In preparing for the coming surge of patients, Kaiser Permanente hospitals are working to shift physicians and nurses and to use telehealth in new ways to make up for the expected shortage of intensivists.
Speaking during a March 24 webinar put on by the Commonwealth Fund, Stephen Parodi, M.D., executive vice president of the Permanente Medical Group, said Kaiser is looking at providing specialty telemedicine. “There are not going to be enough intensivists to do business as usual,” he said. “But we do have intensivists who can use their knowledge to provide that to hospitalists, where we have a larger work force, to provide the critical care at different ratios than what we are used to doing in the United States.”
He said they would look to back-fill for the hospitalists who are going to be doing critical care with physicians capable of providing the subspecialty or internal medicine care for the regular hospitalized patients. “Right now, they are not doing outpatient care because they are doing telehealth. We have a bunch of surgeons in ambulatory surgery units who are not doing surgery because we have ended elective surgery, so we can repurpose those individuals.”
“As I look it, there is a found work force that is going to require coordination at the state level. We are working with governors and state departments of public health and all the health systems in an entire state, not just Kaiser, to make sure that we take the found work force that is already licensed and in use and repurpose their skills and provide them any additional training or specialty backup via telehealth to expand the ability to provide care. And it is not just specific to physicians. I am including nursing, respiratory therapy and the other ancillary staff. We are going to require state-level flexibility to break through some of the current regulatory gridlock so we can flex to a surge standard of care.”
Parodi was joined on the webinar by Ashish Jha, M.D., M.P.H., professor and dean for Global Strategy at the Harvard T.H. Chan School of Public Health and director of the Harvard Global Health Institute, who gave a nationwide overview of the shortage challenges hospitals are facing. One thing he noted was that nationally it is estimated there are about 750,000 hospital beds. Models estimate a 40 percent infection rate over a six-month period would require that we have a lot more beds than we have now, he said. Even taking into account discharged patients and cancelling elective surgeries, the country may need three times as many beds as could be made available, “so our strategy has to go beyond opening up capacity,” he noted.
The second big issue Jha noted is that the country is going to need a lot more equipment in order to take care of all the people coming to the hospital. “New York is starting to feel this most acutely,” he said. Speaking about ventilators for ICUs, he said, the best estimates are that there are between 60,000 and 100,000 ventilators in the country. “Projections we and others have done say we may need as many as 400,000 ventilators for the country,” he said.
The other big issue is personal protective equipment. “One of the big things we have seen in China and in Italy is a very high rate of infection of doctors and nurses. All the beds and doctors will do no good if there are no doctors and nurses and other healthcare professionals to staff them and take care of patients. Overall as a country, we are starting to see New York as the canary in the coal mine, and starting to get into trouble with both ventilators and personal protective equipment, as well as enough doctors and nurses and beds. But this will roll across the country over the next two to three to four months. This is a challenge I think we can rise to. There are a lot of creative ways we can meet the needs we have. But it will not happen without bold leadership at the federal and state levels and leadership at the individual hospital and health system levels. It is a big challenge, but I think it is something we can conquer.”
Parodi noted that Kaiser Permanente has been on the front lines in Washington state and California, the initial hot spots, and had some experience with the initial response with the Princess cruise ships. “What we have learned is that it is critically important that we have the right guidance around protective equipment and messaging to the front-line staff,” he said.
The second thing that has been critically important is turning on telehealth, which has contributed to the ability to have social distancing in Kaiser’s medical clinics, office buildings and emergency departments. “In fact, we are implementing some telehealth procedures in the hospital settings, so we can minimize the number of people going in and out of rooms and minimizing exposures for healthcare workers.”
He said the health system is increasingly being able to ramp up testing on the outpatient side so they can a inform models that Jha was talking about in terms of increasing hospital capacity.
“There has been a great deal of work done to increase hospital bed capacity to the levels you have heard referenced in New York,” Parodi said, both with existing infrastructure as well as additional hospitals that need to be brought online, including converting hotels. “This has been a public/private partnership at the state level with healthcare systems to bring on other alternative venues of care – having tents, having mobile hospital units available to prepare for the surge is going to be critically important,” he said.
Parodi added that a great deal of work is being done to source personal protective equipment so they have adequate supply, and while they are waiting for adequate resupply they are implementing CDC guidance to reuse and extend the use of N95 respirators and other personal protective equipment so they can cover the potential shortfall before resupply. “All those are being implemented now in anticipation of the surge coming in the next two to three weeks,” he said.
He noted that Kaiser Permanente is working hand in glove with both the CDC and the state health departments to ensure public health distancing measures are fully implemented. On a positive note, he cited some California data that may illustrate that the social distancing measures are working. “We can actually track cold, cough and flu calls into our call center. Before the social distancing measures were put in place, we were receiving 14,000 calls per day. Over the past week since California issued its strict social distancing measures, those have reduced down to 4,000 per day. I think that is emblematic of the fact that we actually need to push these first lines of defense when it comes to social distancing. These public health measures are just as important as the preparatory measures to make sure we have PPE and protection for our healthcare workers.”
