AMGA CAO/COO Council Meeting: Planning for COVID-19
March 20, 2020
This summary is based on a presentation to the AMGA’s Chief Administrative Officer/Chief Operating Officer Council on March 20, 2020. For more information about the CAO/COO Council, please click here.
Presenter: Anita Geving, M.H.A., B.S.N., R.N., Chief Operating Officer, The Polyclinic, Seattle, WA (March 20, 2020)
Anita Geving: You will be able to use a lot of parts of the pandemic plan for H1N1 or Ebola you already have in place. This virus lulls you into thinking you have time, and then it spikes up. As soon as we saw one case in our community, the reality was it had already been in our community for four-to-six weeks, which is a lot more exposure then we thought was going on. We immediately instituted things we normally would, which are screening, segregation, and social distancing.
Immediately on Day 1 we had out guides for screening, and they were updated rapidly, as we received more information over the next few days. A policy decision we made as part of our pandemic plan for screening was that anyone who has mild symptoms or symptoms they can manage at home, we don’t bring them in during an outbreak like this. Right away, we implemented this and that puts a lot of stress on our triage RNs and office staff to provide this information about how patients really do need to care at home.
One thing I could change is I wish we would have restricted portals of entry even more early on—such as the loading dock, which allowed people to get into our building without a screening process. We have now restricted down to one portal of entry for all buildings, so this is good control, and every individual who enters the building will be evaluated for recent respiratory symptoms. If we knew what we know now, we would have been more restrictive from the beginning. We know that COVID presents like the common cold with a runny nose, sneezing a bit, and we weren’t masking those people, which was a mistake. We should have masked anyone who had upper respiratory symptoms from the beginning.
For segregation, our pandemic plan calls for as soon as we think we have a patient with the virus, we cohort and restrict certain sites to have availability to take care of those patients. We also realized we need better control over training for employees and providers. One thing we did learn early on was we knew we would have to retrain the staff on PPE and section control principles and double bagging for insulation, so we made an early assumption that our physicians probably knew this and we had to redouble our efforts and do retraining for the employees who were working in respiratory clinics.
Just this week (week 3), we found that people get a little bit comfortable with the work situation going on and they are a bit lax, so we have dedicated infection control RNs to monitor the providers and employees to make sure this doesn’t happen and watch how they attend to patients in the respiratory clinics.
We have restricted visitors, and our policy is if the person needs support (physician or behavioral), we allow those people. For parents who have children, we only allow the sick children in and no other children. We have decided early on that we moved all of our admin to remote working and that happened only a few days into the work, so it really pushed on our IT resources (most people could work remotely on the admin side, but now 100% are remote).
PPE and Testing
PPE is a challenge and constantly will be. The things we are finding of great need are surgical masks more than n95s (we restricted number who need these, and we can’t get what we need to get for testers too) and more testers. There is still so much influenza going on, we decided to do rapid influenza tests to rule that out before we do COVID testing. COVID testing has been very difficult for us. Criteria for testing from Public Health Officers (specifically County Public Health Officers) have been really restrictive. The availability of not just tests, themselves, but the swabs to actually do the testing with is a challenge. There are quite a few studies going on (The Everett Clinic looking at test that doesn’t require the N95 use), but so far we have not seen anything, and we need the pharyngeal testing.
We are also having human capitol issues. Staffing became an issue, so we wound up giving bonuses to our staff for working the front lines to keep up with notable challenges, such as closure of all the schools. So we needed to put ourselves in a position where we could take care of our patients 24/7. We are giving $100 per day for daycare per employee (not per child). We typically wouldn’t do unlicensed daycare providers, but in this environment if you have schools closing down, the people feel very uncomfortable sending kids to daycare that is unlicensed. So we give them $100 a day for the family members who may be taking care of their children.
Question 1: Has anyone discussed how to approach this from a comp standpoint?
Anita: For our physicians, we decided we needed to do a guarantee for 90% of base for time we think we will be doing this.
Question 2: How many providers in sites does The Polyclinic have?
Anita: 150 providers and 11 main sites we have to manage.
Question 3: How is it that you are managing your supply inventories and are you doing anything for theft from patients or staff?
Anita: Our supply chain folks are constantly looking for more supplies. The first issue we ran into with our vendors was that they are only allocating what our historical volume has been, and we actually reached a peak of going through 4,500 surgical masks a day. Now since we are down to essential services only, we aren’t using quite that much. We need gowns, gloves, face shields, face masks. Every day, I feel like I am working two-to-three days in terms of supplies. You have to understand what your burn rate is everyday and whether or not you have something in the line to get more. There is a 30-day mitigation requirement in Washington, and the CDC also recommended as part of this that there should be enough supplies available as if all healthcare workers were on premise, so we are trying to accommodate this as well. Surgical masks have been a struggle, but so far we have pieced it together.
On the lessons learned level, I would have retrieved all hand sanitizer and masks from hand hygiene stations early on. What we found was they are such a hot commodity that we have had our hygiene stations wiped out. We have had a break-in in to our main supply inventory area, but luckily they couldn’t do much, although a pallet of hand sanitizer was gone. We are preserving and protecting our PPE.
Joe DeLisle, AMGA: My brother-in-law is a pediatrician, and they have had to lock down the masks because the cleaning crew has been stealing them.
Anita: Now only three people know where our masks are, and they are the point of contact for masks. We do not put anything out; everything is behind locked cabinets.
Question 4: How do you handle primary care? Telehealth? Continuity of care of patients?
Anita: We just started our move to essential services this past Monday, but prior to that, we are still running our clinics. We have clinics segregated, and we have physicians rotate into their clinics. We did have a lot of patients last week calling in and canceling due to feeling uncomfortable. But before the move to essential, we only had 85% of our usual volume in primary care. This is a transition week. Our primary care physicians are still here, but we are gearing down, and we are converting visits to telehealth. We have three buckets:
- Essential Services Only: All things that must be seen on site, and if we didn’t see them it would increase the mortality rate of our patients
- Things We Definitely Can Defer: Things like physical exams and other visits that can be rescheduled
- Everything Else: We look at whether or not it can be telehealth (most things can be done via this). We made a deal early on with our payers that we want to be paid for telehealth visits as if they were being seen in the office and nothing changed.
Question 5: What is your cancelation rate?
Anita: It was definitely higher and normally patients will call in and cancel, but most of the time they reschedule. A big thing we are seeing is they aren’t rescheduling, and now we have to re-outreach to our patients to get them to come back and have their appointments. Our OB area is seen as an essential service, and we really have to make sure we talk about how we clean or are taking care of stuff from our end. They are reassured by a greeter asking questions and masking people with upper respiratory symptoms. This seems to be very reassuring to our patients even if you think it might not be.
Question 6: For drive-through testing, what does the staffing look like?
Anita: We are not doing this because we don’t have enough supplies for this. Love to hear what others are doing.
Thomas Nantis, Vanderbilt University Medical Center: We at Vanderbilt have two assessment centers up and running that are staffed with MAs and RNs as well as a site leader. This weekend, Nissan Stadium will be working with health authorities to develop a five-lane drive-through where we will be taking swabs and putting them in plastic bags to be tested. We are seeing 500 patients a day at our sights now, and it will be very interesting weekend for us.
Anita: Another note is that it is so helpful in hospitals to know whether patients are COVID-positive or not. We are at the point now where they are testing antiviral uses, but we can’t do that if we don’t know whether the patient is COVID-positive. We are trying to be in a position where we can do more testing. Right now, we are relying on swabs, testing kits, and the media. On ROCHE equipment and on a 6800, they will allow you to do test but this has been a challenge for us. University of Washington has really been helpful during this process but we are seeing three-to-four days for results since testing is going to other parts of the country. Washington State was really long testing period that is well over a week, so testing has been a struggle.
Question 7: What is the positive return rate on tests and hospitalization?
Anita: Across Washington there is a 6% positive rate, and The Polyclinic is also charting a 6% positive rate. The other thing you may want to consider is separating out the patients versus the employees. We have been testing a lot more providers than patients. We have also been treating patients as presumed positive due to constraints with testing, so it would be helpful to know what we are actually dealing with.