COVID-19 Webinar Series Session 4 – Health System Capacity: Protecting Frontline Health Workers

12:00 p.m. – 12:05 p.m.     Welcome and Introductions

• Sarah J. Dash, MPH
  President and CEO, Alliance for Health Policy
  @allhealthpolicy

12:05 p.m. – 12:15 p.m.    Opening Remarks

• Stephen Parodi, M.D.
  Executive Vice President, External Affairs, Communications, and Brand, The Permanente Federation and Associate Executive Director, The Permanente Medical Group,Kaiser Permanente
  @StephenParodiMD
• Patricia (Polly) Pittman, Ph.D.
  Fitzhugh Mullan Professor of Health Workforce Equity and Director of the Mullan Institute for Health Workforce Equity, Milken Institute School of Public Health, The George Washington University

12:15 p.m. – 12:30 p.m.     Moderated Discussion

(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)

Good afternoon. I am Sarah – president and CEO of the Alliance for Health policy. Welcome to the fourth event in our covid-19 webinar miniseries as covid-19 continues to spread Frontline health workers are at high risk of becoming infected themselves today. Our panelists will explore steps necessary to protect these workers.

0:35

The Alliance for Health policy gratefully acknowledges the National Institute for Healthcare Management foundation and the Commonwealth fund for their support of today’s webinar. You can join our conversation on Twitter using the hashtag all Health Live and follow us at all Health policy. And the alliance is here as a resource during this rapidly evolving crisis. If you have unanswered questions or ideas for programs that you would like to hear, please share them with us. We want to hear your questions today. So I’m going to briefly Orient.

1:04

You all to the go-to webinar platform and quickly review some technical notes. You should see a dashboard on the right side of your web browser select the speech bubble icon with the question mark to chat with us about any technical issues. You may be experiencing and you can use the second speech bubble icon to submit questions that you have for the panelists at any time. We will collect these and address as many as we can during the broadcast later today. You will also find all of our materials on our website and a recording of today’s webinar.

1:34

Then are now I am pleased to introduce today’s panelists. We’re joined today by. Dr. Stephen parodi who is the Executive Vice President of external Affairs Communications and brand at the Permanente Federation and the associate executive director of the Permanente Medical Group. Dr. Perotti is a practicing infectious disease physician by training who is at the front lines of the outbreak in California next. I am pleased to introduce. Dr. Polly Pittman.

2:04

Who was the director of the Mullen Institute for health Workforce Equity as a George Washington University’s Milken Institute School of Public Health. Dr. Pittman overseas and extensive research Enterprise focusing on policies that enable the health Workforce to better address Health Equity issues her portfolio includes directing to her supported research centers, Stephen Polly. Thank you both for joining us today.

2:28

Thank you for having me.

2:31

Thank you. Let me start with a couple of questions first. Let me let me open up with a question for Kali as as covid-19 continues to spread Frontline health workers face the highest risk for being infected themselves or one of the highest risks. What are the issues at the top of your mind to protect health workers?

2:52

Well, we have to some extent a situation of a lot of confusion and improvisation right now particularly with the shortage of of protective gear. So I would say that my major concern right now based on what we’ve seeing in countries around the world not only during times of pandemic but just countries that phase chronic shortages of health workers that there’s a danger of sort of getting into a downward spiral of something.

3:21

vicious cycle where you have, you know, the the lack of training the shortages in terms of protective gear weakening of guidelines and confusion about the guidelines the national level creating sort of a difficult context in which you’re already facing a whole sort of cascade of potential absences from the workforce starting with The fact that I’ll large number of our nurses for example our are older and they need not be able to present to work. The family needs of the workers themselves whether they are due to child care or because someone sick in the family. I mean of the 18 million of workers in this country eighty percent are women. So you’re talking about a lot of mothers and grandmothers some even great-grandmother’s and the nursing Workforce.

4:18

So you have that level and then you have the Exposure and a lot of differences across the country in terms of sort of what the protocols are in terms of quarantine. Then you have the actual infections which may be as high as 12 percent based on other countries and then you have you know, God forbid you have deaf also of health workers. So essentially you have the threat of a lot of absences as a result of the problem and that obviously results in moral distress in the room.

4:50

Meaning Workforce fatigue and low morale and so you get a situation where that intern and contribute to more absences and that’s what we call and health workforce planning sort of a downward spiral that feeds on itself. So that’s that is not occurring right now, but that is the danger.

5:12

Thank you, Paulie. So to Steve you you operate at Kaiser Permanente and some of the states that are most impacted by the outbreak including California and Washington. Can you tell us a little bit about what is happening on the ground? And what steps is Kaiser Permanente taking to protect healthcare workers amidst the surging or about to Surge number of cases? Yes. I can definitely speak to that. So we actually had an early experience.

5:41

The work that we did to support the Princess Cruise evacuees from Yokohama in February and that actually gave us the experience for providing care within the hospital setting and also containment strategies and quickly understanding that we needed to move to a mitigation strategy given the spread of the virus in the communities. And so we have taken a number of steps.

6:11

Both in Washington state as well as California early on but now throughout the country and to implement several different intervention. So one is tailoring the personal protective equipment for how the virus is spread and it is primarily spread in the community by droplets. So moving towards enhanced precautions that protect the health care workers with the gowns gloves goggles and the right surgical masks.

6:41

To preserve the n95 respirators for aerosol generating procedures was an initial early step. The second thing we did was we recognized that there were supply chain shortfalls because of the manufacturing crisis in China. So we implemented CDC guidelines for reuse extended use of n95 respirators early on the second thing.

7:07

We did was we actually implemented Telehealth in a Huge way so that allows for reduction of foot traffic through our Medical Office Buildings and increasingly through our emergency departments and just to give you the latest statistics that we’re seeing. We have reduced the number of primary care visits by 90% in the last week.

7:30

We have also reduced the number of sub specialty physicists by now 50% So what that means is that we now have a large amount of our Workforce that can actually work from home and contribute to the Social distancing efforts that are really critical to reducing the amount of spread in our community and also in our Healthcare facilities, we turned off elective surgeries more than a week ago to reduce the the volume of patients that are requiring intensive care as well as hospitalization for surgery. So that’s allowed us to prepare for future surge in the coming weeks. We have ramped up testing.

8:11

So we have greater capability and understanding of the epidemiology not only in the community but also to increase Hospital capacity and reduce the burn rate of personal protective equipment. So when you’ve got testing that can be turned around in 8 to 24 hours that allows you to take somebody off isolation who doesn’t need the enhanced precautions if they test negative and if they test positive we’ve got reasonable assurance that we can protect the workforce adequately.

8:42

We’re also taking steps to work with manufacturers to ramp up production either domestically or internationally in partnership with federal and state authorities so that we can get more personal protective equipment available. The other thing I’ll just mention is that we are working with hand-in-glove with our state authorities throughout the country to make sure that we’ve got other alternative evaluation side.

9:11

Sites and or places where we could do hospitalization that includes tents. It includes other hospitals that currently aren’t in use but could be brought up to speed and be in use and actually working with National Guard working with Department of Defense where we could have Mobile hospital units in place as well. So a lot of different efforts.

9:37

This is a huge public private effort that’s going to require prolonged respond great. Thank you so much Steve. Well so many follow-up questions, but one just early on you mentioned this issue of moving from containment to mitigation. And I know you and your colleague group in the journal de medical American Medical Association just about 11 days ago that it’s critically important to move from containment to mitigation. But for those who aren’t maybe as familiar with that terminology, can you explain what the difference is?

10:10

Yes, so containment is really an initial strategy where if you can Identify the cases are people that have the disease you isolate them and then you do aggressive contact tracing. So anybody who is around that person.

10:25

You also isolate those individuals and the idea there is that you are preventing any spread into the community and hopefully actually completely terminate the outbreak and that’s actually what was successfully done back in 2003 with SARS and our initial strategy in the United States was to ice Select these individuals and hospitals and what became abundantly clear really towards the end of February is that we had ongoing Community spread occurring even despite the lack of adequate testing capability.

11:01

And so once you have spread out in the community despite those containment efforts, you have to shift to directing your resources to minimizing the the spread and actually using your limited personal protective equipment resources your Emitted Hospital resources so that you’re directing the right treatment to the right level of illness. And so that’s really what an overall mitigation strategy leads us to it essentially is if you think of it scaling a larger Public Health response because you’ve got a larger problem that goes beyond containment.

11:36

Great. Thanks. I’m going to ask one more follow-up question before I turn to Polly again. So, you know, you mentioned kind of really making the best use of limited Hospital resources scaling them up to where its most serious earlier on you mentioned CDC guidelines were using extended use as a personal protective equipment and on the CDC website, they talk about different layers of capacity.

12:02

They talk about conventional capacity contingency cuz City crisis capacity and they’re pretty clear that sometimes in a crisis capacity that any use of the PPE or the personal protective equipment may not be in line with three of our ideal standards of care. Do you think do those guidance guidance has keep changing in light of the supply shortage. Do you think hospitals will ultimately be able to get the supplies that they need? What is that interaction? Like?

12:32

Yeah, so I think that right now having all of those Those options available to us is critically important you see some of the the early interface with the virus and what’s happening in New York and the ability to flex regulation whether it’s the hospital infrastructure, whether it’s the personal protective equipment guidance and whether or not we need to flex in terms of personnel and how they’re being deployed and I think we have to have all those levers in place.

13:06

Because we are going to need to be able to essentially if you look at the models when it comes to what a surge might look like even with optimal mitigation strategies on the public health sector side.

13:20

We’re going to need to be able to increase Hospital capacity by two three or more times to be able to provide the care and and we do need to be cognizant of even if you haven’t been been in a Locale that has been hit by the virus in a significant way. This is the time now to basically be on wartime footing for preserving that personal protective equipment are hope based on the fact that China is starting to ramp up manufacturing. There are sites that are now beginning to come back online that by late April early.

14:01

May will start getting resupply from China, but we’ve got to bridge that gap between now and then Great. Well, thank you. Thank you for that Insight. So I’m later. I want to ask you about telemedicine but I want to ask Polly, you know, Steve mentioned expanding capacity through temporary tents or hospitals or just kind of building up that capacity. But even if you expand that how do you stack them sort of from a from a workforce planning perspective, you know, if we face that downward spiral there aren’t enough people. What are some ways to mitigate those potential provider?

14:42

As little people have to come out of retirement. What is being done around the country? Right? So I think Steve spoke to what Healthcare organizations and even in these of Kaiser Permanente because vertically integrated payers as well our animal I’m there, but it’s really interesting to think about what state it’s going to do.

15:05

What accrediting organizations can do what educational institutions can do the licensure in Allure is an important lever. So outside of the health system itself. You have all of these organizations that manage kind of bureaucracy in the healthcare Workforce and much as Steve indicated within the healthcare organization. We need greater flexibility at that level as well. So some of these measures I think our emergency fixes and some are sort of things that we probably should have been working on all along and they’re more long-term Solutions. One of the things we should have been.

15:42

You want all along but we need to emerge, you know, sort of an urgent sense. The dress now are issues around expanding scope of practice that is done at the state level legislatures level.

15:54

And for the most part the public has been aware of the discussions around the the the expansion of scope of practice for advanced practice nurses, but they’re also really important expansions available for pharmacists and for Respiratory therapists and for Clinical Laboratory people for Paramedics for LPNs for CNAs all of those kinds of members of the team can potentially do more when they’re chained up and so having that authorization for healthcare organizations to be able to use it for snow and that way is a really important lever. The second sort of large area is Expediting licensing.

16:33

And as you mentioned we can do that with retired Personnel, although they may be elderly and me may be more at risk and that may not be as Advisable but certainly there are a lot of health professionals that do not work in direct patient care that could be mobilized and that may be renewing licenses. It may be issuing lab since has across States in a temporary manner. There are also opportunities to use international professionals may not be licensed in this country that could receive emergency licenses.

17:08

And of course is the whole sort of army of students that are graduating this very year on nursing students about a hundred fifty seven thousand. We have the Physicians that are starting their residencies. There are all kinds of opportunities to mobilize that Workforce with temporary licenses as well. You can have for example nursing students that haven’t graduated could be operating as LPNs.

17:37

You know LPNs and haven’t graduated could be operating is the amazed etcetera. So there’s a lot of room for creativity there, but it involves leadership on the part of the licensure bodies in coordination with or in response to the needs of the healthcare organizations have so those are those are two large areas. I think we’re a lot could be done at the state level and at the licensure level.

18:03

Okay, so he let me ask you kind of are you looking at sort of transferring skills or you know looking at you know areas of your work force that permanent a medicine who maybe haven’t been as involved in critical care Respiratory Care. I mean are they gonna have to amp up their skills? Like, how are you looking at kind of maximizing everybody’s capacity? Yeah, I couldn’t agree more with a lot of the comments that Polly was making just now.

18:33

So at the at the state and federal levels getting the flexibility and and suspension in the form of emergency Declarations of some of the health code so that we can move towards ratios that are probably going to be changed because of the surge repurposing of staff that hasn’t had that particular training, too.

19:02

To be able to provide that in time training now before the surge occurs is critically important and that includes every single discipline whether it’s a Physicians nurses respiratory therapist on Down the Line.

19:18

We are actively developing plans for you know, for instance knowing that there’s going to be a need for more critical care being able to repurpose critical care physician so that Can provide consultation on a telemedicine basis to multiple hospitalists? They’re going to be repurposed as essentially think of them as residents that are doing critical care and then repurposing other subspecialist to backfill the hospitalist and having the Adult Family Medicine Physicians than backfilling the emergency department. So actually thinking through what does that look like?

19:59

What do the ratios look like for you know again a Doubling or tripling of what would be a normal hospital senses and working in these different conditions that I was referencing earlier and then repurposing the the nursing Workforce and training them up and working at this these different ratios and then having extenders do some of that work as well.

20:22

If you think about it what we’re finding with the telemedicine work on the outpatient side is that we’re going to have a found Workforce so Before even moving to the retired Workforce taking your existing Workforce that is you know right now in the moment, they have the training they have the licensure and then moving them to Alternative settings that they might otherwise not have been doing before is going to be critically important the other thing. I just want to point out to use. This is not just the hospital Centric strategy. So we’ve got to be thinking about skilled nursing facilities and what immediately comes to mind.

21:02

is the initial experience in Kings County up in Washington state where a lot of the morbidity and mortality was centered around a particular Skilled Nursing Facility and so repurposing either the Skilled Nursing Facility so that we can provide the care there with the appropriate PPE and and or training or actually using alternative sites like hotels to provide skilled care there or post-discharge care out of a hospital is Be critically important. Thank you. And and we’re already getting some questions coming in from the audience, which is great. So, please keep them coming and Steve and Polly is you’re both talking you’re answering some of them but just really quickly on this Post Acute piece or the post-discharge. How does that impact your ability to actually kind of move capacity through the the system’s if the Post Acute settings aren’t ready, you know, is that something that you’re looking?

22:02

cat Yes, and and our early experience has been exactly that that you know, skilled nursing facilities and or just Post Acute Care settings are are not inherently prepared to take care of this sort of complex need for isolation and just increase the amount of infrastructure that needs to be in place. And so again working with your State Health Systems is critically important.

22:33

Oughtn’t to make sure that you’ve got those pieces in place and again its infrastructure its people and in many cases if you think about it and I’ll just call this out we have actually again other found capacity.

22:48

A lot of Ambulatory Surgery units are now closed, you know, a lot of other sites that are providing, you know outpatient procedural care are now closed so taking that found staff and repurposing them for These skilled post-discharge needs is going to be important and that requires again public-private coordination.

23:14

Great. Thanks. So I want to turn to a question from from the audience which is about how we can ensure that Frontline workers know the latest and most correct information and you know how important is disinformation and confusion over covid-19 in that regard probably do want to take a first crack at that question.

23:36

Well, I’m certainly hearing a lot of concern from Frontline workers that are feeling as though both from the perspective of the CDC guidelines. And from the absence of sort of issuing new OSHA’s infectious disease specific standards is distressing to them. I think you know as Steve said the fact that the knowledge base is evolving very quickly.

24:00

And so a lot of this is also at the level of the healthcare organization and and you know who has sort of issued a list of what they call Health worker rights and you know foremost among them is just the right to be kept informed and I think this issue no continually naughty just the training but just continually updating the Frontline staff about sort of the you know, what is happening in terms of the science what is happening in terms of the conversation about how the guidelines should be flexed as DC.

24:34

Add it’s just really important to engage Frontline worker in this engage the representatives in it. And I think that ensure the Kaiser Permanente has a terrific relationship with their work who organizations but not all hospitals do and there’s more conflict and and I think there’s a lot of distress and particularly among the nursing Personnel about this perhaps less. So among physician staff Jose VAR there.

25:01

I defy a chime in on that one because this is a Really important important point that Polly is Raising. So, you know when I have talked about the pandemic, they’re really to pandemics that were dealing with there is one that is of course the one we’ve been just talking about the virus itself. And then there’s this other pandemic of fear and you know, we’ve seen it in the community and we see it, you know reported every night on the news, but you know healthcare workers are not immune to it.

25:34

And so there’s a critical piece to being successful with this which is communicating in a clear honest and direct fashion. And actually we have learned that you need to do this via multiple modalities. So it’s by video. It’s by email.

25:50

It’s by in person unless less so now because we’re doing social distancing but you know town halls and in fact later today, I’m going to be doing a town hall for for all our workers to address exactly what Ali was talking about they need to understand that we respect their rights engaging with labor.

26:10

If you have active labor unions and being clear and transparent with them is critically important and then actually being honest about the fact that the the data the science is changing and so being able to explain that in a clear manner is critically important so I can’t stress enough for all of you that are on the line that Locations are are clearly Paramount and you can’t over communicate.

26:44

Eight. Thank you both for that question. So we’ve we’ve heard a lot about telemedicine lately and Steve you mentioned some of the ways are using it. We’ve got a few audience questions about it.

26:56

How how are you using telemedicine and especially are there any remaining barriers to leveraging the power of telemedicine in this response, you know, there have been some changes in the Medicare program, but what more needs to happen to fully take advantage of this technology Yeah, sure. I think that you know, I know there’s still work being done at the federal level to open up even more Avenues of being able to provide telemedicine across state lines. And of course there are state level regulations that need to be dealt with I think the initial flexibility that has been provided is critically important. We’re going to learn a lot actually many of the traditional doctor.

27:44

A office visits and and or ancillary provider visits advanced practice provider visits. I think we’re going to learn can be done by telling mess and in the future.

27:57

The other thing that I want to mention here, is that what we’ve done and and I would encourage other health systems to do is that a lot of the routine screening the mammograms the cervical cancer screening the Colon cancer screening not the diagnostic procedures. But the ones that are screening we’ve actually suspended those for now again to increase the social distancing as is possible. And for some of the colon cancer screening you can do it still virtually. You can send them a fit kit or a card in the mail and they can mail it back in rather than doing the colonoscopy. So you don’t actually have to completely suspend things. So so opening up our minds.

28:44

And two more in different innovative ways of doing the care I think is going to be important. The other thing I’ll just call out here also is the ability to do video visits. So we’re not just limited by telephonic means and I have to say that we have seen incredible uptake of this.

29:03

So we’ve over the last week seen a 500% increase in the number of video visits that we’re doing welcomed both on the provider side and Patient side. So again, I think that we have not fully. We’re just learning here. I mean, we’re literally going to understand much better about what the what the practice of care delivery in medicine looks like coming out of covid-19.

29:33

Dean great. Well, thank we have about one minute left. And so what I’d like to do is ask each of you to maybe share one thing that we should be watching for in the next week as we all continue to watch this unfold.

29:52

Yeah, I would I would say in particular we should be ensuring that the nursing Staff feel supported and appreciated by not just their employers by the public at large often time nurses are victims of gun violence at the hands of patients. And this is a time where we really need to honor our health workers and express our enormous gratitude towards them.

30:19

I think that that We go a long way towards Shoring up the emotional resources. I think we you know, there’s a danger that they could be a mass Exodus people don’t have to show up at work and they won’t show up at work or they don’t feel supported and safe.

30:37

So it’s really important to be supporting our Frontline staff.

30:42

Holly fave and what I would say the thing we need to look out for is the the public health response and and continue to bolster it, you know last night when I got home. I heard some news reports that you know, perhaps we should be thinking about backing off social distancing backing off some of the critical Public Health measures.

31:08

And so I think what we need to actually bolster is The opposite that we need to double down on the work some of the comments I heard from the New York Governor resonated with me that you know, in fact the social distancing is our first line of defense. We need to continue that we need to ramp up testing so that we can have a more targeted approach to social distancing. But until we do that we’ve got to hold the line when it comes to the basic public.

31:42

up measures Right. Well, thank you both so much for joining us. He’s prudie and Polly Pittman to talk about health care capacity and protecting Frontline healthcare workers. Thanks to all in the audience who asked questions. I know we didn’t get to everybody’s question. But hopefully we can address some of those in future webinars a recording of the webinar will be available on our website soon. So thanks again and stay tuned for future webinars in this series where we will be addressing some more of the supply chain and other questions that have been discussed.

32:15

Today even poly. Thanks so much again for joining us.

32:21

Thank you Sarah. Thank you.