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MARCH 20, 2020 -- With the San Francisco Bay Area already mired in coronavirus cases, the lead physician for Kaiser Permanente's national coronavirus response shared advice on sorting patients, preserving PPE supplies, protecting staff and patients, and optimizing resources.
"It's time now to scale," Stephen Parodi, MD, said in an online interview Thursday with Howard Bauchner, MD, JAMA's editor in chief.
"Open your surge plans up and get them going. Even if you haven't seen it in your community yet, it will be there, and you need to be ready," said Parodi, an infectious disease physician in Oakland, California.
He described the experience at Kaiser's hospital in San Jose, California, in which "almost half the hospital is filled with either COVID-confirmed or persons under investigation."
"We have filled one entire ICU just with COVID patients," he said. "That means we had to repurpose another unit to take care of the regular ICU patients."
Greeters Sort "Sick" From "Not sick"
Bauchner asked how the hospital is sorting patients when someone comes in with respiratory symptoms, a cough, and a fever.
Parodi said that telemedicine options have greatly reduced the number who come to a facility, but when they do come, trained greeters are in place to screen for symptoms.
If the person is deemed "not sick" they go to a designated "clean" area in the clinic or the emergency department. Those who are sick are taken to a tent or a particular area where healthcare providers are already wearing personal protective equipment (PPE), Parodi explained.
"Essentially, it's a triage method," he said, which should reduce healthcare worker exposure and preserve PPE.
He said many parts of the country will soon have access to automated testing for COVID-19. But for now, most areas are limited by manual testing and the availability of swabs. He said Kaiser is working with the local public health departments to get more.
Because of the surge of patients, Kaiser has moved toward cohorting patients diagnosed with COVID-19 and those suspected of having COVID-19 on one ward. Two patients who are confirmed to have COVID-19 and not known to have other contagious diseases can share a room, he said.
This can even hold true for two patients on ventilators in the ICU, according to Kaiser's surge plans, Parodi continued.
That allows healthcare workers in that ward to don the PPE before they open the door and go from patient to patient, thus allowing for reuse of PPE, while following Centers for Disease Control and Prevention (CDC) guidelines, and thus preserving the PPE supply.
"We've already moved toward N95 [mask] reuse, extended use," he said. They are also using stockpiles of expired masks under CDC guidance.
He emphasized that hospitals must have a protocol in place to make sure that when a patient is screened and has symptoms, he or she is masked at the point of entry.
"Let's say they are clinically deteriorating and need intubation, then we're using airborne precautions — you're wearing a PAPR [Powered Air-Purifying Respirator] or CAPR [controlled air-purifying system along with eyewear]."
ICU Surge Comes Quickly
Parodi warned that the surge comes quickly and that in the San Jose facility, they went from zero COVID-19 patients in the ICU to 10 in one week.
"You've got to be prepared for that level of surge," he said.
Parodi said their short-term experience is that patients are requiring 10 to 14 days on mechanical ventilation. With that, he is concerned about the current and potential supply of ventilators.
The Italian experience indicates it will take mass triage to determine who should get the ventilators, he said
"A lot of these individuals we actually saw or heard from on the outpatient side a week before. They were relatively doing well, they had a cold or cough, and they rapidly deteriorated in a second," Parodi said.
He said that trend is also happening on the inpatient service when people are sick, but stable, and then rapidly deteriorate over hours and need to be transferred to the ICU for intubation or rapid response.
Some in Their 30s and 40s on Ventilators
Kaiser, which cares for 12 million patients nationally, has seen patients in their 30s and 40s who have required mechanical ventilation with COVID-19, in addition to people in their 70s and 80s.
"I've been surprised about that," Parodi said. "Twenty percent of the patients don't fit the classic cohort described in the Chinese data."
As for mortality rate estimates, he said that until more testing becomes available, he can't give accurate data on what they're seeing thus far.
As with other facilities, Kaiser's supply of PPE is already strained. "We've got to be planning for the next month to 6 weeks."
As such, the team is coming at this from several fronts, starting with reuse and extended use of PPE, cohorting patients with COVID-19, and canceling elective surgeries.
"We were looking at [about] 5 to 10 days on hand of PPE, but taking all of those steps, we've now got more than 30 days of PPE on supply."
He said they are also turning to hardware stores and other local sources to replicate PPE from nontraditional materials.
In addition, they are using baby monitors in rooms with COVID-19 patients to minimize healthcare providers coming and going from rooms, thus preserving PPE. For example, a physician can virtually examine a patient by talking with another practitioner who is physically in the room.
Parodi said it's important to support all providers and staff with "aggressive communications" to explain what you're doing and why. Training by video or other means on PPE is also critical.
Spelling people and reassigning roles is also important, he said.
One ICU strategy Kaiser is using, he said, is turning intensivists into attending physicians and having hospitalists serve as residents. "That allows for intensivists to cover more beds and actually gets their expertise and eyes on more people."
Parodi added that providers may need to be moved to different roles because of their own vulnerabilities to the virus or because they are more essential in a call center, for example.
In an unprecedented move at Kaiser, Parodi said, they've increased working from home for a healthcare workforce.
"Typically this time of year, we get about 4000 calls a day regarding cold and cough. We're now getting 14 to 15 thousand calls a day," Parodi said. To handle all those calls, they repurposed some of the primary care workforce and had them help take the calls from home, which reduces staff exposures.
"This is a staggering number," he said, "but 99% of the individuals are able to be triaged to be at home."