July 31 Employee Huddle

July 31, 2020

Please Note: When time does not allow us to answer every submitted question, we answer questions at the next week KD Huddle. Submit a question now for next week by e-mailing dvolosin@kaweahhealth.org.

Questions and Answers from the July 31, 2020 Kaweah Health Employee Huddle

1. I know that in these COVID days there are no visitors allowed. Is there a way to accommodate staff as to where they can visit family during breaks or after work? It would lift morale to get to visit their loved one after a difficult shift.
   We evaluated this about a month ago and decided to maintain our current restrictions to avoid overwhelming areas. We will keep this on the top of the list, though, for a first step in lifting restrictions.

2. With EVS being short staffed, and working so hard to keep up with the terminal cleanings with this current surge, is the District considering extra shift bonuses for that department?
   While we have vacancies (5 LOAs & 3 full time positions), here are a few things we’ve done recently to boost our EVS staffing levels:

1. Additional help from the Labor Pool.
2. We have recently reconfigured days off rosters/schedules to meet current needs.
3. We have also made some operations modification (reduction of office cleaning days), so we can augment service deliverables in patient care areas.
4. We will be staffing up on each shift in anticipation of call-offs.
5. We have opened more positions to backfill if an employee needs a LOA or leaves Kaweah Health.

3. As we are seeing a surge in patients, does the hospital have a projection of how high the surge volumes will get?
   We are seeing a surge in patients and have experienced a steady increase the last month. We have seen this taper off this past week but anticipate it to rise again with the upcoming holiday, if schools return to campuses, and the impending flu season. The projection models from Johns Hopkins and other organizations can be used to see where we might be but this is also based on the social actions of the community. Surge volumes could get high enough in the community that our hospital is forced to work outside its normal and surge capacities.

4. Are we preparing for a flu/pandemic surge?
   Yes, as we move forward we are planning for these two viruses to be happening at the same time. Normally when flu season hits, we see a huge spike and demands for beds and backup in the ED. We are hopeful that the community will still take masking seriously and that it will help stop the spread for both of these viruses.
5. We are learning more about beds available vs. staffed beds. Is staffing also a concern?
   We are hiring and have opened up a lot of positions to prepare for the current and future surges. We are having weekly orientations and onboarding all the time. We are also hiring more travelers and cross training staff. A lot of staff have been taking on more. Our 4T and 2N staff members have trained up so many can move into ICCU so that the current ICCU nurses can move into ICU if that care is needed. We have non-clinical licensed staff who have been pulled back to the bedside. A lot of these staff members have embraced this challenge are ready to help team members. The staff members who have worked at the bedside for the past two months have been working hard and going outside of their comfort zones with different shifts changes. We are also hiring student nurses to fill the role of sitters. The CNA programs get their clinical hours in skilled nursing facilities. The SNF’s are not letting them in so they aren’t able to finish their program. We have opened up student nurse positions to help out with that critical need.
6. Is Kaweah Health going to offer any kind of reduced work schedule or any other options for working parents to help with childcare?
   This is a challenging issue. Each school district and private/charter school seems to be establishing their own schedules of in-seat or distance-learning options. If we assume that children will all be distance-learning this fall, we will do our best to apply flexible schedules, change the length of shifts to shorter or longer where possible, change days of the week, and ask employees who can to swap shifts with those who have no other choice than to be home with their children.

Kathryn Price, our Director of Kaweah Kids, is looking at establishing a distance-learning center, but it’s a complicated process. We believe we have the teachers and can likely find the space. Kathryn is working with licensing to understand the requirements.

We understand that ProYouth will be providing some of this as well as the Boys and Girls Clubs. I’ve heard that some employees’ teens are going to help others with smaller children.

We’ll update as soon as possible on what we can provide. In the meantime, we want to encourage our staff to work through their Manager/Director and our LOA Team for information on their specific circumstances. If an employee is unable to utilize daycare and is concerned about others in their household, they may need a personal leave, and might possibly be eligible for Unemployment Benefits.

7. What would need to happen in order for all staff to be tested routinely? We would need to see significant and repeated outbreaks occurring throughout the departments and have a supply of test kits available to maintain testing at this frequency. If the state mandates routine testing of hospital staff we will implement routine testing.

8. Have the thermometers come in yet and are we ready to start district-wide screenings?
   No, the thermometers have not come in yet. Just a friendly reminder everyone should be screening at home before they come to work. If you have concerns, Employee Health is here to help.
9. An employee’s friend is elderly and her husband is going in for emergency surgery. She needs to know what is going on and is very stressed not able to be with him. Who should she call?
   We will give her the number for the department manager where her husband is right now. If patient is in the ED she needs to call the manager or ED charge nurse.

10. Do you know of any clinical trials of a COVID vaccine in Central Valley? Would it be a good idea to volunteer?
    There are no clinical trials happening in the valley at this time. Keep your ears open though, if they do happen they will likely be through UCSF.

11. What is the status of the “Hero’s Stimulus Bill” that was being worked on?

Below is language from the government’s proposal.They appear to be working on a second round of stimulus checks, similar to what individuals received before.From my research, the bill has passed the House and is or will be next to the Senate.I’m following this and other employee-related bills making their way through the process.

Language from the bill referenced in the question:

• Would give each essential frontline worker $13/hour premium pay on top of regular wages for all hours worked in essential industries through the end of 2020.
• Would cap the total maximum premium pay at $25,000 for each essential frontline worker earning less than $200,000 per year
• and $5,000 for each essential worker earning $200,000 or more per year.”

12. Why are the test results not being communicated to the patient or why does it take so long for the results?
    We are working with ordering community providers to reach back out to their patients with results. We do have processes set up for patients to be called when results come back for providers within the KD system so this is good to know we had a fallout so we can follow-up with urgent care. Specimens from patients who are asymptomatic typically get sent to a commercial lab that takes about 14-17 days to turn around. Our KD employees and hospital patients are tested here in the hospital with a one-day turn around. Symptomatic patients in the community are typically tested by the County with a 2-3 day turn around. If someone is a confirmed positive we have the team members who live with them quarantine for two weeks.

13. There are several videos claiming that hydroxychloroquine, azithromycin, and zinc are extremely effective in fighting the virus in the correct dosage. Has KDH used this particular combination of medications? If yes, what was the outcome. If no, is it possible to try? Hydroxychloroquine was considered as a potential treatment for COVID-19 early in the pandemic before scientists and clinicians had an opportunity to fully test or develop medicines that could treat the virus. Based on studies available at the beginning of the pandemic, hydroxychloroquine was prescribed for some patients at Kaweah Health. Early studies on the use of hydroxychloroquine in patients looked to show positive results but the way the studies were conducted this may have been misleading. Many studies using hydroxychloroquine have been published in the months since the pandemic started. A majority of these studies have not been able to show a benefit with hydroxychloroquine.

The studies that show no benefit that many clinicians are basing their treatment decisions on are studies that have adhered to the gold standard of clinical research and have looked at various patient types. These studies have included various different types of patients ranging from those with a possible exposure but no symptoms yet (asymptomatic patients), non-severe, non-hospitalized patients, and hospitalized patients who required oxygen support. The use of hydroxychloroquine for COVID-19 has continued to be discussed in the news and on social media but based on the best available current science, the studies are showing that it does not work as originally thought. The scientific and medical experts in the country and many of our local providers are currently not in favor of using this medication for COVID-19 treatment. Studies for azithromycin or zinc have not been as readily available. One study evaluating hydroxychloroquine for non-hospitalized patients with COVID-19 also looked at those patients also taking zinc.

The study investigators found that the addition of zinc to hydroxychloroquine did not improve symptoms during the study period. While zinc is still currently in use, there are not studies that support any benefit to patients. However, it is largely a safe drug to use in patients. Another study evaluating hospitalized patients with COVID-19 found that taking hydroxychloroquine with or without the antibiotic azithromycin did not show improved symptoms after 15 days. Azithromycin may be given to patients with COVID-19 that have other medical reasons, such as certain types of pneumonia. Lastly, the FDA has issued a warning that giving hydroxychloroquine with remdesivir may reduce the activity of remdesivir, a drug that has been shown to have benefit in patients with COVID-19. All of these medications, especially hydroxychloroquine and azithromycin, do have side effects and in some patients can cause harm. It is important to keep in mind the potential benefits of any given treatment and weight these out with potential negative effects of these drugs and other factors that are specific to the patient to come to the best treatment decision. Given the studies that have recently been published around the use of hydroxychloroquine and showing no benefits, use as treatment for COVID-19 infection at Kaweah Health hospital has fallen out of favor.

14. Is Kaweah Health using Remdesivir?
    Kaweah Health is currently using Remdesivir in patients that meet the criteria set up by the FDA when they granted emergency use authorization (EUA) for this medication. Patients are evaluated to ensure that they meet these criteria by the clinical team.

15. Does KD have adequate medicine and supplies to meet the needs of the number of Covid-19 patients you are receiving? What does KD’s supply of Remdesivir look like?
    For FDA-approved products with reasonable data to support their use in the management of COVID-positive patients, we are doing our best to keep the medical center supplied. There are supply challenges, but currently, drug supplies are sufficient to continue our use of those medications.

Regarding Remdesivir, it is not an FDA-approved drug. Since there has been a declaration of a public health emergency and Remdesivir has shown benefits in COVID-positive patients, the FDA has issued an emergency use authorization (EUA) to allow for its use in the treatment of COVID-positive patients. Since Remdesivir is not a FDA-approved drug, the federal government controls both which patients can receive the drug as well as how the limited drug supply is allocated throughout the country. In the EUA, the FDA outlines clinical criteria that must be met for a patient to qualify to receive Remdesivir. The allotment of the drug to specific facilities is controlled by the federal government, specifically the Dept of Health and Human Services (HHS), in collaboration with State and County Departments of Public Health. Kaweah Health continues to monitor and purchase our allotted amount of Remdesivir. Our demand has consistently been greater than our allotted supplies of the medication and it is not uncommon for our supply to be depleted before the next allotted amount arrives. We continually monitor medication supplies to make sure that patients that are started on Remdesivir are able to finish the prescribed duration of therapy.

16. We received several questions on how patients are being diagnosed and reported as being COVID positive. How does KD determine whether COVID is a primary or secondary diagnosis for patients.
    The guidelines for COVID are if the patient is being monitored, evaluated or treated for COVID and they came in for that reason, COVID is used as the Primary Diagnosis. The code that is specific to COVID 19 is U07.1 and that went into effect on April 1^st of this year. This code is used when COVID is the admitting diagnosis or can just be a secondary diagnosis if that wasn’t the reason for admission. There are exceptions to this rule, like if they have sepsis due to COVID, then sepsis is listed first (CMS guideline) then COVID, or if they came in for ONLY comfort care and we don’t treat them except to make them comfortable, so there are some exceptions, but for the most part, if they came in for a COVID related problem, we are coding it to COVID. There are some instances where the patient is admitted and tests negative but later in the stay tests positive, so the admitting diagnosis would not capture the COVID patient. We are able to capture the data by diagnosis in any order – admitting, primary diagnosis, secondary etc. If they came in for say, a fall and broke their hip, the hip fracture is the primary Diagnosis and COVID would be 2^nd especially if the COVID is not the primary reason for their stay. Admitting diagnosis is not key factor in reporting for High impact HHS funding.

17. It is being reported that hospitals are overinflating their COVID numbers because they are making money off of COVID patients. Is there any truth to that rumor? Can you quickly go over the reimbursement rate for COVID patient and dispel the myth that the hospital is getting rich off of this pandemic?
    Kaweah Health receives a fixed amount per patient depending on their condition. There is a fixed payment for diagnosis that need a respiratory system. COVID is a respiratory virus. Medicare has bumped up the normal rate for respiratory syndrome patient by an additional 20%. That 20% was put in place because of the belief that COVID patients will stay longer, assume more resources, staff will need more personal protective equipment, providing different drugs, etc. The cost of care for the patient went up for us more than that 20% reimbursement rate. We can assure you that hospitals are not making profit off taking care of COVID patients

COVID arrives in March, and by the end of the month, we started to shut down vital services. The most vital being elective surgeries, both inpatient and outpatient. As a result we started generating operating losses. We lost $2.7 million in March. We lost $14.9 million in April and $11.1 million in May. Then on May 18^th, we started reopening surgeries and as a result, the loss in June was $3 million. We went from breaking even to a $31.7 million operating loss in those four months. That’s how we would have finished the year if it weren’t for the federal stimulus money. As part of the CARES act, Kaweah Health received $14.4 million which was applied to the lost revenue and reduced our loss to $17.4 million as we ended the fiscal year on June 30^th, 2020. We are very excited to have just received $10.9 million from the federal government and this will help cover the loss we expect in July and August.

Additionally, over the course of the pandemic, we discharged 271 COVID patients. 84% were covered by Medicare or MediCal. They pay us a fixed regardless of how long they stay. The cost for taking care of a non-COVID patient that stays for 5 days is $15,500. This covers staff, supplies, etc. The average length of stay for a COVID patient is 11.2 days and that cost is $32,000. Medicare did increase their rate payment by 20% to $18,700, but MediCal did not implement increases to their rates. Of the 271 COVID patients that we have cared for, we experienced a $3.2 million loss.

18. How is Kaweah Health’s financial implications affecting Kaweah Health employees?

Unfortunately, we have had to take drastic measures. For the new Fiscal year, the board adopted a budget reflecting actions that do affect the employees. We will be freezing wages and not providing merit increases, but there will be no wage cuts. Additionally, we will not be able to match our 401k match which will save the hospital around $9 million. We are looking at employee health plans/benefits and shifting more of that to our employees. All of this has been done to preserve jobs as another round of layoffs is the last thing we want to enact. On a side note, we have budgeted, for the first time, to have a zero operating margin and to break even.