It was a Sunday in mid-January when Amy Compton Phillips, the chief clinical officer for Providence St. Joseph Health, was first alerted that a patient with COVID-19 had shown up at one of the health system's urgent care centers.
"It probably wasn't all that surprising, being that we're on the West Coast, that we ended up with 'patient one' here in the U.S.," Phillips said during a virtual conference call hosted by HIMSS Wednesday. From the very beginning, infectious disease physicians warned hospitals on the West Coast it was only a matter of time before the virus made it to their doorsteps, Phillips said "Because of the incredible interconnectedness and the deep business ties we have here in the Seattle market between Microsoft and Amazon and all of the tech companies we have and the direct flying back and forth that happens on a daily basis, we were going to end up seeing this," she said.
A nurse practitioner called the Centers for Disease Control and Prevention (CDC) for testing Jan. 19 after that patient said they recently returned from visiting family in Wuhan, China, and had a fever and a cough. The CDC called back Jan. 20 with the positive test results, and the patient was admitted into one of Providence's hospitals located in Everett, Washington.
It was a fortuitous location for the first patient to be, she said. That particular hospital had what the health system calls a B.E.S.T. unit, which is a Biocontainment Evaluation and Specialty Treatment Center. The unit had just had a drill a few weeks earlier for containing infectious pathogens. "Even starting early in January, we started talking about 'If this happens, what supplies will need? What protocols will we need?' We started having some background conversations, so it was not out of the blue," she said.
Here are some of the additional details Phillips shared during the virtual event about the health system's next steps and lessons learned.
On the health system's initial response: "We were actually able to flip the switch and say: 'All that pre-work we've been doing and talking about—the not if, but when—it's time to flip the switch and turn it on. Our IT team, our information services group sprung into action and took the shell of the electronic medical record alert that we had built previously and updated the content for everything to do with coronavirus and implemented that within about eight hours."
On gathering information quickly: "We started having tiered communication huddles. Initially, it was clinically just the physicians and the nurses so that we could hear what was happening out in the regions, out in the facilities. People were walking around asking 'What are you seeing? What are you hearing? What are you feeling?' And then would be calling that in, making sure we had a centralized mechanism to aggregate and distill out what was happening. At the same time, our infection preventionists and our ID docs were subject matter experts and saying 'What is it we need to do.' … As we've gotten more and more patients in our system and we've seen more and more impact on daily operations, we've actually broadened out those huddles to include a broad array of people and put it into a virtual emergency operations center that cascades out to regional emergency operations centers in the different markets so we can manage the complexity of the system."
On who is involved: "The emergency EOC doesn't just have clinicians on it anymore. Supply chain is critical. Government affairs is critical. Finance is critical. How are we going to pay for all of this in a different way?"
On testing: "We’ve absolutely been dealing with shortages of tests, which is why I’ve got the CEO of Roche on speed dial right now. There just simply are not the reagents in the country so we’ve still been triaging who gets tested, which is why this virus has spread through the community because we couldn’t screen everybody for it early on. The testing capacity logjam is starting to break right now. I’ve heard the government say they’ve sent out 4 million test kits Those haven’t hit our state yet, so I’m not sure what the deal is with that. But we do have LabCorp and Quest tests which have come online this week; the University of Washington in our market has been able to run 1,000 tests a day, LabCorp is at 2,000 tests a day. Our own internal test this week [indicates] we’ll be able to run about 500 a day if we’re able to get enough reagents. That logjam is starting to break."
On handling the volumes: "We know from statistics coming over from abroad that about 80% of people are OK with this condition, about 15% could qualify for hospitalization and about 5% need respirator support or ICU care. We said ‘Well, can we do anything to change those stats. Can we take care of people where they are, where they are more comfortable in their own home in a way that’s safe for them?' We worked closely with our telehealth group and they were able to rapidly create, at capacity to give patients seen in the ED, a thermometer and a pulse ox and have them monitored at home using our telehealth capacity, remote patient monitoring, to say, 'How are you doing? Are you safe to stay at home or are you going the wrong way?' Because that’s one thing we’ve seen with this particular germ is that patients can be OK for a while and then decompensate rapidly. Having this capacity to monitor at-risk patients at home has made a huge difference and made our clinicians much more comfortable treating patients at home rather than admitting them for observation in our acute care facilities."
On lessons learned from China and Italy: "The whole concept of fever clinics and drive through testing have come from abroad. A big part of that is how do you minimize the potential for contaminating healthy people with people who already have the germs. Right now the information out of Italy, what we’re reading about in news reports, is we really need to think about our ventilator access … Right now we’re redeploying our ventilators so we can have them, especially since we have 10 nursing homes in Seattle that now have COVID-positive patients, so we’re expecting in the next couple of weeks we might have a great need for ventilators. We’re deploying those ventilators up here just in case. We’re also identifying additional ICU bed capacity by taking shell space and rapidly building out ICU beds with negative pressure. We have some incredible facilities people who are a bunch of MacGyvers who have created negative pressure rooms out of standard rooms so we can be ready, just in case."
On an unexpected problem: "For patients that are admitted into the hospital, we have very strict isolation protocols and they can’t get visitors. It’s incredibly isolating, particularly for older patients who are getting admitted. That kind of social isolation is just yet another contributor to delirium and all kind of other bad things that happen. So we’ve started deploying iPads in our facilities to make sure we break that down and people can keep that connection they need to stay sane while undergoing acute therapy."
On tools that have helped: "From telehealth, the reason we were able to rapidly do things like create a chatbot, ensure we had Express Care Virtual to do virtual visits for patients that are convenient for them and minimize the use of PPE and then care for patients in their home is we had a telehealth infrastructure already built … In addition, we had our clinical analytics are headed up by a physician, Dr. Ari Robicsek, who by background happens to be an infection control specialist and epidemiologist. As he started seeing the COVID cases started growing, he knew what was coming and they started working on a tool to help us better predict and plan for what is coming … Last week, we were able to go through and see that what is happening right now in Seattle two weeks earlier looks exactly like what’s happening right now in Portland. So, in Portland, we’re expecting is going to look a lot like Seattle does right now with a dramatic number of cases, which is very helpful."
On what's made her want to tear her hair out: "One of the most interesting things I did not expect was the criticality of having a very active and engaged government relations group. Our advocacy team has been unbelievable in this space because if you guys aren't living this right now, you will. The cacophony that comes from having CDC recommendations different than the World Health Organization (WHO) recommendations different than NIH and FDA recommendations is overwhelming. Then your state governor declares a state of emergency and says you're supposed to follow WHO guidelines, but OSHA says you have to follow CDC guidelines. You just want to pull your hair out. So we've been very engaged with our government relations team, saying, 'We've got to have some sense-making out of this.'"
On the next steps: "We are very much thinking about how do we load balance where things are happening. What they’ve done in China is they created whole fever hospitals so people with fevers and infections are treated here. Everyone else goes there, because, as it turns out, people still have [heart attacks] and break their hips and do all those other things we do in healthcare. We’ve had conversations, 'Have we gotten to the point that we need our fever hospitals and our everything else hospitals which means patients would be driving more but we’d still be able to have a healthcare infrastructure as we care for people with COVID-19?'"
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