Providers in emerging COVID hot spots face complex set of challenges

As COVID-19 cases surge across the country, hospitals and clinicians in emerging hot spots are faced with similar challenges that their peers in New York and Washington and other states dealt with in the early months of the pandemic.

Shortages of personal protective equipment and inadequate access to diagnostic testing persist, but the providers in the new hot spots are also dealing with the added complexity of a worn-out workforce and caring for patients and balancing COVID cases with the need to bring back non-emergent procedures. 

"I think the biggest challenge people are experiencing is fatigue. And it's not physical fatigue, it's quarantine fatigue, mask fatigue, fatigue around washing your hands," said Dr. Tony Slonim, president and CEO of Reno, Nev.-based Renown Health. "I mean, it sounds ridiculous, but people are tired of being asked to do things they don't want to do and they're not acting rationally, You see this on the internet."

At the same time, the new hot spots have had the benefit of experience and learning from peers and the time to re-examine how they treat COVID patients, keep staff safe and conserve resources.  

“We are much more conservative about putting patients on ventilators” now compared to the beginning of the pandemic, said Dr. Marcus Schabacker, CEO of ECRI, a non-profit organization that works to improve patient the safety and quality of healthcare. “We are finding other ways to supplement oxygen.” 

Modern Healthcare talked with leaders in a number of emerging hot spots. Here are their stories.

Dr. Catherine O’Neal
Chief medical officer
Our Lady of the Lake, a nonprofit healthcare ministry in Baton Rouge, La.

On what’s changed since the first COVID-19 hospital admissions: We learned so many lessons. The first and I think the biggest impact for the patient is that we stopped intubating and sedating patients so heavily. In critical care, intubation is a risk and sedation is a risk. But at the beginning of this, there were some articles coming out of Europe that said that’s what we should do, and because it was such an unknown, we did that. It took about a week before sanity hit and we realized that these patients are just like any other patient with sepsis … If you don’t intubate them early, then you don’t have to sedate them and paralyze them, and that equals a shorter length of stay and a lower mortality. We are saving lives today by just applying that medicine that we knew worked but we thought this virus was so different, and in that respect it’s not.

On persistent challenges: What hasn’t changed and what we all thought would be a non-issue this far down the road is access to a reliable testing supply. I am still spending too much of my day every day trying to figure out how to get testing, how to get a quick turnaround so we know what you have when you come into the door and we can put you in an appropriate room with appropriate PPE. We recently submitted a paper for publication looking at how much PPE you burn when you have a delay in test results, and it’s extraordinary. If we want to be efficient with our PPE and keep our supply in this country adequate, one of the best ways to do that is have adequate testing, and the fact that we don’t three months later is one of the biggest hindrances to continuing medical care for everybody.

Janet Hadar
President
UNC Hospitals, Chapel Hill, N.C.

On testing: Just (recently), the state of North Carolina is no longer requiring a doctor’s referral to get a COVID-19 test, so we are already seeing an increased demand for testing. Now we are having to think about how to screen with more scrutiny. Wait times are increasing because we are having to manage those who don’t necessarily need (a test).  

On redeploying staff: The response across the board has been one of terrific collaboration. Nurses are now rotating in and out of the COVID units just so caregivers in that area can have a break. It’s both emotionally and physically draining. And you know the stress isn’t just on our caregivers. I was down in our kitchen last week, and I was reminded that our cooks are in front of hot grills for eight hours wearing masks. They do it and they do it with a great attitude, but it has impacted every aspect of our workforce. 

On staff fatigue: In March, everyone, myself included, expected this quick spike, like what we were observing in New York and New Jersey, but we soon came to realize that this is going to go on. We will have COVID patients here in a year’s time. They are sick, many of them are quite sick, and it adds to the ICU burden. We were quite a busy medical center prior to COVID, running between 90 to 92% occupancy, and as we returned to more scheduled care, we are right back to that same occupancy. It's busy. There is no downtime when you come to work here.

Cathy Denning
Group senior vice president of sourcing operations 
Vizient

On the PPE shortage: Hospitals and caregivers are really making do with what they have vs. having what they need, and so there is a concern about the extended use of products and the reuse of products. They have put processes in place to make sure that they make the most out of the inventory that they have, but certainly there are some areas of the country that do not have what they perceive that they need.

On changing up the supply chain: Who would have known that the swabs that we are using to do the COVID-19 testing in the nasopharyngeal cavity were predominantly made in the Lombardy region in Europe? And what was the epicenter of the European COVID-19 epidemic? It was the Lombardy region. That virtually shut down manufacturing of those products, causing a global issue. Coming out of this, one of the things that we will advocate for through our bid process is expecting suppliers to be transparent, but also working with federal agencies that have some sway, asking suppliers to, as part of their regulatory requirements be transparent about where products are made, where the raw materials come from, and how many stops does a product take between the place that it’s finished and the time it gets to the member dock…Even if it’s made in another country, making sure there’s adequate inventory here in the United States and having U.S. warehousing available (is important). Everyone in their emotions believes that onshoring manufacturing is the only solution, and quite truthfully, we couldn’t do that if we wanted to. We don’t have the manufacturing capacity.

Dr. Marjorie Bessel
Chief clinical officer
Banner Health in Phoenix

On staffing: We are using an external staffing crisis agency to bring hundreds of nurses and respiratory therapists to us to assist in staffing to meet the needs of the surge we are experiencing … We are well over 1,400 (positive or suspected COVID-19) patients per day at Banner, and what we found is the COVID patients are very labor intensive … One COVID patient doesn’t equal the labor intensity of what one patient pre-COVID was like. It’s an additional burden that is also putting stress on our staff.

On supplies: We expect the supply chain to be disrupted for some period of time. We are only in the first wave and we have every expectation there will be a second wave, (which) is likely going to be no better and possibly worse than what we are currently experiencing. Our most difficult issue right now is isolation gowns. We are going through about a million isolation gowns a month at this time, so we are being creative in that space. (We are going back to the previous decades) when we used to have cloth gowns and you would launder them. We have piloted that in a couple of hospitals and it has been really well received by our employees.” 

On preparing for the surge: We had the luxury of time to put plans into place and those plans are having to be pulled off the shelves and implemented … (The downside to that) is the community, and society in general, feeling like it wasn’t going to come to us, that we could be complacent about CDC guidelines. There is some fatigue around it. I want my life to go back to pre-COVID also, but it just isn’t in the cards for us. We still have a long way to go.

On using triage only as a last resort: There is a lot of misunderstanding that we have people not getting ventilators who need them and that is not the case. We absolutely have plans in place to do triage if it were to get to a point like that … (but) we are committed to doing everything we can not to get to that. The healthcare systems are working collectively in the state so no one system would get to such a dire situation that would have to do something like triage. We are committed to sharing the load and if we have to do a triage situation all of us in the state would do it at the same time.

Dr. William Jaquis
President
American College of Emergency Physicians and attending physician at Aventura Medical Center in Florida

On ED volumes: We (recently) had this tremendous influx of patients and we want everyone to come who needs to come, but now we also see sick COVID-19 patients as well. I think for many of us the difficulty is we don’t see where the end point is. You see the resources dwindling. We talked a lot in the beginning about flattening the curve … but now we just see that slope going up and up and up again. 

On supplies: We are doing OK not but if we continue at this pace, we will exceed what we have in many places, not just South Florida but also across the country.

Dr. Vian Nguyen
Chief medical officer
Legacy Community Health, a federally qualified health center, Houston.

On new challenges: At the beginning of the pandemic, there was a lot of focus on education, learning about the virus, and then how to protect our patients and staff. What I’ve noticed over time… is that those things are still in the forefront, but an added layer of complication to all of this is that a lot of staff are getting sick. So not only are we still managing education, and keeping our patients safe, we're dealing with staff shortages. And (access to) PPE, which has already been a top priority in terms of trying to get what is needed to have our staff be safe in the clinic, is compounded by so many other businesses outside of healthcare also trying to get the same supply. It feels like a really long nightmare.

On telehealth: A fortunate tool during this pandemic is the ability to have payers and patients both be more open to technology. For those who we are able to convince that telehealth is a good option and a comparable option to coming to the clinic, what we've seen is convenience for patients. They don't have to get in the car, fight traffic, or worry about coming in late, and so our no-show rate for those types of visits seem to be lower than what we had seen prior to our ability to do that. Coming out of the pandemic we will learn that telemedicine is something that should stay in our healthcare system. We already feel some challenges there. We've gotten emails about how certain payers are going to stop covering telehealth visits at the end of July, at the end of August, and it really does feel very backwards to not embrace a technology that has actually helped us come out of this pandemic.