EvergreenHealth wound up being in the news early on related to coronavirus. As a harbinger of what was to come, the hospital had the first coronavirus death as well as the first health care worker infection, stemming from the outbreak at a local nursing home. That first US case was in Seattle in late January, and the first COVID-19 death in the US was on February 29th, which seems like ages ago now. The cases of COVID-19 have not surged like in New York City, but numbers are increasing, with the biggest single death rates for Washington State coming Friday, March 27. A field hospital is coming to Seattle’s CenturyLink Field. Here’s a March 20th NY Times piece on planning in Washington State and a March 30th piece suggesting a possible slowdown in Washington State related to their measures to reduce the spread.
A couple of days ago, I caught up with one of our fellow SHM colleagues, pediatric hospitalist James O’Callaghan, and as immediate past president of the medical staff at EvergreenHealth, he has been an active member of COVID-19 planning for the hospital. He’s a voice for pediatric hospital medicine throughout the country, as well.
We caught up, while his wife, a fellow hospitalist and palliative care doctor, was in the midst of a virtual happy hour. A rare moment of respite in the craziness. His kids were texting him from the next room.
Jim noted that the current state is cautiously stable. The numbers are slowly going up each day, but they are not seeing a surge.
EvergreenHealth was Ground Zero for US deaths. They had the painful inflection of seeing the mini surge as patients came from a local nursing home. This was a clear initial stress on the system, with numbers rising slowly. They had several patients arrive, intubated, and on the ventilator for 2-3 weeks. Thankfully, a few have been successfully extubated.
Those first 2 weeks, with that surge of cases. What was that like? How are the hospitalists prepared for a surge of cases?
Because of the geographic location, all those initial cases came to EvergreenHealth. They were coming on a daily basis. Once we started getting these daily calls, we established a more county wide coordination. We needed a regional focus. Within 1-2 weeks of what we were seeing, I’d walk in on morning huddle, they realized they had 10 more patients that needed to leave the nursing home. The cases began to be distributed throughout the region.
On any other given day, these are competing hospitals. This was not an easy thing for folks to suddenly come together to manage. We haven’t overloaded capacity, but we are starting to open up wards that were closed. It’s always being discussed. We have a massive virtual conference call every day at 1pm with folks from logistics, IT, finance, as we try to model this out.
We are in the midst of a staged approach for addressing hospitalist volume. The census is slowly building for the adult hospitalists. On the medical staff side, when do the hospitalist need help? We don’t want to wait for them to get overloaded and completely collapse.
- 1st stage: Co-management agreements were being looked at. We went to general surgery and asked for them to take back over general surgery cases. We weren’t sure how these conversations would go early on. But since general surgery was no longer having elective cases, and they weren’t busy in clinic, they were happy to help. We began to unravel these co-management agreements. Cardiology, as well, is willing to take back the atrial fibrillation and heart failure cases the hospitalists were managing; since the catheterization lab is closed for elective procedures, and clinic volume is down, they are also willing to help.
- 2nd stage: If we do move into a surge, we will move into the next tier. We have surveyed all the primary care doctors who are part of the network to see who would come back into the hospital. Primary care doctors who used to be hospitalists are open to coming back. We are not necessarily asking for subspecialists to be PCPs. But, at this point, all things have been on the table and discussed.
I co-led a webinar on March 25th, discussing with community-based pediatric hospitalists across the country – over 250 people – this very issue. Pediatric hospitalists are being surged to take care of adults. These are pediatric hospitalists that don’t want to have to do that but are willing if needed. We would rather have more adult primary care physicians, who understand adult issues, adult medications, who would be better prepared. And even then, perhaps only taking care of those who are more chronic and are improving. This may be more reasonable for PCPs, leaving the more acute for the hospitalists.
Is there hospital capacity for a surge of patients? What’s being done to prepare?
Interestingly, we were a bit fortuitous. Our ICU at Evergreen is old, built in the 1970s. We are in the process of paying for a new ICU, but it’s still very early on. Our old ICU is in an old 3-story building, with the ICU on the top floor. Engineering was able to get to the roof, jerry rigged the HVAC, and the entire ICU became a negative air floor. We wouldn’t have been able to do that if the new ICU, in the middle of the new tower, was operational.
Since we did it there, the engineers realized on the 8th floor of the new tower, we could do the same thing, on a medical-surgery unit. In addition, there’s a 5th floor in the maternity tower, where our pediatric hospitalists offices are, that is vacant. It’s on the roof. We were able to get to the HVAC system there, and we developed yet another dedicated negative pressure unit. We were able to add over 50 new negative pressure rooms.
I floated up there today, going toward my office. It was not being used now, but last week we had higher numbers, and it was in use. It’s a temporary surge unit that’s available if needed.
What is the status on other levels of preparedness around PPE, ventilators?
We are hopeful that in recognition of what’s happening nationally and in New York City, that hospitals are learning and being proactive, prepared.
- We think we have enough PPE. We’ve secured supplies but are scrambling to get more.
- As for ventilators, one weekend we were concerned about running out. Thankfully, we were able to secure ventilators for rent. Systems definitely need to be counting ventilators and figure out where they are.
On REGIONAL preparedness
One advantage that we had in Seattle is that most of the northwest regional hospitals were already coming together on a quarterly basis for the next earthquake. No one was thinking about a new virus hitting the scene. We were having regular regional disaster drills about next big earthquake hitting Seattle. Therefore, these hospitals already had a system in place for regional coordination, the northwest response team. We had the connections, so it was easy to set up plans.
If this hit other regions, would they, do they, have that level of coordination? Our CMO was already easily communicating, transitioning to talk about COVID, because of the earthquake response that was built in. We had folks at EvergreenHealth immediately step forward that knew the number of ICU beds, the number of ventilators, if we needed to create negative airflow rooms and how many we had in the hospital. We had that information at our fingertips because of that earthquake response team.
What are your pediatric hospitalist colleagues discussing?
We see kids getting infections, but they are largely asymptomatic. Seattle Children’s Hospital is starting to screen a lot on the inpatient side and urgent care. We recently reported about 650 tests, with only 5-6 positive in kids. So low numbers, 1% positive, and the 5-6 positives are all outpatient doing fine.
Yet, any pediatric center locating at a bigger hospital, even with low numbers, needs to be aware of what’s occurring. For instance, while EvergreenHealth was using existing ventilators, they were counting 2 more ventilators in the NICU that they could potentially use. The NICU was hesitant to release these ventilators. They were asked, “Are you using them right now?” When they said no, well, then those ventilators would possibly be used for adult patients. Which seems fine – no current baby needs them – but then, the head of maternal-fetal medicine, said, “Whoa, if I don’t have a conventional vent nearby, ready to go, I can’t do a high-risk delivery of a baby. For example, twins at 34 weeks might need them. If you can’t get more ventilators, then we might have to transfer all our high- risk moms into UW.”
Alright, not ideal. But that only works until you use their ventilators. Then it doesn’t matter where you deliver because there are then no ventilators for you anywhere.
What if we had all the adults with the vents they needed, but then this mom came in, had to deliver at 28 weeks, then the baby didn’t survive because we didn’t have any ventilators?
These unfortunately are needed, real discussions happening around the country right now. NEJM this week had 2 articles about resource allocation. These are conversations we know we should have been having for years but have been avoiding. Are you having that conversation about ventilators and resource allocation?
On some level, I wasn’t aware until this morning [3/25/20], that those conversations were happening. Interestingly, this morning, I was made aware of a committee that had formed – a resource allocation committee, with the CMO and CNO on the committee, with a needed redundancy built in. That would be the medical staff officers next. Our current president of the medical staff is a critical care anesthesia physician and could be working clinically. The VP is an ER physician. Therefore, the current CMO suggested that I be the backup on this committee. We would need that objective provider, who’s not actively taking care of these patients, to assist with these decisions.
How’s the morale in the ER? Staff? One month in?
I have been walking around the hospital and recently talked with the ER staff. They are not overwhelmed at this time. The ER volumes are down about 50%. Early on, we thought folks may have stayed away from EvergreenHealth due to the initial cases. However, I think volume is down in a lot of ERs because the message is getting out to call your PCP and avoid ERs for non-emergencies. Patients are being more vigilant. Our primary care doctors rolled out quickly for telehealth to manage patients at home.
Half of the ER is set aside as negative airflow for COVID-19 patients. The ER docs are waiting for the hammer to fall, but it hasn’t happened since that initial surge. We are currently having a different experience than NYC. We have reached a steady state. If you asked me at the beginning, I would be very worried about the end of March. Maybe this is flattening of the curve? I am cautiously optimistic.
This is good news/bad news. Patients aren’t coming that would have 1 month ago. There are pediatric hospitalists on national listservs, seeing volumes down. The assumption now, as we are good at social distancing, is that we are preventing the spread of other viruses currently, so pediatric volumes are dropping nationally. This raises questions. Will we close peds units? We were frequently admitting the worried well. Will we ultimately lose our jobs?
Two different extremes, in hot spots, the volumes are high, in the ER/ICU, but specialists with volumes down worried that this will be the new normal. Specialists, PCPs, are closing offices if they can’t switch to tele health. I am hearing about dermatology offices closing, with employees laid off. A pediatric group that laid off employees.
I was talking with those 250 community pediatric hospitalists on that webinar, and one of the things we are being asked to do is to get people out of the hospital faster. Even faster than before. Even normal newborns, at 12 hours, we are getting mom and baby discharged. We are planning the things we need to do at the 24-hour mark and having them done at our lactation clinic. Colleagues around the country are thinking of doing the same and have that close follow up with PCPs. Normally, I would have said great, but now they need to know, to check, if the PCPs are still open.
The economics of these offices closing and laying off employees is a whole other situation. It’s a conversation we need to begin having to be sure these offices and their employees make through this crisis.
For adult patients, too, how are discharges from the hospital being handled? Are specialists’ offices staying open and available? There are a lot of new questions and dynamics to be answered daily.
About Dr. James O’Callaghan
James J. O’Callaghan, MD, FAAP, SFHM is a Clinical Associate Professor of Pediatrics at the University of Washington and Seattle Children’s Hospital, Seattle, WA. He has been the lead pediatric hospitalist at EvergreenHealth Hospital, Kirkland, WA, since 2008 and recently served as the President of the Medical Staff. In addition, he has served as a member of the SHM Pediatric Committee as well as the HQPS Committee.