The advent of new COVID-19 cases in the U.S. who lack identifiable travel history or exposure, signals community transmission of SARS-CoV-2. This has led to a need for changing how hospitals and health systems approach the COVID-19 pandemic. For The Permanente Medical Group (TPMG), it meant changing their strategies for slowing the spread of COVID-19 from containment to mitigation.
“Without rapid uptake of new approaches to care across hospitals, COVID-19 will pose a critical risk to an already strained health care system,” said Stephen Parodi, MD, in a JAMA viewpoint article, “From Containment to Mitigation of COVID-19 in the US.” And in a recent video interview with JAMA Editor Howard Bauchner, MD, Dr. Parodi discussed telemedicine, staffing revisions, equipment allocation planning, and other strategies for mitigation.
In a discussion with AMA Health System Program Partners, Dr. Parodi, associate executive director of The Permanente Medical Group and national infectious disease leader for Kaiser Permanente, shared key frontline strategies they are employing, particularly to address shortages of personal protective equipment (PPE).
Kaiser Permanente in Northern California includes 21 hospitals and has an average daily census of 3,000 patients for the entire system, with 216 individuals who are either COVID-19 confirmed positive or are awaiting results.
Reducing nonessential foot traffic
One of the key strategies is to reduce all nonessential foot traffic in medical buildings, which not only helps mitigate opportunities for the spread of the virus, but also helps to preserve PPE.
“Given the widespread community transmission that’s occurring in Northern California, we would use all our personal protective equipment within about two weeks if we didn’t significantly reduce the non-essential foot traffic in our medical centers,” said Dr. Parodi.
To curb foot traffic, TPMG is encouraging patients to take full advantage of the telehealth options that are available for specialty and primary care practices, which is having a positive impact. Video visits for primary and specialty care, for example, have doubled in the past week and increased by more than 150% in the past 2 weeks, and as of March 16, the Call Center was booking 92% telehealth appointments for primary care visits. At the same time, there has been a 40% reduction in the number of surgical and specialty in-person visits over the past two weeks.
Adjusting protocols for call centers
TPMG has also modified protocols in the call center to triage individuals who choose to stay home and call in to access their care, rather than going into the clinical setting. As of March 1, the call center had received an average of 3,900 calls a day across Northern California. This has increased to 11,900 calls a day.
About 98% of these calls can be handled at the call center level, said Dr. Parodi, adding that they have been able to reduce the volume of patients coming into the clinic significantly. The remaining 2% of calls can be handled by their individual physician with a telephone or video visit.
Creating a “sick, not sick” triage
If a patient does present to a clinical office, TPMG has deployed “greeters” who use a “sick, not sick” triage approach to determine whether a person requires face-to-face care from a physician.
“They are redirecting them to an area, typically it’s a tent that is staffed by individuals who are trained to don the PPE,” said Dr. Parodi. “They’re able to keep the respirators and other separate precaution gear on for the entire duration of their shifts.”
These individuals will switch out when they need relief from the shift and are changing their gloves and washing their hands between patients.
With school closures, the switch to telehealth also has been important in terms of preserving the workforce, as many physicians and other health care workers can continue providing telehealth from their home.
The Permanente Medical Group has leave policies in place, as well. By activating these policies and sharing messages about this, it has allowed physicians and health care workers to provide and receive necessary childcare. “Making that switch sooner rather than later is important,” said Dr. Parodi.
Even if an organization or medical practice has not cared for a patient with COVID-19, it can be an extremely stressful situation, because of the anticipation of what might eventually happen, said Dr. Parodi. The employee assistance program has been on site to help, but it is also important that leadership be available through phone calls and consistent communication.
“We’re having frequent town halls and answering questions, and it’s been amazing,” he said, adding that a level of transparency around this “ever-changing situation” and saying, “we’re here for you” helps curb stress in these events.
Reusing N95s per CDC guidelines
To continue to provide proper protection when caring for patients with COVID-19, The Permanente Medical Group has moved to using the CDC protocols for reuse of N95 respirators and have provided the necessary training for their health care workforce to be able to implement this.
“We’re looking at preservation of PPE in a holistic fashion,” said Dr. Parodi. “Ironically, we have about the same number of N95s as we do surgical masks and isolation masks that you would use for droplet precautions.”
Opening a second ICU
A San Jose hospital has been particularly impacted because of two families who have been “super spreaders” of the infection, said Dr. Parodi. An entire ICU at this hospital has been filled with COVID-19 patients with 10 on ventilators and two deaths despite a rapid response.
This resulted in opening a second ICU and bringing in additional ventilators. This allows for a venue of care and creates a floor that provides PPE in a “resource stewardship fashion to be able to respond and also bring additional ventilators to support” patients with COVID-19 and regular care for others who need ventilator support.
Freeing up ventilators
Because of the acute need for freeing up ventilators, The Permanente Medical Group is postponing elective surgeries, which gives additional hospital capacity of about 10% and frees up ventilators for critical care services.
The opening of a second ICU has doubled the capacity of ventilators available. It has also allowed for ventilators to be repurposed for the critical care units.
“We have also worked with our hospitals to evaluate and determine whether we need to purchase additional ventilators to accommodate what we anticipate is going to be a surge,” said Dr. Parodi.
The AMA and the Centers for Disease Control and Prevention (CDC) are closely monitoring the COVID-19 global pandemic. Learn more at the AMA COVID-19 resource center and consult the AMA’s physician guide to COVID-19.