November 4, 2021 Community Engagement Virtual Meeting

QUESTIONS FOR 11/4/2021 COMMUNITY ENGAGEMENT MEETING

1. CURRENT COVID NUMBERS IN KAWEAH HEALTH
   1. Positive COVID-19 cases currently in Kaweah Health:
      As of this morning, we had 109 COVID-positive patients in inpatient beds and another two COVID-positive patients in the Emergency Department waiting for an inpatient bed to open up.
   2. How many are in ICU and do we have empty beds in our ICU?
      24 of the admitted COVID inpatients were in the ICU and we have 22 COVID patients on mechanical ventilators. At 7:03 this morning, only one of our 21 beds in our medical ICU were available for admission or transfer and only two of our 20 cardiac ICU beds were open.
   3. Positive Employees at Kaweah Delta:
      Since the beginning of the pandemic 1,569 of our employees and 39 of our providers (physicians, physician assistants and nurse practitioners) have contracted COVID; as of this past Monday, 39 (10 from 2020) of our employees and none of our providers are out on a COVID-related leave of absence; over the course of the pandemic, we have lost four employees and one provider to a COVID-related death.
   4. Hospital Census:
      As of this morning, 329 of our 344 adult inpatient beds were occupied, representing an occupancy rate of 95.6%; in addition, we had another 35 patients waiting in the Emergency Department for an inpatient bed to open up (what we call an “admit hold” patient); including these admit hold patients, our real adjusted occupancy rate was 106%.
   5. Vaccinated employee percentage:
      Our employee vaccination rate for those employees that are subject to the Governor’s vaccination mandate is approximately 80%; for our Medical Staff providers, it is approximately 98%.
   6. Deaths: Ask Gary –

Yesterday the County reported that we were at 998 deaths in our County and then I was informed right before we went live today that we have crossed a grim milestone and are now at 1,002 deaths. Some might say that number reflects a low percentage of our population, but, every one of those 1,002 people is the most important person to their family.

1. When talking about our census, are most of the hospitalizations due to COVID-19 or are these patients in the hospital due to other illnesses?
   Of the 364 adult, acute-care inpatients currently admitted to the Kaweah Health Medical Center or waiting in the Emergency Department for a bed to open up, 111 of them have a primary diagnosis of COVID, representing 30% of all admitted adults patients; the other 253 adult inpatients (70%) are being treated for heart attacks, strokes, trauma, non-COVID respiratory conditions, cancer, sepsis, and other injuries and illnesses.

2. We have had a huge jump in our ICU patients. What are your theories behind the rise in acuity in our patients?
   Yesterday morning we had 112 COVID-positive inpatients in the acute medical center (the most of any acute care hospital in California). 26 of those patients were in the ICU and 21 of them on mechanical ventilators. As a non-physician, I’m somewhat guessing why we have so many patients in the ICU but my first thought is that COVID-infected people wait too long before they contact their doctor or go to the ED. As I read about the deaths of COVID-positive patients, most all transition from the ED to the ICCU and then to the ICCU with worsening oxygen saturation. They tend to be very hypoxic where they have insufficient oxygen in their bloodstream, starving critical organs of oxygen-rich blood. Most develop viral pneumonia directly from COVID and some develop bacterial pneumonia. They all need breathing support going first from a nasal cannula, to BI-PAP or C-PAP, and then to a ventilator. A healthy blood level of oxygen saturation normally measures 95-100% on a pulse oximeter; readings lower than 90% are considered dangerously low and should trigger a call/visit to your doctor, urgent care center or ED.

3. Kaweah Health called a Code Triage yesterday. Can you explain what that means?
   A Code Triage is essentially the formal declaration of an emergency; it can be triggered by an external event (e.g., multi-vehicle accident) or an internal event (e.g., fire, flood, loss of power, etc.). In this case, we had too many patients and not enough staff to take care of them. At 1:30 P.M. yesterday afternoon, every adult inpatient bed in the acute medical center was occupied and we had 111 patients in the Emergency Department; 51 of them needed inpatient admission but we had no available beds. As such, we called a Code Triage and set up the Incident Command Center in our Acequia Wing Conference Room. All leaders report to the Command Center and we start building a staffing pool from all departments throughout the organization. We contacted numerous hospitals throughout the Central Valley hoping to facilitate transfers of patients but no beds were available. We did consider going on diversion (shutting down the ED and directing all ambulances to other facilities) but chose not to. That always remains an option depending on how matters transpire over the next few days.
   1. What sort of threshold/criteria needs to be met before calling a Code Triage?
      There really is no formal formula, algorithm or ratio that triggers a Code Triage but rather a judgement call by administrative and physician leaders that patient demand is quickly overwhelming the acute medical center and we must declare a “all hands on deck” emergency. Leaders essentially drop everything and report to the Incident Command Center to focus on the crisis at hand; a labor pool is created where we call in staff from all outlying areas to support direct patient care; medical staff convene and rally to identify patients that can be discharged now if certain resources are put in place (i.e., oxygen support, durable medical equipment, nursing home transfers, follow-up physician appointments, etc.).
   2. How is the hospital better equipped for emergencies after calling a Code Triage?
      Leaders essentially drop everything and report to the Incident Command Center to focus on the crisis at hand; a labor pool is created where we call in staff from all outlying areas to support direct patient care; medical staff convene and rally to identify patients that can be discharged now if certain resources are put in place (i.e., oxygen support, durable medical equipment, nursing home transfers, follow-up physician appointments, etc.).

4. What has the state’s response been since asking for help over the last week?
   On Monday we submitted a staffing request of 25 nurses (critical care, emergency, medical/surgical and mental health) from the State and received approval yesterday afternoon. We learned last night that 17 of them will be arriving today. We submitted an additional request for eight more critical care nurses and hope to receive approval today and receive them by this weekend. These nurses are procured by the State through commercial staffing agencies and are paid for by us.

5. What would happen if the State did not assist with staffing - would we have to close off rooms due to a staffing shortage?
   While our physical capacity is being stretched to the limit, we do have the ability to create additional patient care space within our healthcare system but we need the staff to care for patients in those spaces. In addition to looking for outside resources, we continue to highly compensate our staff for working overtime and extra shifts and we are now asking staff to care for one to three more patients per shift than they normally would.

6. You mentioned a few weeks ago that we might have to transfer patients to other facilities.
   1. Have we been doing that? If we haven’t, why not?
      We have tried to transfer patients on several occasions but have not been very successful because patients and families don’t consent to the transfer or there are no hospitals willing to accept transfers at the level of care we need (primarily intermediate critical care).

6. 2. How far away would we have to transfer patients to due to Fresno County being overloaded as well?
      Yesterday we reached out to Sierra View Hospital in Porterville; all Adventist Health Hospitals in Tulare, Hanford, Selma and Reedley; Community Regional Medical Center and St. Agnes Medical Center; none of them had beds available for transfer. It appears that only those hospitals in highly-vaccinated communities (i.e., Bay Area and Southern California) have open beds.
7. What are current staffing ratios like in light of the overflow of patients?
   Nurses are generally taking one to three more patients than normal nursing ratios allow but we are operating under a State-approved exemption due to our extremely-high inpatient census. That said, we have hired and contracted with many more Licensed Vocational Nurses and Certified Nursing Assistants to help support our Registered Nurses. We are also working closely with our County and State to procure additional contracted nurses through nationwide staffing agencies.

8. How many people did we vaccinate at our vaccination clinic in Tulare with Kiki Torres?
   We newly-vaccinated 43 community members at this event.
9. Do we vaccinate our hospitalized patients that request the vaccine?
   We do not currently vaccinate our hospitalized patients. We are currently evaluating this for our ED patients. We currently provide vaccinations at our 5 hospital based Rural Health Care clinics, Sequoia Health and Wellness Center, and our 2 Urgent Cares (this includes 1^st/2^nd doses, along with booster doses for all 3 vaccines)

10. With the recent announcements from the FDA and CDC regarding Pfizer’s emergency use approval to administer the vaccine for children ages 5-11, do we have a timeframe when this will be available to that age group at our clinics?
    Yes, we are looking to operationalize this within the next 2 weeks (based on product availability and our pharmacy and therapeutics committee’s review and approval….expected. We are currently working with Tulare County and the State to receive the new product formulation for this age group which is different than the supply we currently have to vaccinate patients that are 12 years of age and older.

11. What is Kaweah Health’s policy on social media in regards to its employees?

Most of the time it is our community members who report these posts to us because they think they are inappropriate. We don’t counsel for this, but just share with the employee that they should consider reputational damage for us and for themselves. We can’t tell them not to post.

12. How difficult is it on the staff when they are at still seeing so much COVID-19, but the rest of the County seems to be under the belief that COVID is going away and are resuming life without precautions?

I know that they are exhausted but they truly have superhero powers and they still come to work every day taking care of our patients and one another with compassion and care. I would love for our community to openly express their appreciation for our staff and our providers like they did back in the early days of the pandemic. Your thank you cards, and parades, and lunches and snacks truly mean the world to them and give them energy and inspiration.