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March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

  • 1.  March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-25-2020 11:25
    An excellent audio interview of an ED doc in Kirkland. His lessons learned include broadening the differential as well as what equipment or tests can't be used if you suspect coronavirus.

    Best,
    Helene 

      
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  • 2.  RE: March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-26-2020 16:08
    Thanks for posting this. The highlight of this interview is how to most efficiently evaluate CV-suspected patients using a "one time in the room" approach, thus reducing exposure and preserving PPE. Ingenious.

    ------------------------------
    Charles Pilcher MD FACEP
    Chair, Board Quality & Safety Committee
    EvergreenHealth
    Kirkland, WA
    Editor, Medical Malpractice Insights - Learning from Lawsuits
    https://madmimi.com/p/5f4487
    ------------------------------



  • 3.  RE: March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-26-2020 23:39
    Thanks. What I found very interesting was how divergent and broad the symptoms could be. They found coronavirus in patients that caused symptoms of a wide range of suspected conditions.  I never would have expected to find COVID-19 in the differential. That was the Learning that impacted me the most because Americans at risk are self diagnosing. We are being told to stay home, not call 911, not to go for a test, not report an illness unless we have high fever and difficulty breathing. However, by the time the patient has high fever and difficulty breathing, it may be too late to repair the damage to the lungs. Especially true for people with other conditions who may at first presume that their symptoms are an exacerbation of their existing illness.

    Anyway, hanging in there in Brooklyn where I was thrilled over finding good quality toilet paper, today. A real coup!

    Best,
    Helene

      
       Website 
       Twitter 
     






  • 4.  RE: March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-27-2020 00:03
    There seems to be a bit of misunderstanding about coronavirus testing, even among a minority of healthcare workers. If symptoms are mild, anyone who is sick should assume they have a coronavirus infection and self-quarantine. Since there is no approved treatment for COVID-19, and since asymptomatic patients can test positive, there is only an epidemiologic reason for testing. If one's symptoms escalate to include shortness of breath, and O2 supplementation and/or a ventilator is needed, the diagnosis can (in most cases) be made on clinical grounds. The treatment remains supportive even when hospitalized. Fortunately a sufficient number of hospitalized patients are being enrolled in studies to see if we CAN find drugs that work. Testing should be more liberal for those healthcare workers at risk for spreading the virus amongst their co-workers and patients. In this case, a negative test helps preserve the workforce. 
    If I'm overstating the case, others can chime in.

    ------------------------------
    Charles Pilcher MD FACEP
    Chair, Board Quality & Safety Committee
    EvergreenHealth
    Kirkland, WA
    Editor, Medical Malpractice Insights - Learning from Lawsuits
    https://madmimi.com/p/5f4487
    ------------------------------



  • 5.  RE: March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-29-2020 19:13

    I think you're right.

     

    The high risk groups that need testing beyond healthcare workers could be a little broader depending on local testing capacity:
    Skilled Nursing or Long Term Care residents

    Dialysis patients

    Others with high levels of multi-person contact? ?Grocery checkers

     

     

    --------
    Ben Broder, MD, PhD, CPPS (he/him/his)
    Regional Assistant Medical Director of Quality and Clinical Analysis (Regional Offices)
    , Diplomate in Clinical Informatics, Hospitalist, KFH Baldwin Park

    Kaiser Permanente / Southern California Permanente Medical Group, 393 E Walnut St 3rd Flr NW, Pasadena, CA 91188-8034

    626-405-2501 (office) 8-335-2501 (tie-line), 626-245-0457 (pager), 626-720-9422 (mobile)
    Yesenia C Gaitan (assistant) yesenia.c.gaitan@kp.org 626-405-6151

    Hospital Clinical Improvement Team (HCIT)

    Clinical Analysis

    KP Insight

    Hospital Quality Composite

    SCAL Quality Data Map (list of many quality related reports and resources)

    Evidence Based Medicine or New Technology Questions – click to email EBM Inquiry Service

    NOTICE TO RECIPIENT:  If you are not the intended recipient of this e-mail, you are prohibited from sharing, copying, or otherwise using or disclosing its contents.  If you have received this e-mail in error, please notify the sender immediately by reply e-mail and permanently delete this e-mail and any attachments without reading, forwarding or saving them.  Thank you.






  • 6.  RE: March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-27-2020 03:13
    Charles, you're in Kirkland so you understand this better than most. But I have to disagree with the statement that there's only an epidemiological reason for us to test everyone who is symptomatic. I understand the logistical reason why difficult-to-get tests should be saved for the very ill. But the seriously ill are treated for COVID-19 while they wait for the test results anyway. There are humane reasons to test all who have symptoms and contact with infected people. There's also a great public health danger from people who are mobile and have mild symptoms.

    We have heard from doctors on the front lines, and it has been reported, the patients who are coming into the hospitals now on average are far more ill than the ones who came in at the beginning of this crisis. FEMA believes that as of tomorrow (Friday) evening all the ICU beds available for coronavirus patients in New York City will be filled. Because the patients are more ill, they need to stay in the hospital longer and they require more care and equipment. That means the wait for an ICU bed is even longer and for some patients won't come in time.

    Why are the patients more ill?  Because sheltering in place is not working for everyone and because the testing is unwieldy and slow. The testing process takes a total of over two weeks. By the time you get positive results, the disease has progressed further making treatment more difficult. 

    Sheltering in place sounds smart if you have a mild form or a different condition. But just because you have a mild form doesn't mean that you're not passing it to other members of your household who might be more susceptible. This is such a highly contagious virus that people who use the same elevator at work can pass it on. So how do you protect people you are required to shelter 24 hours a day with?  

    You can wash your hands and use a Kleenex or an elbow for a cough and clean your counters. You can try to clean all of your door knobs and light switches and faucet handles and toilet handles several times a day... but with what? There are no containers of purell or germ X or Clorox wipes or Lysol spray left on any of the shelves of any of the stores in New York city. It's even hard to find dish soap. You can try to keep your distance but since the apartments in New York City are on average a 600 square-foot one bedroom or a 1000 square-foot two bedroom that's difficult. There are no masks or gloves available for untested and therefore undiagnosed COVID-19 patients. For a family of four living in a two bedroom apartment it is impossible to not be on top of one another. 

    For anyone who has symptoms, mild or not, they want to get tested to protect their roommates or family. They want to get tested because they believe, even though it's not true, a doctor can cure COVID-19. 

    Here is why it takes two weeks from requesting testing and receiving results. A patient with symptoms in New York City today has three ways to get tested, all of them bad.
    1. they can stand in line outside of Elmhurst Hospital or one of the other hospitals like Bellevue for days waiting to be tested along with hundreds of other people with symptoms, 
    2. they can call 911 which we know should only be used for emergencies, or 
    3. they can try the process by phone.

    I've recommended the phone process but you still have to wait up to four days and have up to five phone conversations to get the test scheduled if you qualify. And the criteria have been changing over the past week as we learn more.

    Here's the testing perspective from the patient point of view. Imagine that you are a caregiver for a family member or like two people I know - you are a healthcare provider for seniors. You have symptoms and you want to rule out coronavirus. 

    * Most general practitioners have closed their practice to patient appointments for the duration of this pandemic and have converted to telehealth. If you call your primary care physician they will tell you to call 311 to make an appointment for testing or to call 911 if you feel that your situation is urgent.   
    * So you call 311 where you choose the prompt related to coronavirus. You wait anywhere from 20 minutes to 90 minutes to get someone to answer, someone who knows absolutely nothing but they give you the telephone number for Health and Hospitals coronavirus hotline. It's a phone number that is not published anywhere on any materials. They control the testing here. 
    * So you call Health and Hospitals where you get another person with no understanding or medical knowledge. They read off a questionnaire and depending on your answers they may connect you with a Teledoc whose job is to determining if you need testing. Since the clinical criteria for diagnosing COVID-19 is changing, the bureaucrat asking you questions on the phone may triage you incorrectly. 
    * Often they can't even get hold of a Teledoc and they tell you someone will call you back. No one calls you back.  
    * So you call again the next day and go through the process again. Then if the Teledoc determines that you should get tested, you are told that someone will get back to you to schedule the test next day or so. 
    * The demand is so high in New York City that a return call takes a minimum of three days. They call you back on a number that comes up as spam on your mobile phone. They schedule a test for you at an emergency room, the place you were trying to avoid burdening in the first place by not calling 911. The test may be scheduled for the next day or a few days later.
    * You get swabbed and you're told that results will be back in 72 hours. A week later you still don't have results and there is no way to confirm that the test was ever even received. (that's what happened to the two healthcare providers working with a senior population. Their tests ultimately both came back positive.)

    What do you do while you wait? What do you do if your test comes back positive but you're lucky enough to have mild symptoms? Move back in to your tiny apartment with your roommates or family? If your disease progressed while you waited those 7 to 8 days to get your test results, chances are you'll know the results as you lie on a bed in a hall. 

    Best,
    Helene 
      
       Website 
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  • 7.  RE: March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-27-2020 13:02

    Unfortunately, under certain conditions such as the current pandemic, the social contract has to be re-negotiated.  And that includes with regard to lab testing.

     

    From a patient perspective, absolutely, it would be ideal to have universal rapid access to testing and results.  From a system perspective right now, there is limited capacity of collection kits, instruments, and testing reagents.  I can promise you that everyone in the lab industry, from manufacturers to clinical labs, has been working around the clock for weeks now to grow capacity and test as many and as fast as we can.  But in a setting of limited capacity, you have no choice but to prioritize testing to those individuals who can benefit most. Which includes health care workers in quarantine and inpatients.  That's why health systems are limiting access to testing. It's not that outpatients don't deserve testing.  It's that the system has to focus its efforts right now in order to do the most good.

     

    The more that the public tries to get access to testing in the immediate future, the more it's going to bog down our ability to produce fast results for the most critical individuals. And speed matters right now.

     

    Please be understanding of this.  BTW, my family and I are sheltering in place right now even though we have neither symptoms nor exposures, and we live in a lower-prevalence region.  I hope everyone on this thread is doing likewise to the extent that your health care delivery responsibilities allow.

     

    Thanks

    Brian

     






  • 8.  RE: March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-27-2020 13:10

    Brian – I completely agree.

     

     

    --------
    Ben Broder, MD, PhD, CPPS (he/him/his)
    Regional Assistant Medical Director of Quality and Clinical Analysis (Regional Offices)
    , Diplomate in Clinical Informatics, Hospitalist, KFH Baldwin Park

    Kaiser Permanente / Southern California Permanente Medical Group, 393 E Walnut St 3rd Flr NW, Pasadena, CA 91188-8034

    626-405-2501 (office) 8-335-2501 (tie-line), 626-245-0457 (pager), 626-720-9422 (mobile)
    Yesenia C Gaitan (assistant) yesenia.c.gaitan@kp.org 626-405-6151

    Hospital Clinical Improvement Team (HCIT)

    Clinical Analysis

    KP Insight

    Hospital Quality Composite

    SCAL Quality Data Map (list of many quality related reports and resources)

    Evidence Based Medicine or New Technology Questions – click to email EBM Inquiry Service

    NOTICE TO RECIPIENT:  If you are not the intended recipient of this e-mail, you are prohibited from sharing, copying, or otherwise using or disclosing its contents.  If you have received this e-mail in error, please notify the sender immediately by reply e-mail and permanently delete this e-mail and any attachments without reading, forwarding or saving them.  Thank you.






  • 9.  RE: March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-27-2020 14:13
    It is very helpful to have those insights about testing. As this continues to build remaining in quarantine seems to be the thing we can best control!




  • 10.  RE: March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-27-2020 15:04
    Brian, we know and understand that. Everything that you said is accurate. But the process for deciding who gets tested and who doesn't is broken. The access for who gets tested and who doesn't is also broken. Common sense is in as short supply as the test kits themselves. 

    In New York City alone, the barriers to access for testing are so high that they discourage even the highly symptomatic until it's time to call 911. Which is one of the many reasons why 911 is overburdened. Fear exacerbates symptoms. 

    I sit on the Board of Directors of a healthcare company (an FQHC) here in New York City that provides free healthcare and social services to over 100,000 of the most fragile New Yorkers. We have over 20 clinics in the five boroughs of New York and our patients are already the most ill in the city: homeless, drug addicted, working poor, immigrant poor, HIV positive, behavioral health issues, diabetes, Hep-C, and more. We treat children as well. 

    We have been ready to offer testing to our patient base which will greatly help the emergency departments across the city but we can't get enough protective gear and tests to test all of our highest risk patients who are symptomatic. They are the patients who will go from early symptom to dangerous symptoms far more rapidly. They will also be a significant source of the spread of COVID-19. Tiny apartments with many people if they're not homeless. This will rip through the shelters just like it rips through nursing homes. 

    If we can identify them early enough we can take some of the burden off the emergency departments. Of course, we would have to use their ICUs until Jacob Javits is set up and the hospital ship arrives. We have partnered for decades with the major hospitals and they are used to relying on us for community care. We began in the early days of AIDs and have been there for every major community health challenge since.

    Best,
    Helene

      
       Website 
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  • 11.  RE: March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-27-2020 15:31

    I'm not in NY, but I totally get what you're saying.  If FDA had allowed the lab industry a longer head start, diagnostic testing might be in a stronger position.  I can't speak for the NYC hospitals and clinics, but I hear they're in full crisis management mode right now.  Unfortunately in these types of circumstances, the marginalized get hurt even worse than everyone else.

    --Brian

     






  • 12.  RE: March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-28-2020 10:37
    Thanks to Dr. Pilcher and all our front liners for struggling mightily to make up for the criminal failure of the US government to mount a unified, systematic national public health response to this pandemic.

    RE: Testing. China posted the corona genome internationally and based on it, Germany promptly created a test that was adopted by the WHO and dozens of other countries. But not by the US. The first US test from the CDC was a flop, and since then Trump has said, "We are turning our focus away from testing"-there was never a focus on testing!

    China and South Korea beat back the advance of corona by an aggressive, nationwide campaign of widespread testing, assiduous tracing of contacts, and isolating the infected/exposed. (Providing protective equipment, beds, vents should go without saying…)
    The US has criminally failed to mount any national response but a two-trillion dollar corporate bailout.
    Leaving hospitals, states, localities and individuals to fend for themselves and devise an inconsistent patchwork of practices and policies.
    Too many healthcare personnel are accepting or excusing the lack of testing, including the CDC, which has been ignominiously bowing down to the White House.
    The latest example of this disgraceful fawning is Deborah Birx agreeing with Trump that there's no shortage of vents.

    Here's the problem: If you fail to test, trace, isolate, treat (even if only symptomatic support) on a massive scale, you allow the virus to spread undetected in the larger non-symptomatic population.
    This creates a huge and unrecognized reservoir for resurgences of the disease.
    In the case of the 1918 influenza epidemic, this is what happened in the fall after infections fell off in the summer: it came roaring back in September, mutated and more lethal than ever, killing millions upon millions.

    Nobody should appreciate this better than SIDM and the ListServ community

    Ruth Ryan RN

    ------------------------------
    Ruth Ryan
    ------------------------------



  • 13.  RE: March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-28-2020 11:06
    It's too late to do mitigation ie screen, trace contacts and isolate those contacts ...

    The initial "small forest fire" has sent too many burning embers into the wind so our country is now filled with thousands of subsequent disseminated brush fires : this virus will wash thru multiple cities/regions until most of us have been infected / resolved (and some of us sadly die)

    Obviously we continue safe hygiene practices to flatten the curve but the horse is out of the barn from a mitigation perspective 

    India's idea to totally shut down for three weeks is interesting but will minimally help in my opinion because of the prevalence of severe poverty (which precludes true self isolation)

    Pandemics are called just that for very good reason : they sweep thru the entire population 

    Tom Westover
    Cooper Medical School
    Camden NJ

    Sent from my iPhone





  • 14.  RE: March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-28-2020 11:09
    So well said, and needed saying.

    With that litany you would think, that as previously discussed, any loyalty bias would have completely disappeared.

    Rob Bel M.D.




  • 15.  RE: March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-28-2020 11:11
    I saw a great utube by the South Korean ID physician leadL by Asian Boss, titled “Everyone should see this interview with a South Korean infection control expert” also the National Geographic did a nice review of US state mortality from Spanish flu that illustrates concerns with lifting quarantine too soon.




  • 16.  RE: March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-28-2020 12:56

    Testing everyone and quarantining positives and contacts is the way to stop this pandemic quickly.  This could have been done for a lot less than 2 trillion dollars.

    Why not focus funding getting mass testing up and running?  It would have stemmed the pandemic and gotten the economy up an running a lot faster.

    The way to win this war is not by building the hospitals which are all downstream, but to stop people from getting infected in the first place.  Test and isolate are the way to win this war.

     

    Ted Palen, PhD, MD, MSPH

     

    NOTICE TO RECIPIENT:  If you are not the intended recipient of this e-mail, you are prohibited from sharing, copying, or otherwise using or disclosing its contents.  If you have received this e-mail in error, please notify the sender immediately by reply e-mail and permanently delete this e-mail and any attachments without reading, forwarding or saving them.  Thank you.






  • 17.  RE: March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-28-2020 13:03

    Yes – but that assumes that testing supplies are available at that level.  What I'm hearing from colleagues is that the reagent manufacturers are nowhere close to being able to support mass testing.  RNA extraction reagents appear to be one of the limiting factors. In the mean time hospitals are having challenges securing supplies even for the most limited testing currently going on.

     






  • 18.  RE: March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-28-2020 14:15

    Amen.

     

    Without doing the traditional public health work of testing, tracing contacts, testing, isolating as soon as we relax social distancing we're going to get another surge.

     

    US is almost last in terms of testing per capita and some hard hit states (California) are doing even worse (5 tests per 10K people in CA, national average is between 10 and 20 per 10K).

     

    --------
    Ben Broder, MD, PhD, CPPS (he/him/his)
    Regional Assistant Medical Director of Quality and Clinical Analysis (Regional Offices)
    , Diplomate in Clinical Informatics, Hospitalist, KFH Baldwin Park

    Kaiser Permanente / Southern California Permanente Medical Group, 393 E Walnut St 3rd Flr NW, Pasadena, CA 91188-8034

    626-405-2501 (office) 8-335-2501 (tie-line), 626-245-0457 (pager), 626-720-9422 (mobile)
    Yesenia C Gaitan (assistant) yesenia.c.gaitan@kp.org 626-405-6151

    Hospital Clinical Improvement Team (HCIT)

    Clinical Analysis

    KP Insight

    Hospital Quality Composite

    SCAL Quality Data Map (list of many quality related reports and resources)

    Evidence Based Medicine or New Technology Questions – click to email EBM Inquiry Service

    NOTICE TO RECIPIENT:  If you are not the intended recipient of this e-mail, you are prohibited from sharing, copying, or otherwise using or disclosing its contents.  If you have received this e-mail in error, please notify the sender immediately by reply e-mail and permanently delete this e-mail and any attachments without reading, forwarding or saving them.  Thank you.






  • 19.  RE: March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-28-2020 14:38
    Is anyone doing online surveillance and contact tracing?  Even given limited test availability it could be possible for people to self-identify based on symptoms, then have a public health worker ask followup questions to see if it's a likely case, and then query for travel history and contacts.

    On the other hand, I'm seeing that only about 5% of tests are positive here in Utah, a lower-prevalence state. Suggesting that symptoms alone may not be very specific.

    Sent from my iPhone





  • 20.  RE: March 2020 - COVID: Lessons Learned and First Hand Account From Kirkland, WA. - Lessons Learned and First Hand Account From Kirkland, WA | ERcast

    Posted 03-27-2020 16:47
    Another reason to suggest testing even those individuals who are isolating with mild or even no symptoms is that, if tests show to be positive, and isolation has been carried out for 2 weeks, the individual presumably has immunity for a least a short period of time. This being the case, that individual need no longer be isolated and may resume a normal life without fear of re-infection. This would put them back in the work force, importantly if a health care worker. Without testing, after recovery, the person may not have had the virus and should still shelter in place.