Coronavirus Update- March 6, 2020


– Hello. Hello hello. Can you guys hear me okay? Is this working? Okay. Hello. I think let’s get started,
just so we have time. Thanks for coming. My name is Dan Fulton,
I’m an infection doctor. And we wanted to have an opportunity to share what’s been
going on with coronavirus. People are obviously hearing
a lot about it in the news. Quite a few updates coming out regularly. Last week sometime I read a report, I didn’t like reading it, and it was that staff just felt
like they weren’t getting the information they thought they needed or having the opportunity to hear and ask questions and share perspectives. So what I thought we would do today is talk about coronavirus in general. Review what the current state is at. Mary Greeley and McFarland Clinic. And then talk about
some anticipated states that we may see, and then try to leave plenty of time for
discussion as we go forward. If you do have questions along
the way, that’s also great. So let’s talk for a minute
about coronaviruses in general. Why coronavirus? Why now? Well it turns out that there’s a lot of coronaviruses in the world and they infect both humans and animals. There’s now seven human coronaviruses, but there’s all sorts
of other, cat and dog and snake and other
types of coronaviruses. What can happen is if there’s humans very close with animals, and if a human has a coronavirus and an animal has a coronavirus at the same time, even if they’re different,
there may be some unique mutation and
remixing of those things that then creates something new. And that’s why we see new coronaviruses popping up from time to time. We already have four coronaviruses that circulate all the
time in our community. We’ve known about them since the late 1960s and early 1970s. They generally cause common cold virus. Sometimes they cause some pneumonia. Very rarely people get
very sick from them. But in general they’re pretty mild. Part of the reason we
know that is in the 70s we infected a bunch of
college kids with them on purpose to see what happened. (laughing) They all did fine, so these are around and our immune systems are used to dealing with coronaviruses. So then we have these new coronaviruses that have popped up
over the past 20 years. SARS was one that came out in 2002. From East Asia. Kinda a similar remixing. This caused about 8,000 cases worldwide, had about a 10% death rate. In the western hemisphere Canada, Toronto, had probably the worst of it. Then it kinda faded away. It just went away. We haven’t seen a case in over 15 years in the western hemisphere. Then in 2012 there was
this Middle-Eastern version that we think came from camels. And some remixing there. That one had about a 30% death rate and didn’t have as many total cases. There may have been
other cases that weren’t reported, but again,
that one has dramatically faded away too, it’s just not active. And now we have our current coronavirus. This one is thought to come from a snake. Kinda the snake virus, interesting. These are numbers from Monday night. They are obsolete, we’re
over 100,000 cases total now. But one thing I wanted you to notice has something to do with
the way viruses spread. A virus that has a high mortality rate, like this MERS CoV here, when people die right away, they don’t spread the virus very well. It’s kinda like Ebola,
when people die right away there’s not time for the
virus to move around. So viruses that have a
very high mortality rate often don’t spread very well. As opposed to viruses like the common cold that don’t kill anybody,
but the little kids share those viruses for weeks and weeks. They spread everywhere because
they have that capability. So one unique thing about this coronavirus is that although it is more severe than our common cold viruses,
it is not as severe, we don’t think, as SARS or MERS was. And what that is doing
is creating a scenario where it actually does seem to have the capability to really move about. That’s a big bummer, on the
other hand it’s not as severe as SARS or MERS were,
so that’s a positive. This is something else that’s interesting, this just came out yesterday. They broke it up by 10 day
intervals, this is in China. And what they’re showing
here is the mortality rate. So when this first was discovered, the mortality rate was
being reported at 14 to 18%. And then if you look over
the past several weeks the mortality rate of people diagnosed in China with coronavirus
has dropped dramatically. So we’re not looking at a 15% mortality, we’re looking at a 1%, which again, it’s still 1%, but it’s
dramatically lower. There’s a few theories
why this is happening. One is testing is becoming broader, so we’re testing a wider range of people. There’s always a bias towards testing sicker people first with a new thing, so it always looks worse
than it is at first. Also, we’re probably getting better at supporting these people. China’s had a great experience of how to take care of people with coronavirus and they’re probably just doing a better job of it over time. And the third thing is that
viruses naturally evolve. And they evolve quickly; viruses mutate. So if we have a population of 100 viruses and some of them, they’re
all very slightly different, but some of them are more likely to kill people right away and some of them are more likely to act
like the common cold. The ones that are acting
like the common cold are the ones that are going to spread. And the ones that have
very high mortality rate are the ones that are gonna
select out of the population. So most viruses actually mutate towards being less mortal over time. So this was the data from Monday night. This is the data now. I don’t have numbers, but countries all over the world are reporting cases. There’s over 100,000 cases. A lot of the countries it’s one or two, but these countries
highlighted here are still the ones that are on
the CDC travel advisory. Level two or level three travel risk. That hasn’t changed. But there are cases all over the world. In the United States, this was
our data from Monday night. So this is the data from today that’s just got case numbers for you here. So we’re over, I think we’re
at about 150 cases total. A few things to point out here. There are no cases in Iowa. And the cases in Nebraska,
these were people that were in biocontainment units, so they were actually brought in as part of a travel screening process. They were actually ill and came to a place where they could be in
appropriate isolation. Most of the community
outbreak that we’re seeing right now is in Washington, in Kirkland. But there’s cases popping
up in the community in California, in New York, Florida. I think it’s just a matter of time before we have cases popping up in Iowa. They did some genetic
analysis of the virus in Washington, I couldn’t tell you how they do this, but they were able to estimate that it had
probably been around in Washington for about six weeks already. It may have been already in
the community moving around. So what does coronavirus look like? Well how do people look? It looks like influenza, so if people are coming into your clinic and they’re complaining of an influenza-like illness, which a lot of people are right now ’cause we have a lot
of influenza right now, that’s what coronavirus looks like. That’s created obviously a big challenge for figuring out who’s at risk. Most patients have a fever. Most of them have a cough. And then a smattering of all those other influenza-like symptoms. Feeling sick, muscles aches,
headaches, body aches. It’s not really a diarrhea
illness generally. It’s more a fever and a cough illness. So of the people that ended
up getting really sick, going in the intensive care units, 60% of them had some
other health condition that put them at high risk,
like diabetes or COPD. That means 40% didn’t. People that otherwise are not ill can get pretty sick from this, at least from those initial days in China. One interesting thing
is that it seems like kids are handling this really well. Only 1% of the people testing
positive for this are kids. They must be getting it, I think they’re probably just not getting very sick. Maybe people are used to their kids having runny noses and then you put up with it, or maybe you don’t bring them in ’cause you don’t wanna expose them, but it does seem like in
terms of the data we have, this is not making children very ill. That’s good news. Maybe bad news is that I had heard some theories that people in China weren’t doing as well because so many folks smoked in Wuhan, and it turns out that their smoking rates there weren’t, in this study at least, aren’t that different than Iowa. Our rate is around 20%. Although Story County’s a lot better. I think we’re at 10 to
15, so good job you guys. So right, I think another thing is that in China, as I
said, the virus is changing. It’s becoming less severe, so even in this big study, less than 1% of people actually ended up dying from it. In some ways that’s reassuring, but we still need to be proactive. In terms of what does this look like, if we take pictures of it, most people have abnormal chest x-rays, but not all. CT scan seems to be
better, more sensitive. It’s usually bilateral,
it’s usually patchy like what we would think a
viral illness would look like. So we had somebody come in
that we tested Wednesday and their x-ray showed
a bilateral pneumonia and their CAT scan said this looks like a virus pneumonitis, and
their influenza was negative, so we tested them, and they were negative. So people, this looks like
what a virus would look like. It’s not special. Labs, this is all really small. What I wanted to point out
to you was a few things. First off, the white blood
cell count is generally normal. About 30% have low platelets,
which would be typical of viral illnesses, and
then this study here about this test called the procalcitonin, this is a test we use
during influenza season to help us figure out does somebody have a bacterial pneumonia
or a viral pneumonia. Because it turns positive if they have a bacterial pneumonia. So in this case that
held true for coronavirus generally that people
had low procalcitonin. So for the clinicians out there, procalcitonin might be helpful if you’re trying to figure out does my patient have a bacterial pneumonia, or is this more of a coronavirus just like we would do for influenza? Otherwise, I found all the general tests pretty nonspecific. Just looks like a viral illness. So what is our treatment approach for people that get coronavirus? Well there is no specific treatment. So treatment is what we call supportive. First step is doing what we can to prevent it from being contagious, so that involves appropriate protective equipment which we’ll talk about. And then patients with infections often get dehydrated,
so they’ll need fluids. They’ll probably need oxygen
if they’re in the hospital. They may need bronchodilators or nebs if they’ve got some underlying COPD. They can get Tylenol to help their fevers, make them more comfortable,
although fevers generally don’t hurt
people when they have them, but they’re not comfortable either. And then you watch for
complications of being ill. A secondary bacterial pneumonia which is something we see commonly with influenza. I imagine we could see
that with coronavirus too. And then obviously if somebody’s very ill in intensive care unit, there’s all the potential complications
of lines and tubes and foleies and all those things that are just part of being really sick. So we do have advanced measures if people do have more trouble with their lungs like mechanical ventilation. And then there are these potential options for treatment which I would say are really potential in the sense that we will give steroids
to somebody that has really bad influenza if
we’re out of things to try. ‘Cause we’re just trying to shut the inflammation process
down and buy some time for them to heal, so
that’s something we may do. Ribavirin is an antiviral
medicine that boosts the natural human
antiviral immune process. I’ve given it several
times for people with coronaviruses who were
bone marrow transplant patients who had no immune
system to help them out. It’s really never worked
in that population. It’s not recommended for
coronavirus in general except if you’re out of other options. It might be something we’d consider if we did have somebody that was really, we were out of options for things to try. With viral illnesses
we sometimes will give something called the IVIG which is pooled antibodies from the community. The challenge with that is it assumes that the community has some immunity to whatever virus you’re trying to help your patient
with, and in this case, at least as of now, the community doesn’t have any natural
immunity to this virus. That may not be that helpful. And then there are some experimental drugs that you may have read
about or learned about. Protease inhibitors are something that we’ve used for HIV for 30 years. Coronavirus does have a protease gene, and so there’s been theories that maybe these would help people. I think what’s gonna limit us there is people don’t show up until the virus has already spread in their system and their immune system is responding. That’s what makes people
sick is the immune system. By the time they actually show up to talk to you about being ill, the cat’s already out of the bag and I’m not sure this drug is actually going to help. People have wondered about could we use this drug for prevention
if I had an exposure? It’s an interesting theory. I think they’re looking into that. It does tend to cause a lot of diarrhea. And they’re really not cheap. In terms of who’s gonna be paying for this for prevention for millions and millions of people, I think that’s pretty unlikely unless there’s hard data to support it. I don’t look for protease inhibitors to be the magic bullet here, even though you may read about them on the news. I guess the last thing is
vaccine development is underway. Even if we had infinite resources to develop vaccines, there
are simple, practical, time-related things
that you can’t speed up. You have to find a population at risk, you have to give them a vaccine that you think is safe, then you have to give it time to find out did it work or not? So we won’t have a vaccine this year. Period. I just don’t think that’s a reality. So how does this thing move around? It’s just like other viral illnesses. It’s a respiratory illness,
so it’s in droplets. So there is a distinction that we should talk about between what we call droplets and airborne transmission. This guy, as he’s sneezing, you can see these bigger droplets here. These are gravity dependent, so when we talk about droplet
transmission, droplets fall to the ground within four or five feet. So when we talk about
wearing a droplet mask, the idea is you’re preventing somebody from sneezing into your mouth, but if they sneeze over there it’s not like it’s gonna float around and then come in the sides. As opposed to airborne transmission, which is very small particles, which are capable of
floating around over space. So coronaviruses in general, the four that circulate in a community, are droplet. They are in the bigger droplets, they fall to the ground, and we
use droplet precautions. A mask and hand washing. That’s generally sufficient. With the newer coronaviruses,
there have been a few episodes of what are
called “superspreaders”. One person on a plane is able
to give it to the whole plane. Probably ’cause they’re like this guy, they’re just spewing it everywhere and it is floating around, but in general we think that this new coronavirus is going to be a droplet virus. And actually WHO, the
World Health Organization, is recommending we approach
it like a droplet virus. That’s different than what we’re doing. We’re approaching it like
an airborne virus for now until we get more
information, but it may be over time that the people
that study this stuff determine that droplet isolation is more than sufficient for prevention. Which would help enormously in terms of how do we approach
patients that might be sick. Droplets can land on
surfaces, so that’s where the hand washing and the don’t touch your face idea come into play. It’s not thought that they live on surfaces for very long though. How long is very long? I don’t know, a couple hours at the most, but it’s not like you’re gonna touch a doorknob that somebody touched six hours ago and pick up this virus. Plus you’re gonna wash your
hands regularly anyway right? They have found viral particles in stool. Nobody knows if those are
actually infectious or not. They think they probably aren’t. They think they’re just
dead virus genetics that aren’t really contagious. I probably wouldn’t test
that theory if I were you, but all the same, this
is a respiratory virus. You guys are used to respiratory viruses, we see these all year every year. Think of it like influenza. So what can we do? So because we’re approaching it right now as an airborne infection, that means that we need to use N95 masks which are generally fit tested to the particular person’s
face, or the CAPR. You guys have seen the CAPRs around, I brought the one that sits in the Infectious Disease Clinic. I see people with tuberculosis frequently, so that’s also an airborne one, so we use these frequently in our clinic, so that’s why it sits in my office. They’re pretty slick. You just plug it into the battery pack. There’s a plastic front
that you attach to it. One of the texts was telling me don’t forget to peel off the extra plastic bit or it’s very cloudy and you’ll feel like you can’t see. (laughing) Is Rick here? Anyway, so it just goes
on, and then you’ve got this piece of plastic
that goes under your chin. And a little bit of air
blows out around your ears, but you can hear and the patient can see you, you can see the patient. So because we don’t see
very many airborne diseases, in general this is our approach. Also, there’s a shortage of N95 masks. Starting about a month ago
we did increase our N95 fit testing in anticipation
of having a higher need. I would say what we weren’t anticipating is the run on N95 masks from the community which has really shortened
the supply available. We do have N95 masks that we use for a variety of purposes
in both organizations. We’re fit testing people
that are on the frontlines, although I should say that because of the shortages we’re really trying to stick with CAPRs as much as possible. Especially when we’re still
dealing with just a few cases. I think if we start seeing a lot of cases we’d have to reimagine what we do. I should also say that in Washington, where they had a lot of cases all at once, they just switched over
to the WHO approach which was just treating
it as a droplet disease because they just did not have the capacity to do airborne for everybody. So that depends on how
much we end up seeing here. If we see one or two cases
we’ll probably be sticking with airborne until
they tell us otherwise. If we see a lot more, then
we would be approaching it more as a droplet
depending on the scenario. We use contact precautions. Not contract precautions,
although you’d probably wanna take contract
precautions too in general. But it is contact precautions
with the gowns and the gloves. And then people will be in the hospital in a negative airflow room. In the clinic, it depends on the air circulation of the clinic room. The average is a two hour turnaround time of a clinic room. Different clinics are picking what room can we put to rest for
two hours if we needed to. I’ve been doing this for
years with my TB patients. You just don’t use that
room for a couple hours. We try to see those folks at
the end of the day as well. This is really important,
if you’re sick, stay home. That’s always been true, it’s still true. I think you all are so
dedicated to your work that you often come when you might be ill. I just think especially right now it’s important that if people have a fever and they’re coughing and they’re sick it’s just better to stay home. I think you’ll be hearing
that from your administration and management folks that that’s something we really need to encourage. And the last thing, you’re hearing this all over the news, is wash your hands. Soap and water are great. The alcohol stuff is great. Purell costs $40 on Amazon. (laughing) It’s amazing. Soap and water at home is just fine. So that’s really how we
prevent transmission. Report came out today in MMWR, which is a publication of the federal government, showing that it seemed like healthcare associated infection was very low. The people that are catching this are in either close contact
for long periods of time like in homes, or the
nursing home outbreak in Washington, so they’ve tracked these different exposures and people that were exposed somehow through a brief healthcare
encounter, it seems like the transmission rate in that setting, even when the perfect
protective gear wasn’t used, the transmission rate was really low. So that may also affect how the CDC guides us about what we use going forward. So testing, so really important key facts. Both the clinic and the hospital have all the stuff we need to do the testing. It’s a nose swab and then a
mouth swab in viral media. When we do our limited BioFire test in the clinic or
hospital, that is actually the nose swab, and they
can use that later. And then they swab the
back of somebody’s throat. This has been getting a
lot of media attention. In part because it’s a new disease, so the tests are limited. Imagine if you have a
limited amount of tests and you’re trying to
figure out how do we test whoever first, well you try to target the population at highest risk. That’s people that have traveled to countries with an outbreak, or people that have a known exposure to someone. Well that assumes we know everything perfectly and we don’t. Things slip through the cracks, people are around that have been exposed, we don’t know if they have been. That’s probably where now the
community spread has started. So as of last Friday they
added this last category for testing about if somebody has a fever and they have severe respiratory symptoms like pneumonia, even if they have no exposure history, as long as you’ve ruled out influenza and you don’t think they have something else, then that person should be tested for coronavirus. So that’s the scenario, we’ve tested two people here this week. Both of them tested negative. I anticipate we’ll have
more that we need to test that fit into that category ’cause people have respiratory disease, they have COPD, they have an exacerbation,
their influenza’s negative, their progesterone is low, and for years we said oh yeah, it’s probably virus. It probably was. Probably still is. But we need to know now
if it’s coronavirus. We’ll be doing that
testing, and when I called the Iowa Department of Public Health they were super friendly, they always are. And total time on the phone to get this all coordinated was no
more than 15 minutes. So I told them the story,
gave them the information, they called me back 10 minutes later, they faxed me a form,
the nurse on the unit filled out the form,
sent it with the test, a courier came to Mary Greeley, picked up the samples, brought them to the state hygienic lab, and we heard back the next day. Patient’s negative. The test takes about four hours, it looks to me like it’s being run at 9 AM to 1, so even though it only takes four hours why don’t I get my answer sooner? They’re probably just batching all these together once a day. Is what I perceive as happening. So if we start getting more cases, then all of a sudden
people will start meeting category number two there
and qualify for testing. Iowa right now has 250 tests, so how long those lasts, they can ask
for more from the CDC, and there’s word that there will be commercial tests available soon. I don’t know how soon. I don’t know how well,
this is technology that has been around, so I presume
those tests will work. Once they become
available, then we’ll have to figure out how do we best work with our clinicians and Public Health to test the people at highest risk so that we’re utilizing
our resources well. I have a feeling that once
the test is widely available, people will start to be
widely tested though. It’ll be interesting to see how that goes. I think the federal
government has tried to say well if you wanna have the test, you can have the test, if your doctor says you need the test, then that’s great. Where you’d get that if
you didn’t get it from Iowa Department of Public
Health I’m not sure. Right now IDPH is using these criteria, they put this out yesterday, it’s their same criteria I just
showed you from last week. Travel to an affected area right now is any level two or level three, so those countries I showed you. So Washington, California,
there’s 50 million people out there and we have 100 cases, so you’re talking about
one in a million chance if you had traveled to those places of meeting somebody with, so the risk is incredibly low still on the coast, but that’s something that
may change over time. What do we mean when we
talk about a close contact? Close would be within
six feet for a certain amount of time, usually a couple minutes, and having not been wearing whatever the gear is that we’re recommending. For now that’s airborne. There is a complicated rubric about high, medium, and low contact exposure. If the patient had a mask on, and I had my respirator on, but not a gown, that’s actually a low risk one. If the patient didn’t have a mask on and I had a gown, but not the right mask, that might be a medium risk, and so all those things fit together in a rubric because they help guide
what was an exposure particularly for our
workers, and if somebody has a meaningful exposure, right now the guidance is that they would take 14 days at home on a furlough. That seems like a good approach when you have very few cases. I can tell you that in Washington, in the hospitals that are taking care of these folks, the people that had potential exposures very quickly ended up being 70 to 80% of their staff. You can’t take care of people in that way, so they changed the way they approached it and they said even if you
had a potential exposure, you still come to work, but
you monitor your symptoms and if you get sick you have to stay home. So it’s a moving target. We’re trying to work with
what we know about risk, what we know about ourselves wanting to take care of our community members. So for now we’ll follow guidance. If there gets to be a lot of cases in potentials exposures over time, then we may have to modify or be flexible. A lot of those potential exposures happen when people aren’t in perfectly airborne precautions that were maybe in droplet. So in that case the risk would’ve been incredibly low anyway. A lot of moving parts to
these recommendations, but we do have that
guidance and we’re planning to follow it, especially if we have a few cases that are trickling in. So the current state,
at least at McFarland, Mary Greeley, and I put it this way on purpose because these tow organizations have been working hand
in hand on this issue for over a month since
it started to come out. Both sets of teams have infection prevention teams that always meet. This has obviously become
their focus recently. We started travel
screening about a month ago to initially China and
then expanded it to other level two and level three
countries I think last week. We started increasing fit testing for what I just call frontline staff. Again, as we’ve seen more about shortages that becomes less of a solution. Although I also think that people that are fit tested should be using those things. Then we’ve also been
working with supply chains for over a month to try and
make sure we have access. The challenge is that we get a certain allotment of supplies from our suppliers. We can’t just say well we want extra. So then you try and be creative about going to other suppliers in other ways, but everybody else is doing that too, and the public is doing that too. I would not be surprised
if we see shortages. Particularly of certain types of gowns. And potentially N95 masks if
we try to use more of them. If shortages happen, then we have to be creative and do what we can. And that’s been true
for both organizations as we’ve been preparing for all of this. So what do we anticipate? We have to think about
this very differently depending on clinic versus hospital, inpatient versus outpatient. So first for the outpatients,
most of the patients with coronavirus are
going to be outpatients. 90 plus percent of people that get this don’t need to be in the hospital. God willing. So then we have to have systems in place to be ready to appropriately isolate them as they’re coming in, and then if there is a surge of patients, how
do we take care of them? Right now the clinic is following CDC and IDPH guidance for who to test. We are building phone triage stuff in the background, so if there’s a lot of calls that they wouldn’t just be going to each individual clinic, but they would go to a centralized triage line that would help direct them. Do you go to your clinic, urgent care, the ER depending on symptoms, or if we’re getting enough cases, we are anticipating we would use a centralized
off-site location so that patients who are sick and could potentially be contagious are not walking in right next to the otherwise well person getting their knee replacement or the otherwise potentially
ill person needing chemo. That all just depends on how
many cases we end up having. For now those plans are being
formulated in the background to be activated in the
setting of having more cases. If we get them. McFarland right now is
meeting weekly on Tuesdays and we will be putting
a weekly Monday update from Kelly, our infection
prevention person, with updates from the state and county Public Health folks, and then me doing some editorializing about it. As far as MGMC goes, there is a weekly Friday meeting called instant command which brings everybody together depending on the active issues. It’s LeAnn Hillier with
infection prevention and Chris Perron with emergency team. Everybody else you could imagine from lab and administration, nursing, OR. Because if somebody’s in Mary Greeley it’s gonna look very different. That person does have to be maintained in an isolated setting, in a safe way, for them and for their caregivers. So what that would look like practically is if somebody is suspected to have a case they’ll be in airborne isolation. We’ll do the testing,
if they test negative then they come out and just like any other viral illness, we’re taking care of them, supporting them, treating them as we go. If they do test positive, then they need to stay in airborne isolation while they remain in the hospital. If we end up switching to more of a droplet approach, they would still need airborne isolation
for things like nebs or intubation or those
aerosolizing procedures just like we do with influenza right now. The patient doesn’t have to
stay in the hospital though. If they get better,
then when they’re ready for discharge they discharge home. Then they would follow
post self-quarantine precautions just like anybody else. But I’ve gotten that question a few times, do they have to stay in the
hospital if they get better? No. No, as soon as they’re ready
to go, let’s get them going. (laughing) So right now the plan
is we will have patients be in respiratory isolation until we have more patients than we have
respiratory isolation rooms. At which point we’ll most likely use 3C as a ward of patients that have respiratory isolation needs. Then the question becomes well who takes care of those people? So I’ll be there. And I think the nurse
managers are reaching out to their staff to see do people have special interest in volunteering. People volunteered for Ebola, people volunteered for H1N1. Remember, this isn’t Ebola. This is a respiratory virus. This is influenza. We take care of that every day. I don’t think people should worry too much about this being something they do. This is why we went into this. So we take care of
respiratory viruses every day. So this is my house. This is a painting that
I have above the stairs that my wife Lois and
the kids made years ago. Started when the kids were really little and we’d say Clara, what’s the first rule? Don’t panic. (laughing) What’s the second rule? Be positive. What’s the third rule? Kindness counts. So I thought well what
if we apply these rules to how we, what are we doing now. I do think don’t panic
is a good place to start. This is a respiratory virus, you guys take care of these folks every day. It looks to me like the mortality rate associated with the virus is not going to be as high as initially
we worried it would be. That doesn’t mean it’s not serious, that doesn’t mean we don’t take care, but you guys already do this work. You’ll be fine. I think being positive is, how can you be positive about a virus spreading? Well think about in the
sense of you know your job. You know where you work, you know where you work better than I know your job. So you can positively affect the care of your patients by noticing,
by paying attention. Where are the gaps, how can we do better, what do I think is gonna work better? And then stay positive in the fact that it may not always make sense. We don’t always totally understand the guidance we’re getting
from Public Health. It changes, it changes from yesterday I heard one thing, now
I hear another thing. I think the more we can
stay positive about, we’re all trying to do
the best, and I assume the best about everybody
that’s trying to do this. I think if we focus on solutions and not just problems
we’ll get a lot farther. And then kindness counts is, you know… It could potentially be hard. If it is hard, we’re in it together. I just feel like we trust each other, we’ve been working together for years, and whatever happens, I think if we assume the best about each other,
we’ll get through it. It’ll be fine. It’s hard in a stressful situation to focus on kindness, and I think just remember that if people are stressed that they’ll come around,
and you’ll come around and work together, and
if we can focus on that and remember that, I think
we’ll come through just fine. And wash your hands. (laughing) Wear your gear. And stay home if you’re sick. That’s what you can do. I think there’s a lot
of resources available. IDPH. Story County Public Health
is gonna be really helpful. Infection prevention committees. For McFarland, Board of Directors is the highest up in terms of the chain of command and also their administration. Kelly is our infection prevention person and a member of a bigger committee that’s gonna be really helpful. And then the clinical
managers and of course the physicians and APPs will
be natural leaders here. And at Mary Greeley it’s
gonna be very similar. It’s gonna be Public Health, it’s gonna be the infection prevention committee, there’s this incident command committee. LeAnn Hillier is our
infection prevention lead. And then administration,
clinical managers, and then the physicians and other folks. So I think, I was just in a meeting, we met with Iowa State this morning. Chris Perron made a comment about how if we think about Matt Campbell and focusing on the
process, we’re focusing on the process here too ’cause five years from now this could happen again. I just feel really lucky to have been working with all of you ’cause I think it’s really gone, it’s gone well. So thank you all for your work, thanks for your time, and we’ve got as long as you want to
talk about questions or things that you’re seeing that you need answered or questions, Dr. Carlyle. – We’ve got a question of (mumbles). When you get this first case and then you’re gonna have to deal with contacts, is that gonna be, the contact’s gonna be done through a Public Health study? When you start to look into immunity after you get that sentinel
case, can you envision, or what’s the process? – That’s a great question. I think it depends where
in the process we are. If we’re the first case, I think Iowa Public Health would be very involved. If we’re the 50th case,
I think they’ll be busy. I think it’ll depend. I think the experience out of Washington was the more that we
can do to pay attention to potential contact exposure, especially here in the workplace, that’ll be our responsibility. Our infection prevention
teams have those systems in place and have for years for TB and other things that we track. If there’s a lot of cases,
it’ll be a lot of work. And we may need to pull other people in to be helpers in that setting. That’s at least what they’ve
had to do in Washington. People may have to be reassigned to different types of
tasks to handle that. When it happens, ’cause I agree
with you, I think it will. The better we can do
with isolation up front, the fewer potential contacts we’ll have. I think outside the
hospital, outside the clinic, we are gonna have to rely on Public Health to be doing the community contacts. But I think they’re gonna rely on us to do it within this setting. Yes, Christy. – We’re already starting to see those MyChart messages roll in on patients asking well I’m immunocompromised, I’m immuno (mumbles) whatever, asking what I should be
doing in this situation. Are we gonna be able to, or are you as a department gonna create a dot phrase or something that we can just link that response so that
everybody has a consistent response to these people that are asking? – So the question was as
people are asking questions, is there some centralized
messaging that we can give them? I think that’s a great idea, if you wanted to make a dot phrase that seemed like it was working and share
it, that would be great, but I mean I think,
especially for outpatients, one thing that we’re
looking at is for those patients of yours that are very stable, and maybe don’t need
to be seen in the next couple months, maybe they’re scheduled for just their yearly
physical or a med refill, consider having them stay at home. Not right now, we have no cases in Iowa, but if we start to see
more and more cases, if I was immunocompromised, the last place I would want to be if I didn’t need to be would be in
a healthcare setting. So working with your patients that may not need to come in would be helpful. Again, working with phone
visits would be helpful. And then just focusing on all
those other hygiene things. This is what you can do at home. Social distancing has come
up time and time again. When and how and what does that look like. There isn’t a specific answer. From a system and a community standpoint I think it’ll really depend on when we start having cases. Where are those cases showing up, how many of them are there, how sick are people actually getting? Based on the experience of other places, University of Washington
just went all online today. I wouldn’t be surprised
if some big changes happen if we start seeing a lot of cases. Especially for immunocompromised people, if we’re seeing transmission
in the community, I would say social distance
and avoid those big gatherings. I mean my church is reaching out to me to find out what we should do at church. (laughing) I mean church is social, that’s the point. What reasonable precautions can you take that are pragmatic and thoughtful, make sense, but don’t
undermine the whole point. I’m not sure that was a great
answer to your question. I like the idea of dot phrases for people getting called frequently about how do we not be spending all of
our time on documentation, but we actually can take these calls. But it may mean too for people that are mildly ill that we say monitor. And if you get more ill,
then call and come in. We’re trying to build
that into the triage line. It’s gonna be hard
though ’cause it’s still influenza season, influenza
has a potential treatment, are we gonna just treat
people over the phone? Different clinics may wanna handle that in different ways, so we’ll
have to work together. Yeah, not a perfect answer. Yes. – It seems like you got the Chinese and the South Koreans paired
up for testing very quickly. And tested a lot more people than we have in the United States. I’m not trying to critical
of the CDC we have today, but do you understand why it’s taken us so long to get these
tests out to the public? – Well as of November 2019
this virus didn’t exist. So the amount of information that we have been able to learn in a very short amount of time is astounding. When SARS came out it took
years to sequence the thing. It took years to figure this out. The Chinese have been dealing with this since early December. We started hearing about what they were dealing with in January, they ramped up their testing through their centralized government system very quickly for that region where it was happening. I understand that there’s been some difficulties with how the test was developed in the United States. I’m not sure the details,
but I guarantee you the CDC and federal government weren’t trying to hold that process back. – The process was that… – I think it’s exactly like what I, if you have a limited resource and you’re learning about something new and you have no cases in your country,
then you focus on who’s at highest risk, and then okay, now we’re seeing community spread, now we really need to try and ramp up and be ready to treat,
and so community spread started happening eight days ago. And I’m hearing that there may be commercial tests available next week. I mean it isn’t perfect, but that’s the challenge of Public Health is this pragmatic just in time approach. What if we had better Public Health infrastructure from the
get go, would that help? Probably would’ve, but we are
what we are and I just think, I think the testing is out there, and we now have tests in Iowa and we still only have tested eight people here. Or nine now. I think the places that really need it are where the outbreak
is happening and they’re the ones saying why
don’t we have more tests. They have an argument there. Why aren’t there more? Yes. – One of my nurses attended
one of your sessions and she came back with the understanding that the CAPR shields were a one time use, but another nurse told
me recently that it was per person, so could
you clarify that please? – Yes, and that’s
something that we’ve been trying to be flexible about
as we’ve gone forward. In general, the CAPR face
shield can be reused. Especially in the outpatient setting where after use you can wipe
it down with whatever the cleaner is that we wipe it down with. The challenge we ran into
in the intensive care unit was so many people are
seeing that one patient and they were all hanging their CAPRs end to end on top of each other. We just don’t have the
space to spread them all out so they stay clean and
dry and all those things. As far as the inpatient setting goes, for now we’re saying one time use. For the clinic setting it sounds like since it’d just be your personal one that wouldn’t be mashed with a bunch of others you could probably clean it. We’d have to ask Kelly
what the cleaning stuff is, but that’s my understanding
of where we’re at right now. Dr. Mahaney. – For practical testing purpose and inpatient purpose,
once we have a patient we’ve decided to test,
the process of testing, I assume if it’s busy, the expectation isn’t that you’re the only one who can talk to, to Public Health, so… – [Dan] I hope not. (laughing) – Besides in text, is that something where the nurse can call the
Department of Public Health, get the necessary paperwork, or does that have to be a position to phone call department health to
get approval for a test? – That’s a good question, I would probably have the physician or
provider call at first ’cause they did have some clinical questions about the patient. We’ve tested two. I did the first one just so I knew how the process went. The second patient I didn’t see and I didn’t do any of the testing. I did talk with the doctor that did it. It went smooth and slick. I think I’m available for questions and to be a resource as
people encounter folks. Depending on how ill they are, you may be seeing a lot of them
too, but I mean basically the key is as soon as we think okay, they fit that criteria
of fever, they’re ill with the respiratory
illness, our other testing is non-specific or we’re
not finding anything, hopefully we notice early in that process and get them into airborne precautions and then that testing you
do through Public Health. Does that answer your question? – Yeah it does, so the physician makes the initial phone call to
essentially get permission to test from the Iowa
Department of Public Health. – [Dan] For now. – And from there the
paperwork can be done by… – Right, yeah. When we did it, Amy did
the paperwork in the unit. And I think when Dr. Stuffle did it the floor nurse did the paperwork. It’s one form, it’s not complicated, it’s just patient demographics and the address of your
facility basically. Each form right now is an individualized numbered form though, so you can’t just save the form and photocopy it. You have to get a new form every time. And then Public Health sent a courier, they picked it up from the lab. I was stuck in a coronavirus
meeting for mine, so I hadn’t done the paperwork yet, so they actually picked up the stuff and sent it and we faxed the form forward to state hygienic lab. Public Health has been wonderful. I mean they’re really helpful. They’re in it to be helpful. – Do you think there
will ever be a setting where Mary Greeley has
their own testing on-site? – Yes. I think that’s coming. It’s like a race to the finish, I think. Our BioFire, our swab
that we do right now, we already test for four coronaviruses, so if BioFire figures out how to add the DNA primers on for the fifth one, all of a sudden we’re not
doing anything different. Patient gets one test,
it looks for influenza and it looks for everything else. Coronavirus positive, there you go, got the diagnosis, and we
know what we do after that. Probably it’ll be more of
a standalone test at first. But I do think it’ll be
available, could be ordered. But that then raises interesting questions about well then how do we make sure that’s getting reported to Public Health, how do we make sure the infection prevention teams are
involved in isolation, so when that becomes available there will be, there need to be some discussions about how that looks. Yes. Nope, behind you. – So in the pediatric clinic on Saturday I had a patient who traveled, her husband came in from travel outside the country and I was debating on whether she met the parameters for
testing, and I questioned and I couldn’t find a clear answer, so what are the, this was
before the third (mumbles). – [Dan] Yeah. – What, and this is where
I struggle with this, what are the parameters for fever? So she has a child, and there’s obviously, a fever for an infant is different than a fever for older children, and they said it’s subjective, so what are we seeing for, are there high fevers, low grade fevers? What is “subjective fever”? – There have been studies that show that moms can tell if their kids are febrile as well as a thermometer. So if mom says they’re febrile, they are. And I guess if… – I mean do they seem like they’re having high fevers or are they… – Yup, fevers and cough. I mean it’s variable, but
the fever and cough kids are the ones that you would wonder about. My discussion of Public Health, at least for now that we have very few tests in Iowa, is that they would only recommend testing people who have severe lower
respiratory infection which would mean in the hospital. So then that gives you a conundrum. Well what if I’m at
least marginally worried there’s community spread, and I need to, wondered about coronavirus but maybe the testing isn’t
available, I think right now the approach is you would approach it like any other viral illness. Kids should stay home
while they have fevers and while they’re coughing, and fevers need to be resolved off Tylenol. This is for adults too. Fevers need to be resolved off Tylenol and the cough should be winding down before you would consider
having them go back to their daycare, their
school, or whatever. I think we’re actually seeing a lot of community spread. How long people stay home,
the guidelines will change. If you don’t do the
tests, the recommendation is to approach them like other
viral illnesses right now. We had a patient about
three weeks ago from Western China come into
the emergency department with fever and a cough and at that time China, Wuhan city, was the only place we could test people from, and so she did not qualify for testing. I would have tested her I
could have, but we weren’t allowed to, they limited
that because of the supply. So we approached her as if she had it. We had her self-quarantined
at home as much as we could. And then we talked with her, Nazarene, our nurse talked with her every other day for two weeks until she was well. And then we said okay, you’re okay to, and that was more than what Public Health was recommending at that
time, but you have to take a pragmatic approach, but right now if they’re not very ill, I don’t know that Iowa Public Health would test them. Mr. Deere, did you have a question? – Yeah, a question and hopefully a helpful reminder for the room. With regards to HIPPA. Nothing about COV-19 suspends HIPPA. And I think there’s an
abundance of curiosity that goes beyond what’s
necessary for treatment that we need to be very careful about throughout our health care environment. My question– – Can I share that comment
on mic for the people? Mr. Deere was saying that HIPPA still applies to people with coronavirus. That applies both to how we talk with our community members and
also as care providers. If we’re not involved we don’t need to be involved just like usual. I think that’ll be a challenge in the age of social media and family
and all those things, but it shouldn’t come from us, right? So what was your question? – You mentioned that WHO is suggesting that it is an airborne,
or a droplet, sorry. – [Dan] Yeah. – Is CDC unclear, are they saying airborne today or are they not saying? – So WHO right now is approaching this as a droplet contact precautions illness. WHO traditionally is working with areas that have lower resource availability. So whenever we make any sort
of isolation guidelines, we are taking into
account the infectiousness of the organism, the
severity of the illness, the resources available,
so WHO traditionally has taken a slightly lower need because of the resources thing. But data I think is coming out to say that is probably going
to be the right approach. For right now, the CDC is
recommending airborne precautions. That’s guidance, and we appreciate their guidance, and I think the experience out of Washington was as soon as they had all sorts of infections, it just became completely impractical
guidance and they had to switch to a practical
pragmatic approach which happens to also fit
with the WHO guideline. So for now it’s airborne. If that changes, you’ll hear about it. ‘Cause it would make everything a lot easier in terms of isolation if it was more of a droplet illness. And all four of our other coronaviruses are droplet illnesses, so we’ve been taking care of people with
coronavirus for years. And you wear your mask. You’re fine. There was questions about
what if I’m exposed at work? Do I go home? I’m going home. (laughing) I wanna sleep at home. I think self-monitoring
is gonna be the key and common sense approaches within your family, depending on your family’s risk factors, are going to be key. Hand washing and all
the same, all the rest. I think if there was
extenuating circumstances for people, I think there
is potentially capacity for people to stay if they needed to, but remember this is not Ebola. It’s just not. It’s a respiratory virus. You guys take care of these every day, so potential exposure, okay? Cough, fever, we all get 2.5 respiratory viruses per year. You’re used to this, you
have an immune system. It’s designed to take care of you and experience new things as it comes. I think we take it seriously, but remember you do this every day. And thank you so much for your work ’cause we couldn’t do it without you. Thank you thank you. All right. Have a great day. (applauding)

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