Coronavirus (COVID-19) Mitigation: Preparing Hospitals and Health Systems #JAMALive

Coronavirus (COVID-19) Mitigation: Preparing Hospitals and Health Systems #JAMALive


Hello and welcome to this JAMA interview
this is Howard Bachner editor-in-chief of Jama this isn’t another livestream
we’re trying to do a couple a week I’m joined by Stephen Parodi who’s a
executive vice president at Kaiser Permanente welcome Steve thank you for
having me Howard. so I had heard you in a conversation with a number of people at
the AMA and I was so so extraordinarily impressed and in what you’re trying to
do and accomplish and organize at Kaiser but before we get started could you just
tell people what you do there? Yeah, so I’m an infectious disease physician and I have a responsibility for hospital operations
in the Northern California region and the incident commander response for
Kaiser Permanente nationally. So so I do know you’re an infectious disease
physician so that will really be helpful because I think some of the questions
that are likely to come in and that I’ll ask are going to be particularly around
health care workers which I think continues to emerge as a hugely
difficult issue and in part I’ve been impressed at a lot of institutions like
yours and others are capable of increasing the number of intensive care
unit beds but you need people to work in the in those areas so you’ve had one
hospital that has been particularly stressed could you talk a little bit
about that yeah sure Howard so our San Jose facility in California actually has
almost half of the hospital filled with either Covid confirmed or persons under
investigation so we literally had to revamp the hospital to make sure that
we’ve got enough capacity for a personnel standpoint because to provide
the care to these patients some requires resource intensive personnel and PPE and
PPE preservation which we can talk about in a little bit essentially we have
filled one entire ICU just with COVID patients, which means that we’ve had to
repurpose another unit to take care of the regular
ICU patients as well um we instituted PPE preservation so that when you enter
that intensive care unit, you can don the PPE and take care of multiple patients without
having to change in between patients. Obviously washing your hands in between patients and switching gloves, but otherwise keeping your PPE intact. let’s just walk through what happens at
that facility so what I’ve been struck by is and I know you mentioned this
you’ve switched to so much telemedicine you were gonna do it anyway but this
really pushed you into telemedicine we can come back to that I think we’ve
gotten 10 viewpoints saying health systems should switch to telemedicine we
haven’t published any because I think people just need to look out the window
to know that’s already happening I don’t need to publish a viewpoint to encourage
people to do it I think most places have have quickly adopted and the other thing
is when I spoke to people this morning a lot of the emergency rooms are pretty
quiet people are self selecting when they go I think they know if they’re not
really sick not the best time to go to an emergency department but you you need
to figure out where to put people this has become a huge struggle so someone
comes in with respiratory symptoms and a cough and a fever how do you sort out
whether they go to a an inpatient facility let’s not talk about the ICU
that has other COVID patients or not how quickly are you are you able to test and
do you hold them in a holding area before the test results come back? This
is a great question. So first of all, I can’t stress the telemedicine part of it enough because what you do is you
actually allow yourself to be able to do three hours at the point of care when
showing up into the medical office building setting clinic or the emergency
department so we’ve been able to reduce this by turning on all the capabilities – video,
telemedicine by 40 to 50 percent. So what that allows you to do is actually
pick the points of contact and points of entry and we have greeters in place
who are trained to screen for symptoms and then essentially think about it
sick, not sick. Not sick here for a regular visit, they go to the essentially
clean area which is the the clinic or area in the emergency department. sick they go
to a tent or they go to a particular area in the ED or clinic. Where then
you’ve got people that already have the PPE on and so they can do the
evaluation. We have ramped up testing capability I’m happy to say that in
multiple areas of the country I think that we’re going to have increased
abilities to do automated and really the limitation, I’ll be honest with you, is swab.
And getting enough of those. And I know that we’re working with our public health partners to make
sure we’ve got that. But essentially it’s a triage method and we should be doing
that now that’s going to reduce health care worker exposure and on the other
hand it actually preserved the PPE In an efficient system it’s about a two or
three hour turnaround time or is it longer than that Steve? so right now
realistically it’s longer it’s not it’s really you know from the standpoint of
most locales in the US are still limited by manual testing okay so on the
inpatient side independently on the state you’re in, the turnaround times around
one to two days okay. on the outpatient side we’re talking five days the longer.
so for the inpatient service again not the ICU you’ll cohort all people with
respiratory systems and cough and being suspicious of having COVID together
yeah so we’ve moved towards a cohorting on an entire ward okay so the whole idea
here is that when health care workers are entering that ward
they’re donning everything right then and there. It allows for also reuse of PPE
using CDC guidelines. so for instance we’ve already moved for its n95 reuse
extended use we actually access some of the national strategic stockpile and
some of those masks are expired. So we’re actually using those as well again
using CDC and local public health guidance. now before the test result comes back is
it possible that you’ll have a patient with who eventually you can
firm with having COVID ID near a person who may not have COVID ID? great question
here so you know the the the early CDC guidance was the place every single
person in negative pressure rooms right that’s simply not possible just
physically speaking so we have been able to do it by moving to a droplet form
precautions approach particularly if the patients are not requiring high risk
procedures that are going to potentially aerosolize the virus right we’re placing
them in single rooms and as long as you’re closing the door you’ve got them
protected and so what you don’t want to do is cohort two people that are rule
outs right because one person may be negative, one person may be positive. one
of the things that Howard in terms of like increasing hospital capacity, though, is that
we actively have protocols in place for being able to cohort to people who
are known positive and who are not known to have other contagious diseases that
we wouldn’t want to cohort together right now let’s so you’ve taken me
through I walked into your tent sick not sick this is great then I get to the
ward and as you said you don’t want to put two people together in the same room
if one could be positive one could be negative now the ICU let’s say the
person either deteriorates when they’re on the inpatient service or or they’re
quite ill when they come into the emergency department what’s the process
for entry into the intensive care unit right so there’s an initial evaluation
one of the things that I want to stress for everybody is that you have to have a
protocol in place to make sure when you screen the person at the point of entry
that if they have symptoms but they’re actually masked that’s going to protect
people and once you get people the person into a room and let’s say they’re
clinically deteriorating and they need intubation then we’re actually using
airborne precautions so that’s where you’re wearing a papper or a capper
along with them contact i where and then in the ICU once you have them on a
closed circuit you’re no longer at risk for aerosolization of the virus.
you can use droplet born precautions along with the goggles and contact
precautions and then people make it into the intensive care unit and there, I’m
assuming it’s all single bedded so you can really separate people who may who
may you may know have COVID versus those who you’re not sure so at this
stage in the pandemic we’re able to do that what I want to emphasize is a part
of our surge plans are the ability to have two patients that are both Covid
positive both requiring ventilators to be cohorted in the same room so we think
that you know based on the surge that we saw in San Jose we’ve got to have that
level of preparation let me just emphasize one other thing this thing can
come on very quickly I’m so when and you go from zero to having ten patient that
happened for us in terms of in the ICU within one week so you’ve got to be
prepared for that level of surge. and one of the things that’s crossed my desk
today is that it appears that a fair number of people who are in the
intensive care unit are needing to stay many days now I don’t know how long
you’ve had people in the intensive care unit Steve to answer that question that
unfortunately is going to take up more more bed days and the patient should get
treated the way they need to be treated but is that been your short-term
experience yeah so our short-term experiences in that patients are
typically needing somewhere between 10 to 14 days of mechanical ventilation so
this is a long-term proposition in terms of vent days ICU days and personnel days
yeah and I am concerned that you know about planning for having enough
ventilators I’m talking about across the country to be able to have this level of
response. so one of the other things that we’re actually talking about
actively is crisis standards of care and the Italian experience would point us
towards needing to be able to do mass triage and determining who are the best
patients that need mechanical ventilation who are the patients that may
not benefit from it do you have a sense of the ratio of
people who are on in the hospital who are on the inpatient service versus
who’s in the intensive care unit I’ve been told before it’s somewhere around
two or three to one I don’t know if that’s been your experience so you know
the current two hospitals are in Santa Clara County that we have about a
quarter of the patients are in the ICU relative to the others that are not. I would just want to emphasize one other thing for your
viewers is that you have to plan for almost a fine mobile type of disease
process so a lot of these individuals we actually saw or heard from on the
outpatient side the week before they’re relatively doing well they had a cold
and cough and then they rapidly deteriorate. and is that happening on the
inpatient service where people come in they’re sick they don’t go to the
intensive care unit and then over a period of two three days they do
deteriorate need to be transferred we’re seeing that same
exact pattern okay where a person is relatively stable and can rapidly
deteriorate within hours requiring intubation or a rapid response. The
demographics looking like what was reported from China or Italy you know
older individuals with comorbid conditions particularly hypertension
diabetes I’m just wondering you know there’s been different reports that
there’s been you know slightly younger patients admitted in the United States
you have a large experience now Steve and I’m just wondering what your sense
of the demographics are given that Kaiser may be slightly different than
the rest of the country. Right and just so everyone knows that we take care of
about 12 million patients. It’s a very wide demographic of individuals our
perspective right now is I think the jury’s still out about who is actually
going to end up being the cohort that ends up in the hospital and we have
people that are as young as in their 30s and 40s who have
clinically deteriorated and required mechanical ventilation there is of
course the other cohort, the older cohort in
their 80s and 70s that are also in our ICUs. But I’ve been surprised about the
you know 20% of patients don’t fit the classic cohort that was described in
the Chinese data. yeah I know we had published quite a bit of the Chinese
data we have a report from the Italian cohort coming out it’s going through
revision and it more mimics China than what I’ve heard about in the United
States so there could be some some changing demographics in the u.s. I need
to go back to PPE. Let’s put aside the ventilators. tremendous discussion the
last day or two that there just may not be enough masks and PPE, you know, I
do know the federal government is trying to ramp up I can’t imagine that we’re
gonna be able to create more of this material in the next week or two maybe
I’m not correct maybe I’m not as optimistic you know people talk about
kind of a Marshall Plan, World War II effort but it takes businesses a time to
ramp up and produce new product what are you doing to try to save PPEs
yeah so thank you for that question so first of all I think it’s incumbent upon
all of us to save PPE because the manufacturing shortfall in China is not
going to be fixed in the next month and so we’ve got it actually yeah in our
contact with Health and Human Services and others we’ve got to be planning for
the next month to six weeks using what we have or becoming innovative so the
first thing I would say is the reuse of PPE, extended use of PPE all of those
things should be done now. the second is the cohorting of individuals and
patients because what that allows you to do is reduce the amount and burn rate of
PPE. the third is actually cancellation of elective surgeries and
we took that action last week and what does that do for you it allows you to
number one preserve the PPE for Covid but I’m also worried about the other
disposable medical supplies for just doing basic surgery and so we’ve got to
be able to do emergent and urgent surgery non-Covid
related during this time period so doing that has reduced our Hospital census
by about fifteen percent and it’s also reduced our PPE burn rate. so just to
give you a sense of this yeah we were looking at you know somewhere on the
order of five to ten days on hand of PPE With taking all of those steps that
we’ve now got more than 30 days of PPE on supply, just because
we’ve reduced the burn rate. Now the other thing I’ll just say is that we’re
also trying to source different ways of actually replicating the PPE so
literally going to hardware stores and getting other PPE that could be used
for droplet form precautions, not necessarily airborne precautions so we
can preserve the existing PPE for that and and being able to repurpose or have
PPE made. we literally are sourcing from you know different vendors local to us
to be able to provide masks and literally surgical masks sewing them
together getting the face shields made from hardware store materials again
to extend that life until you know the presidential emergency order which was
actually very well received from our standpoint to repurpose manufacturing
within the US. Now you know I’ve said it in every podcast with Maurizio
and then with Tony and now with you I am I’m anxious for my colleagues health
care workers you know I don’t take care of patients anymore I fully recognize
that but physicians nurses the people who bring product in and out of the
intensive care unit what are you doing with physician and nursing shifts? Yeah that’s a great question so first of all there’s an important
people component to this. So supporting your people with constant
aggressive communications that explain to them what we’re doing why we’re doing
it particularly in the age of like continually changing recommendations and national guidelines has been key. The second is spelling people so
allowing people to take the time off if they need to because this is resource
intensive work. The the third thing that we’ve actively looked at is repurposing
individuals so in the case of let me just give you the intensive care unit
as a case in point, is turning the intensivists into attending physicians if you will
and having hospitalists be essentially the residents. that allows for an
intensivist to cover more beds and it actually gets their expertise and eyes
on more and more people. the other thing i’ll just tell you something that’s
pretty simplistic but in order to preserve again PPE and the number of
people that are having to ingress and egress out of the room using birth
control monitoring and so he’s putting baby monitors in the room so that a
physician can actually virtually examine a patient with another practitioner in
the room so you’re again cutting down on the number of people protecting the
healthcare workforce maximally. Something that’s come up a bit over the last
few days for the first time i think healthcare workers are feeling
vulnerable themselves particularly if they’re older sixty or seventy four
women who are pregnant you know older physicians or or other providers who may
have comorbid conditions there’s the concern if they’re on an ACE or an ARB
that’s a really unsettled question are people asking to work elsewhere and how
are you dealing with that? It’s a great question so first of all this is sort of
unprecedented but we’ve actually increased the amount of work from home
in the healthcare workforce bottom line largely on the outpatient side and this
has been helpful for a couple of reasons we’re able to then actually flex the
workforce to be able to support other functions like our call center that may
be getting overloaded and let me just give you some numbers Howard you know
we’ve been looking a cold and cough script that we have in
place typically this time of the year we get about 4,000 calls a day regarding
cold and cough we’re now getting 14 to 15 thousand calls a day so what has
happened is we’ve repurposed some of our primary care workforce rather than
having them work in the office or potentially be exposed they’re working
from home and actually supporting those calls same thing on the impatient side
being able to again spell people so they get enough sleep and enough rest and
also providing for training on either in real time by video and by other means
so that they feel comfortable with the PPE regardless of whether they’re in a
risk group or not I mean I think we we have to be bit agnostic to that because
the fear about this disease cuts across whether you’re considered a potentially
high risk individual or not and then the other thing I’ll just mention is having
EAP services or Employee Assistance Programs
on-site where we can help where somebody’s either stressed and/or having a
problem. Have you in the script since you deal with it so often when you’re
telling people to come as a you and walk in to one of those tents because when
I’ve talked to people EDs are much less busy which is a
good thing I mean people are know knowing they don’t overwhelm the
healthcare system and if you’re not that sick going to the hospital may not be
the best place for you so when are you telling people to come in? Steve so it’s really if somebody has evidence of shortness of breath and or they appear
to be developing symptoms there respiratory distress we definitely want
those people seen. I have to say both on the provider side as well as the patient
side the telehealth option has been very well received and almost it this is sort
of a staggering number but 99% of the individuals are able to be triaged to be
at home, based on the calls that we’re getting and it’s
only a select few that are coming into the tent or coming into the selected
area where we’re triaging individual yeah we had gotten a viewpoint that
speculated was speculating how this will fundamentally change the healthcare
delivery system and I we didn’t go forward with it because I felt we could
wait on that one let’s just get through the current crisis before we think about
that have you had health care workers that
are Covid ID + so we have had a couple of individuals
that are Covid positive and one of them has required hospitalization. it is very hard at this point in time to determine whether it is related to healthcare
exposure versus community exposure because we have so much likely community
transmission that’s occurring we’re hampered by the testing you know
and but that you’re raising an important point here which is that you know
there’s a constant vigilance that we need to have to protect the health care
workforce to make sure they’ve got the PPE to make sure they got the
training and that’s been a commitment we’ve worked on even before this epidemic. The disaster
preparedness drills have paid off. The scenario of when those people can come
back to work have you have you sorted out it’s it’s really been an interesting
discussion the CDC changed their recommendations I was able to talk with
Jay Butler on Tuesday and he said they were gonna change and they changed on
Wednesday not for healthcare workers but for someone who can’t get immediate
testing has been Covid ID + if they’re well after seven days now everyone’s on
lockdown anyway without testing he said they could re-enter the
workforce now I’m not sure that’s true of a health care worker but do you have
a scenario or have you figured out the paradigm which will allow a healthcare
worker to come back to work? So it is complicated right because we just don’t
have the ideal test that determines essentially if somebody cleared or cured
right I’ve COVID-19 that recent data that you’re just referring to
is going to be helpful right now we’re still adhering to the guidance where
we’re testing the individuals before they come back to work and that with two
successive negative swabs 24 hours apart, then allowing them to come back to
work. Yeah I have a sense that each of the healthcare facilities may make
somewhat different paradigms or create different paradigms than potentially what
the CDC is recommending because they’re they’re going to be so sensitive to
protecting other health care workers and their patients. It may be different
than someone just going back to a different type of job just a couple
other questions. You have a lot of people you care for not not you
personally but Kaiser you said 12 million I assume that’s Kaiser North
Kaiser South I didn’t know if that included Colorado and your new your new
Washington State program. Do you have any sense of what the incidence is looking
like just over the last couple days? Because that’s the figure that
I think everyone’s most interested in yeah so actually so I was speaking to
the entire country so we have eight different regions so that’s that’s the
footprint or the 12 million patients. You know I wish I could give you a
definitive answer. What I can tell you is that we’re seeing significant
increases in the number of patients that are confirmed positive in our hospitals
particularly in Washington State and in Northern California and those appear to
be the current hot spot that being said I’m just gonna give you my point of view on this. Based on the amount of call center data that we’re seeing
significant increases it’s almost like a hockey stick over the last week
I think there’s widespread community transmission occurring in both of those
communities if we had the testing I could tell you for sure and so my
sense is also in our Maryland region that we’re seeing significant increases
in community transmission there based again just on the call center data not
so much the testing. Now this is the time of year thankfully where we begin to see a waning of patients who are positive for
flu which is thankfully the US has been delayed in comparison to China or Italy
what’s been going on with patients with flu? you test very actively for them
now most don’t get admitted to the hospital but many do I’m wondering if
you if you know your flu data for the last week or so
I do actually and so in fact we’ve seen significant decreases in the percent
positive influenza swabs that we’re getting back so you know typically
you’re at epidemic levels if you’re above 10 percent positive, we’re
now at around five percent and that’s been steeply decreasing so when you
think about it we’re seeing unprecedented levels of cold cough
scripts being activated at our call center level with a significant decrease
in influenza tests. That tells me that we’ve got COVID circulating. I can’t tell you
what percentage of those calls are actually Covid positive but I can tell
you that this is the most calls we’ve ever gotten period. Writ large over the
last 10 years that I’ve been following that data so every time I do a live
stream the same question comes up I can’t tell if it’s the same person but I
have to ask because it’s been hard to get an answer to it and I’m not sure
you’ll be able to answer it. A sense of reinfection and is it possible? I think we just don’t know the answer to that question you know there have been a case
report or two suggesting either relapse and/or reinfection you know if you think
about the nature of coronaviruses and I know you were talking with Dr. Fauci
if there’s anybody who’s an expert, he would be. But again my personal
opinion is that you know with coronaviruses, you know human beings don’t
typically develop long term immunity to coronaviruses. you know is this one
going to be different or not I think we’re going to have to research it
understand it and and that really goes into having a long term mitigation plan
and the importance of you know developing a vaccine. You know I’ve left the last medical question for last the most difficult one
any early mortality data Steve? so again, I think that we’re limited
we’re hampered by the testing so in terms of looking at you know what really
is the percentage of mortality that we could expect from this disease there are
plenty of models out there either in the lay press or actually published in the
medical journal you know it varies now honestly between 0.5 percent all the way
up to 3.4 percent the truth is probably somewhere in between what it does help
me do in looking at from a healthcare system perspective is try to model how
we need to scale our response and my message to you Howard and to everyone
who’s listening is it’s time now to scale open your surge plans up get them
going even if you haven’t seen it in your community yet it will be there and
you need to be ready. Yeah again I I think the one or two ways in which the
US has been fortunate it’s a it’s a kind of odd statement given everything that
we’re we’re facing is we were certainly behind China and certainly behind Italy
and I really feel like we became galvanized last week I don’t know which
day Tuesday or Wednesday but when I speak to colleagues and other people I
call around the country people really are conscious of knowing they may have
to scale up quite precipitously I mean I do think you know your area, state of
Washington, Boston interestingly enough my hometown have really been the
three areas that have really had to scale up I think the other
metropolitan areas know that they may need to I think you know the great
fear is New York obviously because of the density of individuals you know you
have six or seven million people living in the five boroughs and I think there’s
tremendous concern about what the future may look like in New York City. Steve so this will go out I don’t know you know five ten fifteen twenty thousand people will see or listen to
the video any other things that you would like to share? so all I can say is that this is going to require a complete and concerted response and it’s really us
the physicians the health care providers working as a system coming together I
can tell you that actually this is no longer just a Kaiser Permanente response
in Northern California or in the state of Washington we are banding together as
an entire health system and meeting directly with public health officials
because the social distancing which we actually didn’t talk a lot about it is
also a key and present issue that has to be addressed and be aggressive and we
know some early data from China in comparing with other countries that aggressive social different thing in conjunction with a lot of measures
that I talked about in the healthcare system are going to be part and parcel
to this response. yeah I continue to hope you know I think that we started
social distancing this past weekend let’s take St. Patrick’s Day parties out
of the mix so we’re only four or five days into it so you know after we’re
into it for two weeks I’m really gonna watch the numbers closely because if the
incubation period you know is 7 10 12 14 days I would hope that sometime by early
April we really begin to understand what the next month or six weeks is going to
look like you know the numbers the last few days are enormously concerning
obviously because of the rapid increase that hockey stick that you
described. I’m hoping some of the other metropolitan areas because of
social distancing will be spared but I’m not optimistic and obviously there’s so
many unknowns. well yeah and Howard you’re really referring to something
that is really an unknown, where are we on that curve and we’ve been limited by the testing and that’s okay I think that even if we don’t know for sure where
we’re on the curve, we need to do this it’s the right thing to do and like you
said time will tell once we’ve got a little bit more data so I’ve been talking with Steve Parodi who’s an executive vice president external
affairs for Kaiser has an enormous amount of organizational experience and
is an infectious disease physician so that was that worked out well for this
pandemic Steve. I want to thank you for joining me and really the best of health
to you and all of the clinicians and other workers who are taking care of
these patients as I said it’s it’s key that we really focus on keeping them
healthy because regardless of what else we do if they’re not healthy we won’t
have an adequate workforce so wish them well and keep them healthy Steve Thank You Howard be well bye-bye you

27 Replies to “Coronavirus (COVID-19) Mitigation: Preparing Hospitals and Health Systems #JAMALive”

  1. Where can we find instructions to sew cloth/gauze/? Masks and instructions as to how to launder them and materials to use & sources to obtain materials. I would treat them like a cloth diaper & dump in bucket vinegar or bleach before laundering but for how long & what concentration?

  2. please update about jenifer haller. what happend first dose about covid 19 result and what is postion about her please explains thank. regarding.

  3. Thank you for doing these. They are very informative, and the questions are exactly what we are thinking of here in Northern California. Its the kind of clear, concise information we are not getting elsewhere.

  4. Newfoundland canada has no cases on your map. We are very small but we have 1 case 2 presumptives. Canada has 600 plus now. I watch your channel as I'm concerned my country may experience same. Its excellent information.

  5. Excellent interview! Keep them coming! These videos need to be seen by millions. Consider doing a 'sample' telehealth' interview for covid-19 respiratory issues and the possible recommendations for at home management techniques as this will become more and more important as this progresses. We see the obvious benefits of 'telehealth' individual conferencing, but certainly it is now the time to utilize all of our technology to access as many people as possible with educational youtube videos put out by esteemed institutions to offer the same general recommendations for at home care and possible makeshift isolation techniques and strategies that could be adopted in the community at large. Again, thank you for such an excellent interview.

  6. There are no tests available. It takes 3-4 days for results. Stop making them, treat what’s in front of you. Push for the instant tests.

  7. According to this video multiple patients can be supported on a given ventilator: https://youtu.be/uClq978oohY

  8. Summary
    Infectious disease Dr Parodi said a hospital in CA is 1/2 full of positive or suspected Covid19 patients
    Said went from zero to 10 patients in ICU in one week
    Patients need 10-14 days of ventilation —- worries about having enough ventilators across the country
    Who may not benefit from it?? Questions already
    Mass triage
    ICU
    Santa Clara 1/4 patients in ICU vs patients on floor doing relativity well with cold but rapidly deteriorate … can deteriorate in HOURS
    30’s – 40’s vents
    And 70-80’s on vents
    70-80% don’t fit China age bracket — changing demographics in USA
    May not be enough masks and PPE in the next week or two …. save PPE gear … China manufacturing them ….next month and 6 weeks we are not going to have PPE gear !!!

    Saving PPE gear – reuse – extended use of PPE – cohorting of patients
    Non covid surgery reduction to save PPE
    Reducing burn rate of PPE
    OMG — they are forced to go to hardware stores for gear
    Trying to extend life of gear
    Anxious for Heath care workers
    Supporting people with constant communication
    Changing national recommendations
    Repurposing individuals – hospitalist turned into attending physicians
    Virtual monitors to reduce PPE gear to protect workers

    Older Heath care workers or pregnant workers = unpresidented letting them work from home to evaluate callers — 14,000-15,000 calls a day was 3,000-5,000

    Allowing people to get enough sleep

    Fear is cutting across all workers

    ED is much less busy as people are staying away unless really sick

    Come to ER
    Shortness of breath
    Respiratory distress

    Teladoc 99% calls triaged are home

    Fundamental change of health care

    Health care workers covid positive— one (actually two a 40 year old and 70’s)

    Last 2 days === 8 regions west USA == significant increase in positive WA state and northern CA — wide spread community spread in those communities

    Maryland community spread too based on call center

    Thankful USA delayed from virus to let flu virus get over – significant decreases around 5% and decreasing

    Most calls we have every gotten in 10 years

    Reinfection??? Don’t know
    Nature of coronavirus humans do not develop long term immunity to them —- long term plan ? Vaccine

    Early mortality data == limited by data = varies from .05-3.4%

    Time now to scale == it will be in your community == be ready

    Behind China and Italy

    Future of NYC

    Complete and certain response to come together

    Entire Heath system == social distancing is important

    Incubation period 7-14-21 days == last numbers alarming of increase

  9. *********PLEASE watch youtube video of covid-19 how to use ventilator to save multiple lives —- dr charlene babcock****************

  10. Chloroquine is used to treat patients for Covid19 infection in the U.S. How about Camostat that could block Covid19 infection? Its mechanism of action is promising. Japan and Germany are testing it.

    “An intravenous drug that has long been used in Japan to treat acute pancreatitis may be effective in preventing infections with the novel coronavirus, a team of the University of Tokyo said” March 18, 2020. <https://www.nippon.com/en/news/yjj2020031800741/pancreatitis-drug-may-block-coronavirus-infection-u-of-tokyo.html>

    “A team of German virology, genomic and pharmaceutical scientists at the Leibniz Institute for Primate Research has identified an existing Japanese drug called Camostat Mesylate (trade name: Foipan) that could treat the Covid-19 disease that is caused by the SARS-CoV-2 coronavirus.” March 7, 2020 <https://www.thailandmedical.news/news/coronavirus-drug-research-german-researchers-identify-japanese-drug,-camostat-mesylate-that-could-be-repurposed-to-treat-covid-19>

    “SARS-CoV-2 Cell Entry Depends on ACE2 and TMPRSS2 and Is Blocked by a Clinically Proven Protease Inhibitor.” <https://www.ncbi.nlm.nih.gov/pubmed/32142651>

    “Camostat is a serine protease inhibitor with activity against the host TMPRSS2 protease that is exploited by SARS-CoV-2 to mediate viral entry.” <https://www.guidetopharmacology.org/coronavirus.jsp>

    “Camostat mesilate (FOY-305) is a synthetic f low-molecular weight protease inhibitor. It is able to inhibit trypsin, prostasin, matriptase and plasma kallikrein. In addition camostat attenuates airway epithelial sodium channel function and enhances mucociliary clearance. Camostat mesilate tablets (FOIPAN®) are approved in Japan and used for the treatment of remission of acute symptoms of chronic pancreatitis and postoperative reflux esophagitis.” <https://drugs.ncats.io/drug/451M50A1EQ>

  11. Are we giving these patients Hydroxychloroquine and Azrithromycine (z-pack)? Chinese studies showed these as safe and effective treatments.

  12. Suspicion is not enough. What if it's flu. What if we're mixing up the facts. Flu or corona…. need to know. Maybe the flu is killing these patients.

  13. The FIRST thing that hospitals and first responders need is PPE–enough and of the proper quality !! We have CDC telling these folks to use BANDANNAS in lieu of proper PPE, and that is NOT ACCEPTABLE!!

    Every. Single. Facility. WITHOUT EXCEPTION. Should have AT LEAST a full month's worth of supplies for precisely this kind of event. Profit-seeking managers discourage this kind of preparedness and that just IS NOT OKAY.

    REUSING PPE!?!?? In a hospital setting!? You are out of your damned mind.

  14. Great interview. An interesting thought to collaborate with a news entertainment celebrity like Trevor Noah or John Oliver. These days your studio set up is far more professional appearing than theirs – since they are now broadcasting from their living rooms.
    I'm a triage nurse – it's been a wild ride hasn't it?
    Warmest regards
    Jennie

  15. Great interview, but I would have liked a little more on how you're staffing nurses/respiratory therapists/ancillary staff. It's great that physicians can treat patients via tele medicine, but nurses are immediate front line, spending their entire shift with these patients, going in and out of their rooms so many times a shift. How are nursing shifts being managed, and how many are being exposed due to lack of PPE, or changes is protocols due to lack of PPE's? Would love to know what's ahead for me and my fellow nurses.

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