CAL-MAT Mission Expansion During COVID-19 Medical Surge

In 2016, the first official CAL-MAT deployment was a single member sent to assess medical needs during the Tubbs Fire in Sonoma and Napa Counties. From its inception in 2016 through January 2020, medical support at wildfire base camps remained the predominant reason for the mobilization of CAL-MAT. The increase in frequency and severity of wildfires throughout California resulted in a slow but steady increase to approximately 200 CAL-MAT members by January 2020. ^{Reference Masri, Scaduto, Jin and Wu13,Reference Li and Banerjee14}

This abruptly changed with the SARS-CoV-2 pandemic. In February 2020, a cruise ship with an outbreak of COVID-19 docked in Oakland, California. Passengers were initially assessed by DMAT teams and then triaged by other medical teams for transport to hospitals, ongoing transportation to home, or isolation and quarantine centers. EMSA utilized CAL-MAT to operate an alternative care site for quarantine and isolation in Pacific Grove, California, to care for 133 COVID-19-positive patients with mild illness. In the subsequent months, CAL-MAT rapidly expanded capabilities and membership to deploy teams of different sizes and composition on a variety of COVID-19 missions, including surge support within health care institutions, alternative care sites, mass testing and vaccination in communities, as well as logistical support for medical surge and biomedical equipment (Table 1). In response, throughout 2020–2021, CAL-MAT enrollment increased more than 10-fold to approximately 2200 members. Figure 1 illustrates a timeline of CAL-MAT operational and mission milestones.

Table 1. Summary of CAL-MAT Missions (March 2020-March 2022–Some missions on-going)

Abbreviations:

ACS: Alternative Care Site.

EWI: Entry Without Inspection (Immigrants legally admitted to the United States from entry points along California-Mexico border transported to sites by Customs and Border Protection. EWI shelters are ongoing with federal collaborators and data for the number of clients managed is not available.

HVAC: Heating, Ventilation, and Air Conditioning.

SNF: Skilled Nursing Facility.

N.A: Not Available.

Figure 1. CAL-MAT timeline of operations and missions.

Skilled Nursing Facility Support

When COVID-19 infections increased in the spring of 2020, prior to vaccine availability, CAL-MAT efforts were directed to support long-term care (LTC) and skilled nursing facilities (SNFs). Once infection was introduced into these facilities, it spread rapidly among patients and staff, creating a staffing crisis due to employee illness or fear of illness. CAL-MAT SNF Strike Teams were comprised of at least 5–7 members, including 1–2 Registered Nurses (RNs) and the remainder paramedics and emergency medical technicians (EMTs) who could deploy to a facility within 12–24 hours, with the following objectives:

1. 1. Perform an assessment for infection control, safety, staffing, and resource needs (Appendix C).

2. 2. Train staff on infection control practices, including reorganizing patient care areas within the facility to create separate zones for infected, exposed, and uninfected patients, and prevent staff from moving freely between them.

3. 3. Supplement critical staff shortages.

4. 4. Engage local and state agencies to coordinate ongoing resource requirements, mainly staffing and personal protective equipment (PPE).

The first 3 objectives were accomplished over 72 hours; staffing support could continue for another week or more depending on need and statewide priorities. Beyond that time, facilities were expected to obtain contract staffing or support from their local health department. The process provided a multi-dimensional approach for the short and long-term support of 65 nursing homes from May 2020 and into January 2021. The mean length of time at a facility was 5.6 days (1–3 days in 19 facilities; 4–6 days in 28 facilities; 7–19 days in 18 facilities). One important procedure prior to the arrival of the response team was to provide the facility administrators with a letter outlining the team requirements and capabilities and facility expectations. Only a small number of facilities failed to regain self-sufficiency. The few that required closure and patient evacuation had problems prior to COVID-19.

Alternative Care Sites

As medical surge increased and impacted local hospitals, CAL-MAT, in collaboration with local and federal partners, established and staffed 6 alternative care sites (ACSs) throughout California. The ACSs provided surge beds for low acuity patients from local hospitals, allowing acute care facilities to prioritize in-patient resources for higher acuity patients. ¹⁵ These ACSs treated patients with mild to moderate COVID-19 symptoms and oxygen requirements of up to 10-liters per minute, and provided isolation and convalescent care. Christensen et al. described details of the ACS operations and challenges encountered. ^{Reference Christensen, Metzner and Lovett-Floom16}

ACSs drove further development of CAL-MAT due to the requirements of in-patient operations. ACS facilities operated 24 hours a day and were staffed by teams of physicians, advanced practice providers, RNs, paramedics, and EMTs. Physical therapists and registered respiratory therapists were new additions to CAL-MAT deployments. Pharmacists maintained the on-site formulary, filled orders, assisted with medication reconciliation, and advised on medication policy and procedures. Discharge planners from the local communities arranged post-discharge follow-up care and coordinated with staff for discharge needs. Mission Support Team (MST) personnel for ACSs commonly included an Incident Commander, Safety Officer, and section chiefs in the 4 areas consistent with the National Incident Management System (NIMS) ICS framework: operations, planning, finance/administration, and logistics. A Chief Medical Officer and Chief Nursing Officer were also assigned for medical oversight at each ACS.

ACS staffing needs were challenging due to the unpredictability of COVID-19 surge patterns and referrals from hospitals. It is notable that staffing for an ACS with less than 50 patients required as many as 45 medical and administrative staff, despite higher patient to staff ratios than standard hospital staffing (Table 2). Breyre et al. explained ACS staffing challenges, including difficulty finding available clinical providers with acute care or disaster experience. ^{Reference Breyre, Sloane and Herring17} To offset clinical resource shortages, composite teams were developed utilizing new RN and physician graduates, retirees, and those without experience working in non-traditional health care environments, requiring baseline and refresher training. The usual orientation and training with a regional CAL-MAT unit was not possible when onboarding so many new staff. Providers from the military and other agencies provided especially valuable support, because of their training for care in austere emergency environments and their team discipline.

Table 2. Alternate Care Site Medical Staffing Matrix (sample)*

Legend:

MIL (Reserve and Active-Duty Military, activated Nationally and Internationally, Federal Disaster Declaration).

CSG: California State Guard (activated for State of California responses by Governor).

CTR: Contracted staff members (contracted ambulance groups and clinical staff onsite).

* Staffing for a point in time for approximately 25-30 patients with 24-hour coverage. Other considerations for a safe and successful operation include additional services/contracted vendors for sanitation/hygiene, food, billeting, security, etc., and establishment of community partnerships.

** Behavioral Health dedicated to staff support.

With licensed vocational nurses (LVNs) and certified nursing assistant staff in scarce supply during the COVID-19 surges, EMTs and paramedics filled a variety of inpatient clinical roles alongside usual clinical staff. Under normal circumstances and in the absence of a statewide disaster response, California EMS personnel may only provide care in emergency response and mobile settings. Under the state’s emergency executive order, the local EMS Agency Medical Directors and California EMSA Director approved temporary changes that allowed EMTs and paramedics to work in fixed sites like ACS. In addition, scope of practice expansion under the emergency order allowed EMS personnel to staff other types of CAL-MAT missions alongside RNs and Advanced Practice Providers. In the spring of 2021, as mass COVID-19 vaccination campaigns began in California, trained EMTs and Paramedics provided staffing for vaccination sites and mobile vaccine outreach efforts that supported underserved communities and vulnerable homebound individuals. CAL-MAT teams were also deployed to COVID-19 testing sites.

The integration and alignment of personnel and the development and expansion of clinical protocols allowed for the best use of clinical skills and scope of practice for the care of patients. However, this often created role confusion surrounding staff member qualifications and practice. Providers and nurses who were not familiar with EMT and paramedic scope of practice in normal times were even less sure of their expanded practice parameters. For example, the administration of intramuscular benzodiazepine is within a paramedic’s scope of practice in the prehospital setting; however, it would require a physician order before administering the medication to an actively seizing patient within an in-patient facility or an ACS.

Supporting the Logistics of EMSA Operations

CAL-MAT personnel were also used to support general operations at EMSA headquarters, including administrative functions within the EMSA Department Operations Center and logistical operations. Prior to COVID-19, EMSA maintained equipment caches for medical response in a small warehouse. To meet the needs of the COVID-19 medical surge, California purchased substantial amounts of biomedical equipment, including ventilators, oxygen administration equipment, monitors, surge tents, and beds. EMSA stored much of this equipment, which required a nearly10-fold increase in warehouse space and the development of modern logistical operations for inventory, maintenance, fulfillment, distribution, and the tracking of medical equipment. CAL-MAT personnel supported all these logistics functions. Additionally, CAL-MAT provided support in the field by staffing mission support teams.

Logistical Advance Teams staffed by CAL-MAT members erected surge tents at hospitals around the state and set up equipment for patient care either in the tents or in hospital space that had been converted for patient care. When oxygen became a scarce resource, CAL-MAT teams established oxygen depots, using industrial scale oxygen concentrators to support health care facilities. Devereaux et al. described the California response to oxygen shortages. ^{Reference Devereaux, Backer and Salami18} COVID-19 monoclonal antibody infusion centers across California were initially paired with ACSs for logistical and supply reasons and utilized CAL-MAT staffing support within the infusion centers. As these sites expanded to more than 30 around the state, contract staff were substituted, but CAL-MAT continued to provide logistical support.

Concurrent Disasters

Given the extended duration of response to COVID-19, concurrent disaster and emergency incidents were expected. Both 2020 and 2021 were severe and relentless fire seasons in California. Under contract with the California Department of Forestry and Fire Protection (CAL FIRE), CAL-MAT provided medical support to 23 fire incident base camps in 2020 and 7 during the summer and fall of 2021, including 2 of the largest fires in California history (Dixie and Caldor). In partnership with other organizations, CAL-MAT also provided critical medical resources for displaced residents evacuated to shelters. Backer et al. have detailed the wildfire medical support. ^{Reference Backer, Wright and Dong19,Reference Backer, Duncan and Christensen20}

In early 2021, EMSA was asked to assist with medical care to immigrants legally entering California through ports of entry and detention facilities at the Mexico border. In coordination with other state agencies and non-governmental organizations, 4 testing, isolation, and quarantine shelters were staffed by CAL-MAT in 2 border counties. The first facility was established in tents, but all operations were subsequently moved to hotels. CAL-MAT provided health assessments, first aid, medical observation, and care to those with mild illness from COVID-19 or other health problems. COVID-19 vaccine and monoclonal antibody treatment was offered to all eligible adults and children.

Challenges to CAL-MAT Expanded Missions and Staffing

Initially, there were enough volunteers to staff CAL-MAT missions, since many elective medical services were canceled, resulting in health care workers being furloughed and few opportunities for new graduates. Over time, this trend reversed, and staffing became challenging. Additionally, prolonged deployments became a problem due to the state’s employment restrictions limiting emergency appointments to 60 working days within 12 consecutive calendar months. ²¹ This regulation became a significant issue for CAL-MAT staffing resources, especially nursing, until it was waived by an Executive Order in March 2020 ^{Reference Newsom22} ; however, a constitutional limit of 189 days per a 12-month period for temporary hires could not be waived, resulting in unanticipated demobilization of some EMSA and CAL-MAT personnel. California instituted several other changes in the strategy to address medical surge and shortages of health care workers that reduced the need for CAL-MAT personnel. Governor Newsom created Health Corps “to provide critically needed services during this public health crisis.” These professionals were used to supplement staffing in health care facilities, mainly acute care and intensive care. Eventually, this program was transferred to EMSA and will be integrated with the CAL-MAT program but used for distinct purposes. ²³

During 2020 through the COVID-19 surge in early 2022, there were 4500 individual CAL-MAT deployments and 476 Health Corps deployments. As the number and duration of health care missions continued to increase, California began using contract workers to staff operations and fulfill personnel resource requests from hospitals. In early 2022, staffing was transitioned to contract personnel for the immigrant testing, quarantine, and isolation sites since CAL-MAT was not designed for the indefinite time frame of these missions. From March 2020 to March 2022, this shift to contract personnel resulted in 61 000 out-of-state license approvals by EMSA, primarily RNs and LVNs but also physicians and advanced practice providers. Finally, the strategy for supporting medical surge in hospitals shifted from external sites to expanding care within facilities by adding equipped and staffed beds. Since all the support services were already available within the facility, care could be delivered more efficiently.

Qualities and Considerations for Medical Response Teams

Of the key team qualities outlined by Oldenburger et al., ^{Reference Oldenburger, Baumann and Banfield2} CAL-MAT demonstrated adaptability and creativity on many levels. As medical resource needs arose in communities throughout the large and diverse state of California, the CAL-MAT program expanded rapidly and deployed individual personnel and teams to support completely new and flexible missions.

The urgency and number of new unique missions continually challenged command and control as teams were rapidly formed and staff were rotated. The ICS command structure provided for rapid yet flexible growth, despite the recruitment of less experienced personnel. ICS is also designed to integrate different levels and types of organizations into a coordinated response. Each of the CAL-MAT missions relied on a combination of local, state, and federal resources for services, supplies, and site support. The California Military Department (Cal Guard) were especially valuable partners in the field. When in normal times, a mission might have been run by a single agency with limited support from others, the overwhelming demands on every agency and scale of operations created complex missions with multiple agencies participating.

Staffing demands also impacted availability of experienced leadership. Use of responders and providers with limited or no disaster response experience led to problems in medical decision making, team functioning, and personal behavior, all of which contributed to team dysfunction and interpersonal conflict. One compensation was to provide standardized processes for efficiency, consistency, and quality control. CAL-MAT standardized processes included staff applications and onboarding, orientation and training, formularies, occupational and safety procedures, such as fit testing for N-95 respirators, and clear procedures for donning and doffing. Moreover, medical practice protocols previously had not been implemented, leading to broad variability in provider and caregiver staff approaches. Practice protocols became standardized through a process of sharing documents and practices across sites and the review and approval by clinical providers who met weekly under the leadership of the CAL-MAT Medical Director. These protocols were updated based on evidence-based data and resources.

Another need identified for the workforce was behavioral health support. While continuity of staff may benefit missions, it can also lead to stress and fatigue. Recognition of stress factors and the support of personnel in understanding and adherence to the expected job performance and Code of Conduct are keys to better mission and workforce wellness outcomes. ^{Reference Arpacioglu, Gurler and Cakiroglu24–26} In addition, the CAL-MAT program has recognized the importance of behavioral health access for personnel in the field. With the expansion of telehealth, this can now be remote with an on-call provider.