COVID19 April 21

Hope and advice from the frontlines of the COVID-19 pandemic

Medline gathered together healthcare providers from areas of the country that were hardest hit in the early stages of the COVID-19 crisis to share their experiences and lessons learned.

Perspectives from Leonard Russ, Principal Partner, Bayberry Health Care in New Rochelle, NY

Located in Westchester County, about 30 miles north of New York City, New Rochelle was the epicenter of the first case of COVID-19 identified in the state of New York. A hospital patient who was admitted to Bayberry Care Center (a short- and long-term rehabilitation center) later tested positive for COVID-19, exposing all the patients and staff.

“Right before the COVID-19 outbreak hit our area, it was although we had a sense that a Tsunami was coming. But there was also a sense of denial about it,” Russ said.

And then it happened. A lawyer living in New Rochelle – the same town as Bayberry Care Center – was the first person in New York State to test positive for COVID-19. Russ said the National Guard was called in and surrounded a mile-wide circumference around the lawyer’s house.

“The next thing we knew, we had admitted a symptomatic patient from the hospital to our facility, and within a few days, that patient became very ill and tested positive for COVID-19,” Russ said. “By that point, everyone in our building had been exposed.”

Next, the New York State Department of Health came in and tested all staff and patients at Bayberry. Russ said he was shocked by the large numbers who tested positive, including the director of nursing and the medical director. All staff who tested positive have been furloughed until they recover.

Two of the patients who tested positive were later hospitalized with pneumonia, but both have been discharged and are recovering.

“Some of our staff who tested positive actually became more ill than our elderly residents. We didn’t know previously, but they had co-morbidities, which we know puts them at greater risk. A couple of them had to be hospitalized,” Russ said.

All staff who tested negative are being screened for vital signs (temperature, blood pressure, oxygen level) each time they come on shift.

“It’s been three weeks, and we have only had one additional person who tested positive – after having tested negative initially,” Russ said. “We’re monitoring patients closely, and I’m thankful there are no new cases there.”

Staffing concerns

“We already faced challenges with staying fully staffed before the outbreak, so now having to furlough staff who tested positive has exacerbated the problem exponentially,” Russ said. “The remainder of our staff is putting in an incredible amount of overtime.”

Despite the risks, Russ said staff are showing a sincere willingness to continue to come to work. “They have an emotional connection and commitment to their patients, especially those who have formed long-term relationships with our residents, some of whom have been with us a number of years.”

Maintaining morale

“We’re trying to do as much as we can in terms of quality of life for our residents. It’s been all hands on board for moral support,” Russ said.

Friends and loved ones are not allowed to visit under sheltering in place initiatives, which makes it more difficult for frail elderly residents who are already dealing with health issues outside of COVID-19.

“There’s a fear factor for them,” Russ said. “We’re caring for the greatest generation. They’ve seen hard times. Our generation really has not, so this pandemic is a rude awakening to us.”

Infection control and optimizing PPE

“Amidst the outbreak in our facility, we’ve had to adjust to strict infection control protocols that require a lot more work to maintain,” Russ said. “We also know that use of PPE is so critical; not having enough supplies will just compound the spread.”

Russ mentioned that his facility has been relying on county, state and federal support to maintain PPE supply inventories.

“At this point, we get down to about a 12- to 18-hour supply before getting replenished. Thankfully have not run out yet,” Russ said. “We just keep replenishing every couple days and planning for the next replenishment at all times. So far we have been able to maintain protocols.”

As a backup measure, Russ and his staff stocked up on cloth patient gowns to substitute for staff PPE gowns in case they run out.

“Fortunately, we have not run out of masks. And we’re reserving our N95s for treating patients who have tested positive,” Russ said. “It’s a constant struggle to get hand sanitizer and disinfecting wipes, and there’s no end to the struggle in the near future.”

Many unknowns

“I’m concerned about the timing of hospitalized patients being discharged to the facility COVID positive. There’s no solid predictor of when the disease begins to resolve. Only another test would indicate if the person has stopped shedding the virus. And it’s virtually impossible to get anyone inside or outside a hospital tested twice,” Russ said.

“We’re trying to have hospitals keep the COVID positive patients longer than two or three days after the onset of symptoms to ensure that even if they are not yet resolved, they have at least turned the corner toward recovery before being discharged to a skilled nursing facility.”

Of course there is also the balance of freeing up beds for the sickest patients. Russ said some rehab facilities with empty beds and additional capacity are being considered as areas for COVID-19 patients to continue to recover after hospital discharge. His hesitation is the unknown as to whether these patients could still spread the illness.

“Another idea under consideration is to convert single homes within multi-facility systems as dedicated COVID-19 recovery sites,” Russ said.  “It’s an evolving situation and things continue to quickly change.”

Staying positive

“It’s my mission to keep our patients, residents and staff healthy,” Russ said. “My director of nursing and medical director are quarantined after testing positive, so a lot rests on my shoulders right now.”

We’re taking it one day at a time, and thankfully our patients who tested positive are surviving. We’re on wartime footing, and just waiting to see when all of this will end,” he added.

“We’re hoping, praying and doing everything we can to make sure they get through this. It’s not necessarily a death sentence.”

Perspectives from Brent Korte, Chief Homecare Officer, Evergreen Health, Kirkland WA

The first person in the United States to die from COVID-19 was a patient at Evergreen Medical Center, one of two hospitals within the EvergreenHealth system.

“The five weeks following February 28 seemed to be both the longest and shortest period of my career,” Korte said. “So much happened in such little time.”

He was at home with his 9-year-old daughter as she was getting ready to go to sleep, when he received a call from his manager.

“She told me there had been a death in the critical care unit – the first person with COVID-19 to die in the U.S. He kept thinking, “How on earth did the first death happen here?”

Korte said he knew he had to face the issue head on – his heart filled with compassion and his mind following all available scientific evidence.

Korte and other leaders from across EvergreenHealth immediately propped up an Incident Command Center, working nonstop all weekend until it was up and running. They were thankful they knew exactly what to do, having received extensive disaster preparedness training because of their location in a region susceptible to severe earthquakes.

“Immediately, we knew we had to protect staff and the community,” he said. He wrestled with the reality that those two missions can seem diametrically opposed to each other. He also realized there are no perfect answers in times like these.

Managing limited supplies

“We’re having to make tough choices in order to conserve PPE,” Korte said. “We’re having to become immediate experts on supply management.”

Here’s his advice:

Planning is vital. Keep the lines of communication open with your staff and supply vendors.

Get your PPE and immediately make a plan on how to conserve it. “We’re measuring supplies in terms of days, even hours of supplies left.”

Get creative. Korte shared how they had no shoe covers, but staff needed to be covered in PPE from head to toe before entering community family centers that house six or more seniors.

Their solution was to sanitize their shoes with rubbing alcohol. With lack of availability from their supplier, they sought help from a local craft distillery that had converted their operations to distilling isopropyl alcohol. They also needed to locate misting spray bottles so they could spray their shoes with the alcohol.

“We had to figure out a way to continue to care for the patients who need us,” he said.

In addition to tapping into local resources for rubbing alcohol, Korte shared that EvergreenHealth is making their own hand sanitizer until commercial supplies become available again.

Keeping up staff morale

Korte oversees a staff of around 600 home health and hospice employees. Here are some tips he shared to keep your staff safe, healthy and informed:

Show your interest and appreciation. “Always remember that labor is human. Healthcare workers are the true heroes in all of this. We communicate with our staff daily through emails. We do my best to answer all their questions. And there are no stupid questions,” Korte said.

Be nimble. Six hospice LPNs were not able to find work from their usual roles, so they were quickly retrained to assist home health nurses who are caring for increased volumes of patients during the pandemic.

Follow your heart. Korte shared a story about a hospice patient whose final wish was to be visited by a chaplain.  Under orders of the pandemic, the chaplain was not allowed to enter the patient’s home.

“Rabbi Sarah, one of our many excellent chaplains, worked with the patient’s daughter to come up with a solution. The chaplain stood on a chair outside the house where the patient lived and sang to the patient through the window as the patient was nearing end-of-life,” Korte shared.

Ways to stay hopeful and motivated

Evidence-based facts are your best resource. “Think with your heart first, followed closely by science. And take media reports with a grain of salt. If there is a physician, clinician, public health official or epidemiologist, listen to them,” Korte shared.

He also shared these additional words of wisdom:

Stay connected and trust in humanity. “I am a father of three, so of course my family keeps me going,” Korte said. “What also keeps me focused is knowing that the decisions we make as health care providers are going to help people live.

So many of the patients we’re seeing with COVID-19 have lived through the Great Depression and World War II. They sacrificed a lot so that we are living a good life today. They deserve everything we can give them. We owe them that.”

He added, “This is a human problem, and humans will solve it.”

Perspectives from Asa Margolis, DO, MPH, MS, Medical Director, Johns Hopkins Lifeline Critical Care Transportation Program, Baltimore, MD; Associate Medical Director, Howard County Department of Fire and Rescue Services, Marriottsville, MD; EMS Fellowship Director, Johns Hopkins University School of Medicine and Assistant Professor, Division of Special Operation, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Dr. Margolis oversees hundreds of EMS clinicians across the greater Baltimore area who have transported hundreds of patients with COVID-19 or those being considered under investigation for COVID-19 since the beginning of the pandemic.

Here are the trends Dr. Margolis has noted.

Observations from the field on how COVID-19 progresses

The Incubation period of the illness is usually four to five days, but it can range from 2-14 days.

Fever is present in about half of patients at hospital admission, and develops in about 80-90% during the admission.

Days 2-5: Patients experience flu-like symptoms such as fever, sore throat, cough, body aches. Some sources suggest up to 50% have GI symptoms including nausea, vomiting, and diarrhea.

Day 7:  The potential for clinical deterioration seems to be during the second week of illness. There is a percentage who developed shortness of breath a median of 8 days after illness onset (range: 5–13 days).

Day 9: The mean time from illness onset to hospital admission with pneumonia.

Day 10: ICU care is required

PPE best practices for EMS clinicians

Dr. Margolis advises EMS clinicians to follow these safety protocols amidst the COVID-19 pandemic and to always stay current with their agency’s medical director recommendations.

  • Most important: Don and doff PPE properly; have a safety officer train and observe personnel, if possible. Improper doffing presents a high risk for self-contamination.
  • Follow CDC recommendations and get test fitted for your N95 mask
  • If a PPE shortage exists, reserve N95 masks for aerosol-generating procedures such as airway management and for cardiac arrest since those patients should be considered a PUI (persons under investigation for COVID-19)
  • EMS clinicians should also wear gloves (two pairs, if possible), gowns, well-fitted glasses that fully enclose the eyes, or a full face shield
  • A surgical face mask should be placed on the patient to assist with source control
  • Practice impeccable hand hygiene: Wash hands for at least 20 seconds or use alcohol-based hand sanitizer
  • Practice social distancing at all times, including around the workplace

Stay strong

It’s more important than ever to keep supporting your healthcare providers. Here are his tips for keeping your EMS clinicians engaged and healthy physically, mentally and emotionally:

  • Share all knowledge and recommendations about COVID-19 openly and often with staff. Having updated information helps ease apprehension.
  • Establish a mechanism to test staff who meet criteria
  • Provide robust peer support and resources for staff and their families
  • Continually show your appreciation for staff and their families
  • Remind staff to stay in touch and keep in touch with them
  • Remind them to keep stress levels down and stay healthy with regular exercise, good nutrition and rest

“I stay optimistic myself, knowing that I’m helping those in need at the worst time of their lives. That’s why I chose to practice emergency medicine,” Dr. Margolis said.

“During this time, provide excellent care as you always do, and maintain your own health and safety so that you can continue to provide care for those who need it.”