cone Health, but it was starting to show its age.

A plan was put in place to replace it by adding on a huge wing to our current main hospital in town, Moses H. Cone Memorial Hospital. That opened earlier this year and the other hospital was left empty.

When COVID started coming around, we thought it would be great if we could cohort these patients someplace to protect the rest of the health system. Initially, there was reluctance. But more and more people started saying it was a really good idea, and fortunately, the people who run our organization were willing to listen.

I was asked to be the chief medical officer and was placed on a team with a former ICU nurse, who is probably the most focused, organized, and capable individual I've ever spent time around. She actually coordinated the original transition from the women's hospital to Moses Cone, and they turned around 3 weeks later and said, "We want you to put people back in there now as a COVID hospital."

Figure 1. Staff finalizing the space as the repurposed hospital was nearly ready to open

This seems like a massive undertaking. Did you think you could pull it off?

During our tour of the space, they told us that we could have 157 beds. They could all be negative-pressure rooms. We could use, I think, 95 of them as ICU rooms if we needed to.

These rooms were well equipped because the labor and delivery rooms had a lot of extra air, suction, and oxygen capacity already in them compared with a regular medical hospital room. They were ready to handle a ventilator. It was actually pretty straightforward to put vents in there.

During that tour, we went to see the former neonatal ICU and were told that it could be converted to negative pressure relatively easily because it was completely closed off from the rest of the hospital. It was a weird experience, walking around and realizing that this is exactly what we need.

Figure 2. Instrumentation outside a negative-pressure area on the Green Valley campus

What we needed was an area where we could go in, throw on our gear, and hang out all day and take care of patients without worrying about having to take the equipment off and on. We could be right there with them and give them the care they needed. That's what this offered.

It turns out that the NICU was designed to hold over 30 or 40 babies, but also to accommodate mothers who are also recovering and may not be able to get out of bed. The NICU was divided up into pods, each of which could hold three or four adult beds comfortably.

Based on that, we decided that we needed to bring patients over here from the get-go. It needed to be an acute care hospital, which ended up becoming what we now call Green Valley Hospital.

Figure 3. The Gratitude Wall by artist Jorge Maturino

That's incredibly serendipitous, that it was just sitting there. So once it was set up, all of the COVID patients were transferred to the new hospital?

It took us a while to convince everybody that that's what we needed to do, but we did.

In March, our big concern was that we had tests, but at first it would take a week sometimes for the results to come back. Because of that, we had what we called PUIs, or persons under investigation. We were assuming that anything remotely respiratory coming in to the hospital was due to COVID. All of these negative-pressure rooms were filled with people who may or may not have had COVID. We had no idea because we didn't have a test to turn around.

We were trying to decide: Do we put our PUIs in Green Valley or do we just take the COVID patients over there? Fortunately, our CEO begged, borrowed, and pleaded, and called all around the country to get better testing for us. Once we got rapid testing, the PUIs all went away, because in the emergency room you could sort out whether a person has COVID or not.

We were then able to admit them directly to Green Valley. We decided to just bring them all over there. Whether they're in the ICU or just need a medical/surgical-type care, that's where they go.

Figure 4. They Call Us Heroes, a selfie wall created by Maturino for staff

Cases of COVID-19 are steadily increasing in North Carolina. How about in your area?

If you look at the total number of cases for North Carolina, it's been steadily rising. But that's statewide. When you look at individual counties, it just fluctuates. There will be a little peak and then it drops off, and then there will be a peak and a drop-off again.

A few weeks ago, medical centers as close as 20 minutes away from us were really slammed, while we had plenty of beds and it wasn't hitting us too hard. But now we're starting to pick back up. We just had our highest numbers that we've had throughout the pandemic, with 70 patients who are positive for COVID-19.

Mind you, we don't need to admit everyone who has COVID. We only admit you if you actually need to come to the hospital.

In treating so many COVID patients, and with cases soaring in North Carolina at the moment, have you seen any of these interesting clinical findings we keep hearing about? The hypercoagulability? COVID toes? Neurologic findings?

I keep waiting to find them. It's all over Twitter, and there are expert opinions suggesting that things like hypercoagulability are a big deal, or there's "COVID brain." But honestly, we haven't seen them. I'm not seeing strange encephalopathy at the rate I thought that I was going to.

But if someone goes south, we might anticoagulate them and then look really hard to see if they've had clots. We'll look for stroke, myocardial infarction, or pulmonary embolism, or scan their legs.

There have been cases where we found blood clots in people who were on appropriate chemical prophylaxis. That makes you wonder that maybe there's something to this, but at the same time we've also increased the amount of medicine that we use for chemical prophylaxis, just because we think it might be more hypercoagulable, and I don't have a lot of objective evidence in front of me to say that it's definitely a big problem.

I'll tell you, as a person on the ground, that I keep hearing this stuff and I keep thinking that maybe it's going to happen, but it just hasn't jumped out to me yet. But there's a huge hypercoagulable story here that we're going to be telling for years to come.

So no COVID toes yet?

Nope, no COVID toes!

Dr McQuaid is a friend and former medical school classmate of Medscape editor Dr Bret Stetka, who conducted this interview as the two caught up over the phone.

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