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‘Preparing for the worst, praying for the best’ – Q&A with a chief medical officer on the front lines of COVID-19

by Raymond DeCorte, MD | Frank D. Sottile, MD

Published on 4/28/2020

Estimated read time: 10 minutes

In the wake of Mardi Gras, New Orleans has become one of the nation’s COVID-19 hot spots. The large, rapid influx of patients has strained doctors, nurses and other caregivers professionally and emotionally. In this Q&A, Frank D. Sottile, MD, chief medical officer of Cerner ITWorks, talks to Raymond DeCorte, MD, chief medical officer of East Jefferson General Hospital in Metairie, Louisiana. The 407-bed community hospital is in a suburb of New Orleans and has a sizable senior population.

Q: When did you get your first hint that something big was about to happen?

A: The Monday before Mardi Gras, in late February, I got a call from a colleague, an ear, nose and throat physician, with a patient who was having respiratory symptoms and had just gotten back from Venice, Italy—right before they closed down that city. At the time, the guidance was not to test for Italian travel, but that soon changed. We had a travel- and person-to-person focus on this virus for a while, and then as it became more prevalent, the travel piece became irrelevant.

Q: How long did it take you to appreciate the magnitude of the COVID-19 wave that hit East Jefferson?

A: We had a pretty good idea of how quickly it was going to hit based on the experience in Seattle with nursing home patients. Once we started to see nursing home patients with symptoms, it progressed fairly quickly. We were praying it wouldn’t but preparing that it would.

We hit the wall at one point, in terms of saturation of our emergency department. We’ve developed, with all the other hospitals in the community, a communication network to help each other. When one hospital’s patient roster is lighter than another, we transfer patients. It’s worked out fairly well.

Right now, we seem to have bent the curve. Our emergency department doesn’t have as many patients waiting for rooms, and we’re certainly not having to transfer patients to other hospitals. We hope this is a permanent change in status.

Q: What’s a key lesson you’ve learned from the COVID-19 pandemic that you can share with us?

A: I don’t think IT staff, outside of the nurses, are trained on proper use of personal protective equipment (PPE). From a clinical perspective, we’re attuned to that, but it’s not something IT staff really think they’ll have to deploy. They should, though, given the high-risk clinical setting they’re in. For instance, they have to be fit-tested for N95 masks; they have to be reminded and re-educated on hand hygiene in clinical areas because it’s not something they normally do. You want to get ahead of it and make sure your IT staff is up-to-speed in the same manner as your clinical staff.

Q: What are some of the challenges East Jefferson is facing amid the pandemic?

A: Testing has been a problem in terms of being able to give comfort or guidance to patients and physicians, but testing doesn’t change the clinical course. Our numbers are tracking with what we’re seeing around the country in terms of the percentage of patients who require ventilation and ICU care, as well as our mortality rates.

We were hit fairly hard, particularly at East Jefferson, because of the age of our patients and the number of nursing homes around us. At times, we’ve had some very contentious discussions regarding end-of-life care. We don’t have as many advanced directives as we’d like at these nursing homes. When patients present with respiratory compromise and have to be put on ventilators, very often their co-morbid conditions point to likelihood of not doing well. That’s been difficult.

The situation has also been complicated by the lack of adequate PPE. We’re preserving PPE for our front-line nurses, techs and doctors, so we don’t have the luxury of being able to outfit our patients’ families. That means a lot of these tough discussions—and also the tough situations the patients are in—are occurring without their family members physically present.

The integration of a telemedicine platform has helped by connecting nurses, doctors and families. If there’s any lesson for other health care organizations it’s this: Plan your telehealth strategy now before you have infected patients in your units. Get that nailed down quickly and ahead of time, so you’re not retrofitting an ICU and risking exposure to IT workers in the midst of a crisis.

Q: I understand another challenge is finding a place for nursing home patients to go after they've recovered from the virus. Can you tell us about this?

A: We’re testing patients now 20 days out, and they’re still testing positive with a nasal swab for polymerase chain reaction tests. Nursing homes want patients to have a negative test before they return. Under state law, they have to wait 30 days to take a patient back or be prepared to manage the patient in isolation, which is hard for a nursing home to do.

The hospitals have enough PPE, but there’s not enough PPE for all the nursing homes, which puts us in a bed-capacity bind. We’ve had a steady influx of patients; which I think we can handle. The problem is on the back end when it’s time to move patients out.

The state has set up a process of getting patients from a Tier One hospital to a Tier Two facility, but those places are mainly converted ambulatory surgery centers and boutique hospitals. They have a limited number of beds and those beds are filling up, too. We’re going to have to ride the time frame and hope we keep this curve bent long enough that we can decompress the hospital, in case there’s another wave.

Q: How has the community responded?

Physicians are giving words of support and encouragement. A lot of them are also contributing donations to help feed staff on the front lines. New Orleans is a food city, let’s face it. The last thing we want to see is our restaurants go out of business. A lot of people are responding by arranging food donations.

Someone did chalk graffiti on the walkway to our parking garages. It’s all words of encouragement with phrases like, “Thank you for what you’re doing,” and “We see your bravery.” It’s very encouraging, and I think everybody’s avoiding walking on it. You don’t want to break that sentiment of goodwill and support that was put in those chalk messages to us. There’s a tremendous amount of support in the community for health care workers, which is gratifying during this scary time.

Q: With tens of thousands of COVID-19 cases in Louisiana and thousands of deaths state-wide, how are you supporting your medical staff?

A: We’re working to have adequate PPE for them, helping educate them, and reassuring them that our recommendations meet the Centers for Disease Control and Prevention's guidelines or better. We’re using donations from communities, facilities and businesses for N95 masks, as well as half-mask respirators with P100 cartridges and N100 cartridges. East Jefferson has an entire team devoted to making sure we sustain PPE by reprocessing masks and gowns when feasible. There’s even a cottage industry that’s developed using raw materials donated from local businesses to manufacture our isolation gowns.

We’re committed to supporting our medical staff; it’s still anxiety-provoking. This is a community hospital; patients are people we know in the community. We have physicians and coworkers who have been patients—and not just in an ambulatory setting but ventilated in the ICU. It’s very stressful, and there’s not much more we can do than to make everyone aware that they have the best equipment and the best chance possible.

There’s also the added stress of not seeing an end in sight. We’re grateful for this little bend—it has really lifted a lot of people’s spirits—but we’re all worried about whether this is just the lull before a bigger wave hits us. So, we’re catching our breath a little bit, preparing for the worst and praying for the best.

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