September 9, 2021 Community Engagement Virtual Meeting

QUESTIONS FOR 09/09/2021 COMMUNITY ENGAGEMENT MEETING

CURRENT COVID-19 NUMBERS IN TULARE COUNTY

1. Positive Cases in Tulare County: 3,597
2. Positive Cases currently in Kaweah Health: 118
3. How many are in ICU and do we have empty beds in our ICU?18
4. Positive Employees at Kaweah Delta: 64 currently on LOA
5. Hospital Census: 343, 344 total adult beds main hospital- Max Capacity

Are the three pediatric patients that are currently admitted normally healthy kids?

We don’t know. We have spoken to a Pediatrician who works with pediatric hospice and they have indicated that a lot of the sick children who are hospitalized in our region have underlying chronic conditions.

Have we seen an increase in people in Tulare County getting the vaccine?
Simple answer is, yes. As of September 7, Tulare County has 219,952 people who have been vaccinated or are in the process of getting the vaccination. Remember this is a moving target and varies slightly based on the resource.

• 46.9% of the Eligible Population is Fully Vaccinated
• 9.0% of the Eligible Population is Partially Vaccinated
• 44.1% of the Eligible Population is Unvaccinated

Keep in mind that if you are getting the Pfizer or Moderna vaccination, these require a 2nd shot to be fully vaccinated, Johnson and Johnson (Janssen) is a single vaccination. Reviewing the data provided by Tulare County through the month of August, the number of the community member being vaccinated has increased by 2 % per week, this past week we saw a 3% increase in those getting vaccinated. We have seen a steady decline in the number of vaccinations since a high of March 2021 at 105,000 vaccines. In August, we have seen an uptick in vaccines - l0,000 more when compared to July.

When is the 3^rd dose, or “booster”, going to be available to the community at large?
3rd dose or “additional dose” is available now for immunocompromised.

The “booster dose” (8 months after the completion of the initial 2 shot series for those that are NOT immunocompromised) is expected to be FDA/CDC approved sometime on, or shortly after 9/20. Which will likely mean it’s available to CA residents a few days after once CDPH accepts/clears it for CA (see below). Would expect it to be available to the public in CA/Tulare County within 48-72hrs after the FDA/CDC announcement. Booster authorization is only expected for PFIZER as the data for MODERNA is lagging (likely a month or so behind) and not ETA on J&J as they have not submitted their info to FDA yet for consideration.

The 3^rd dose for those that received the Moderna vaccine will likely come at a later time.

Process for CA to approve/make available for admin under EUA:

Once FDA/CDC announce, APIC (national council on immunizations) is expected to adopt, at which point Western States Scientific Council (regional version of APIC) is expected to adopt and then that’s when CDPH will adopt thus clearing the way for the standing order under the EUA for 12-15, or full FDA approval for those 16+. Once CDPH clears it, now it good to be administered via standing order by any clinic practicing under the standing order and open to the public. With “additional dose” for immunocompromised this process took 2 days from date FDA/CDC announced for this population.

During the last surge Kaweah Health shut down elective surgeries. Have you done that this time and if so, can you explain elective surgeries?
AstheCOVID-19 numbersincreased this past month, we were again faced with the need to evaluate the surgeries and procedures coming to the hospital requiring an overnight or longer stay in the acute inpatient units. We acknowledge the ongoing need to continue to do true outpatient procedures to uphold our commitment to provide necessary surgical care to our community in a safe, timely, effective, and efficient manner. To manage the demands for inpatient treatment around not only the COVID admission but also those patient who present for treatment and admission through the Emergency Department, we recognized the need to reduce the number of patients that could be consider for surgery with subsequent need for admission.In collaboration with the OR Medical Staff Governance committee, we implemented a scheduling process as follows:

Starting Monday, August 23, 2021, we implemented strategies to limit scheduled surgeries requiring inpatient stays to three (3) patients per day that meet Urgent/Emergent criteria. If patients have to go to the floor for any reason, it is considered an admission. Outpatient surgeries need to have an expected post-operative stay of 4 hours or less. This will allow us to use available staff to maximize the number of outpatient surgeries that can be performed as we advance. Outpatient procedures can be scheduled as usual at this time.

To schedule a procedure that is considered Urgent or Emergent in nature, the following information will be needed at the time of scheduling the patient.

• Surgery Scheduling Form
• Pre-OperativePatient/Procedure Score Tool
• Surgical Necessity Form

Thesurgical leadership team will prioritize the three (3) Urgent or Emergent surgical admissions based on Tier 1 or Tier 2 guidelines.

TIER GUIDE

Tier 1: Emergent with loss of life, limb, or organ; procedure delay likely leads to permanent disability.

Tier2:Urgent with delay in procedure greater than 30 days likely to lead to unacceptabledisease progression,need for hospitalization, probable future adverse medical event, or extended disability. Any procedure required toexpediteinpatient discharge. Most malignancies.

Tier3:Casesdeemednecessary within 3 months but not expected tonegatively affect the long-term outcome or change the complexity of the procedure if deferred greater than 30 days.

Tier 4: Elective procedure with no urgency and done solely to improve quality of life with no direct impact on longevity.

This limitation on scheduled elective surgeries and procedures is reevaluated every week for the next week's restrictions.

Can you explain how this affects the hospital financially?
There is a direct correlation in the financial performance of our hospital and the number of surgeries that are performed and admitted into the hospital.Historicallyover 1/3 of our operating margin has been related to services provided to our surgical patients.

Surgeries and procedures carry a higher reimbursement rate as established by our payers such as commercial insurances, MediCare and MediCal, than most medical admissions. Routinely surgical admissions have a shorter length of stay. We have been experiencing a longer length of stay with our patients who are admitted with COVID as their primary diagnosis as well.

It seems like there are a few different symptoms with the Delta Variant (stomach pains and nausea). What else is different about this variant that we need to be watching for?
Common symptoms observed with the Delta Variant of COVID include: cough, fever, headache (sinus), congestion, body aches, and occasionally significant loss of smell or taste. Severe disease manifests the same way as all COVID strains do: shortness of breath (dyspnea), decrease in oxygen saturation, fatigue, with the potential of temporary bleeding disorders and “white-out” of the lung or Acute Respiratory Distress Syndrome (ARDS) and secondary bacterial infection causing pneumonia. The Delta Variant replicates more efficiently producing larger volumes of virus (1,000 fold more than the original Wuhan China strain) that are expelled during coughing/sneezing of infected people (those who are symptomatic and asymptomatic). Also, the Delta Variant displays a greater affinity within its connect to the ACE receptor site human cells enabling it to cause infection easier. So for every one person who is infected, another 5 to 8 people around that individual become infected.

We have seen the graph the County posted about the non-vaccinated patients vs. vaccinated patients, but, what about patients who have been re-infected? Have we had a lot of patients who have previously had the virus? Have we had any patients that have been previously infected and vaccinated?
Yes, we have had people previously infected become infected again. Additionally, it is possible to become infected even after previous infection and vaccination although this is rare. Previous infection provides a minimum of 90 days’ protection when the infection is considered ‘moderate’ or ‘severe’ which translates into a hospital admission or an admission to the ICU. Mild infection does not confer significant immunity according to studies. Vaccination against COVID has demonstrated a significant decrease in likelihood of hospitalization. However, vaccines such as Pfizer and Moderna have demonstrated decrease protection/efficacy after 8 months – the immunity wanes. So it is possible to be infected several months after vaccination. This is the reason COVID booster vaccinations are being recommended.

Are Kaweah Health’s visitor guidelines changing or are we still allowing one visitor?
The visitor guidelines are remaining in place:

• Only one visitor per patient, for the entire stay.
• Following the Public Health Mandate, visitors must show proof of vaccination or proof of a negative COVID test within 72-hours.
• The visitor will be required to wear a surgical mask in the patient care areas as per state guidelines.
• Children over the age of 16 are allow to visit only if accompanied by an adult and must also follow the masking guidelines.
• Proof of vaccination must be shown along with a Photo ID.
• Visitors must be 14-days past last dose of vaccination.

Are all visitors being re-routed to the Acequia Wing Entrance? Even Labor & Delivery?
Forthepastyear,theMineralKingentrancefunctioned as the Emergency Department entrance and ED lobby as we continued to complete the ED expansion construction project. The ED expansion opened Wednesday August 18 allowing us to vacate the Mineral King Lobby.

With this move, the lab draw station previously located in the basemen is being relocated Mineral King Lobby. To accomplish this, we will be temporarily shutting the MK entrance to complete repairs and upgrades. Visitors and vendors are being directed to the Acequia Wing entrance for screening, as well as monitoring and coordinating the number of visitors coming to facility to visit their family members.

Labor and Delivery patients will enter the New ED Lobby, be screened and directed to the temporary entrance into the MK. Once the MK lobby and lab draw station updates and construction are completed, the L&D patient will be permitted to enter through the main doors. The primary support person with the mother will be allowed to enter through these temporary MK entrance pending completion of the construction in the Lobby.

If a patient is admitted for a non-COVID-19 related issue, but is COVID-19 positive and passes away, is that patient counted as a COVID-19 death?
COVID deaths are reported on Death Certificates. Providers use their clinical judgement to determine both the immediate cause and underlying cause(s) of death and report this information separately on the Death Certificate. Additionally, significant complications that may have contributed to death are listed on the Death Certificate. This information is displayed in a hierarchy with the immediate cause followed by the underlying causes of death with contributing factors listed last on the Death Certificate (i.e. Immediate Cause: Acute Respiratory Distress Syndrome; Underlying Cause: Pneumonia & COVID; Contributing Factors: COPD, hypertension). This information is reported to local Public Health Vital Statistics Programs and from there it is shared with the State and Federal Government for overall tallies. Additionally, hospitals use ICD10 codes to designate this information which is reported to the State and Federal Government.

What is your max capacity of COVID-19 beds available? What was the number of patients you had at one time when the virus was at its first peak?
The peak number of COVID+ inpatients during wave 3 of the pandemic, aka last winter, was 169, on January 5.

The peak number of COVID+ inpatients during wave 4 of the pandemic, aka this summer, was 129 (so far), on August 26.

Do you expect COVID-19 positive numbers to be going up after the Labor Day parties this past weekend?
COVID-19 cases have been on the rise in states across the U.S., and while numbers are starting to plateau and decline in some of the hardest-hit areas, experts predict that we'll see another spike in cases the Labor Day holiday weekend, which often comes with large gatherings and going out to bars and restaurants. But there's another place experts believe will start to significantly drive the spread of COVID past the long weekend. According to doctors, kids returning to schools without the proper precautions in place will lead to significant transmission of the virus.

What determines the amount of beds available when you report them? Is it actual beds occupied or does the amount of nursing staff figure into the available bed #?
We currently are reporting all licensed beds as available beds and are at or near capacity on a daily basis for all medical surgical beds. In additional we are using flex spaces such as our pediatric unit as adult medical/surgical beds as needed. Our current critical care bed capacity is 41 and we are currently running a census of 43.

We are staffing to ratio and acuity through the use of travelling nurses, we currently have 100 in house support our patients and various units. In addition, we implemented a bonus program for staff that work a fourth and or fifth shift in a week. With staff dedication to our patients and the support of the traveler team, we are able to staff 100% of the beds. What we have on a daily basis is approximately 40 patients daily coming through the ED in need of admission. As a patient is discharged, we have multiple patients in line for that bed.

On the daily report, the total number of beds being reported are the actual licensed beds in the facility. As an example on September 8^th the reported beds were as follows:

Location	Room_Type	Bed Utilization	Bed Utilization Rate	Beds Available	Beds Available Rate	Total Beds
KDMC	Med/Surg	235	99.16%	2	0.84%	237
Intermediate Critical Care Unit	51	94.44%	3	5.56%	54
Critical Care	39	95.12%	2	4.88%	41
Pediatrics	8	66.67%	4	33.33%	12
Maternal Child Health	38	44.19%	48	55.81%	86

At this time, we are using every bed and hiring the necessary staff to support the beds.