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Challenges from Presentations to Diagnosis with ACEP · The SHEA Podcast

• 0:08
  SPEAKER_01: Welcome to the podcast series.
• 0:10
  SPEAKER_01: We are all in this together, COVID-19 Allies in Infection Prevention, as part of the Society for Healthcare Epidemiology of America, Shay's Rapid Response Program.
• 0:21
  SPEAKER_01: I am Getri Naval Keley, hospital epidemiologist at the University of Mississippi Medical Center, and I will serve as your Shay moderator and speaker.
• 0:31
  SPEAKER_01: I'm also happy to welcome Dr.
• 0:33
  SPEAKER_01: William Jackwell, American College of Emergency Physicians President, who will serve as your speaker for today's podcast.
• 0:42
  SPEAKER_01: Discussion on the podcast does not reflect today's or ACEP's perspective, but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 0:55
  SPEAKER_01: Today's episode will focus on collaborations between healthcare epidemiology and emergency care providers and how we as a team can work together to address the most important questions surrounding the COVID-19 outbreak.
• 1:08
  SPEAKER_01: So let's get started.
• 1:10
  SPEAKER_01: Welcome, Dr.
• 1:11
  SPEAKER_01: Jacques Wis.
• 1:12
  SPEAKER_00: Thank you.
• 1:12
  SPEAKER_01: Please describe what you or your organization is doing to address COVID-19.
• 1:19
  SPEAKER_00: Well, I think uh any of us could probably spend hours just talking about all the things that we have done.
• 1:24
  SPEAKER_00: It's been an interesting time for us, and we've done a lot of work.
• 1:29
  SPEAKER_00: Our staff's done some great things during the time, as our physician leaders as well.
• 1:33
  SPEAKER_00: But I thought I'd put it into a few categories, if I could, just to hit some of the bigger highlights.
• 1:40
  SPEAKER_00: I think we start with education.
• 1:42
  SPEAKER_00: I think that's one of the best things that our organizations do is provide a platform and a location for people to come for education.
• 1:52
  SPEAKER_00: And that's probably where we started when we started to look at this particular event.
• 1:58
  SPEAKER_00: We have, for instance, a group that we had stood up before that really focused in on emerging infectious illnesses.
• 2:07
  SPEAKER_00: And I don't remember whether that was MERS or SARS or which, but we've quickly stood them up to be able to give us all some insight into what we should be doing.
• 2:16
  SPEAKER_00: And I think a lot of the education was kind of just in time type of stuff, you know, with the rapidly changing environment in this COVID for us.
• 2:25
  SPEAKER_00: It was certainly things that had to be acted on fairly quickly.
• 2:29
  SPEAKER_00: We did start a platform on the engaged platform that was very helpful.
• 2:34
  SPEAKER_00: We actually ended up opening that up to not only our own members, but opening up more broadly to give us insight, to give us a signal of what was happening in our communities, and that quickly took hold.
• 2:48
  SPEAKER_00: Last count, I think that stopped at about 400 pages of information that our staff sifted through.
• 2:54
  SPEAKER_00: And then we also, I think, created a field guide that helped synthesize a lot of the things that we were doing and seeing there.
• 3:02
  SPEAKER_00: A lot of this, I think, too, with external facing was the public and press that we sent out.
• 3:07
  SPEAKER_00: Of course, a lot of things that we did were to help influence other people to do the things that we saw needed to get done, whether it was all of the stay-at-home type things, the public service announcements, all of those pieces that we produced in order to try and help people understand where we were, what we were doing, what perspective we had as well.
• 3:29
  SPEAKER_00: The second category I think really falls into what we did with our elected leaders.
• 3:35
  SPEAKER_00: Certainly a big part, a big part of this has been how our elected leaders have approached this.
• 3:41
  SPEAKER_00: And so we needed to really get them to understand the things that we were struggling with.
• 3:47
  SPEAKER_00: Certainly at the top of that list, everybody has seen was protective equipment.
• 3:52
  SPEAKER_00: It has been somewhat of a struggle, as we all know, to get the protective equipment we have needed.
• 3:58
  SPEAKER_00: There is probably a steady state right now, but that's certainly not been the case in a lot of places at a lot of times.
• 4:05
  SPEAKER_00: And that was a huge issue that we needed some help.
• 4:08
  SPEAKER_00: We did also have an interesting event.
• 4:11
  SPEAKER_00: Every year we host a conference in Washington, D.C.
• 4:14
  SPEAKER_00: called our Leadership and Advocacy Conference and do Hill Visits.
• 4:18
  SPEAKER_00: And we were able to recreate that virtually, which led, I think, to 400 to 500 virtual visits to congressional offices to advocate for our communities.
• 4:29
  SPEAKER_00: And we feel like that's not just the physicians, it's certainly our nurses, everyone we work with, but also the people we treat on issues related to protective equipment, credentialing, licensing, liability, things that were important for us to address.
• 4:45
  SPEAKER_00: And also, of course, with the challenges we have faced in terms of having the right equipment, the right staff, certainly the ability to have some funding support, which still is forthcoming, but that's certainly a part of as well.
• 5:00
  SPEAKER_00: I'll finish with that first question with I think the section and committee work that we have certainly the active committees and sections that have been repurposed in many ways to help.
• 5:10
  SPEAKER_00: I'll highlight a couple, cruise ship medicine.
• 5:12
  SPEAKER_00: You know, as emergency physicians, the scope that we have is really fairly broad, and a lot of our physicians have been involved with cruise ship medicine and help to set standards.
• 5:23
  SPEAKER_00: And so we are certainly revisiting those.
• 5:26
  SPEAKER_00: Also, stroke, of course, telemedicine.
• 5:29
  SPEAKER_00: And I will add also one that I started, which is a supply chain, and try to understand where the masks come from and how they get to us and didn't get to us.
• 5:39
  SPEAKER_00: It was kind of important, I think, for us to weigh in on that and see what we might be able to do differently that uh would allow us to get those things that we need for practice.
• 5:49
  SPEAKER_00: I'm also curious, kind of what you see as the highlights of your organization that you've been doing.
• 5:53
  SPEAKER_01: Thank you, Dr.
• 5:54
  SPEAKER_01: Jacquis.
• 5:55
  SPEAKER_01: I think that's a great summary of really speaking what other organizations, even Shay and what our institution is currently going through and has been through.
• 6:05
  SPEAKER_01: And one of the excellent points which you brought up was education, and that's exactly how we started as well.
• 6:12
  SPEAKER_01: So just educating the employees, educating the leaders, as well as doing some public education.
• 6:19
  SPEAKER_01: This was related to just not regarding COVID, but just other preventative measures which could be performed while in the community as well as while in other healthcare settings.
• 6:30
  SPEAKER_01: And the other great point you brought up was the collaboration.
• 6:33
  SPEAKER_01: So this has been a key factor at our institution as well.
• 6:38
  SPEAKER_01: We have collaborated with multiple, this is infection prevention, ED, as well as in the healthcare setting collaboration, but also outside the healthcare setting with the health department and other facilities which could help us to get the necessary resources.
• 6:56
  SPEAKER_01: So, as you mentioned, PPE, we went through the same thing where the masks were we were running short or going to be almost short of masks, and we had to collaborate with the outside vendors or the outside departments and facilities to help more PPE.
• 7:12
  SPEAKER_01: And it has stabilized for us as well, but I don't know for how long.
• 7:16
  SPEAKER_01: But this is more of exactly what we have been going through, and probably this is the same situation across other institutions in the country as well.
• 7:26
  SPEAKER_00: Yeah.
• 7:26
  SPEAKER_00: Well, it's interesting you mentioned that because one of the first things that I did as sort of outreach was attend a town hall that was set up by my local congressman.
• 7:36
  SPEAKER_00: Uh, went to his town hall first to listen, but then joined a couple later town halls.
• 7:41
  SPEAKER_00: And this certainly the person at the front of that speaking was the health official for one of the local counties talking about that to many of the organizations that were there, and that led to uh obviously some ongoing dialogue between us.
• 7:56
  SPEAKER_01: Very well.
• 7:57
  SPEAKER_01: So, what has been your biggest challenge around COVID-19 and how have you handled it?
• 8:02
  SPEAKER_00: You know, it's interesting, but I'd say I think pretty high level.
• 8:05
  SPEAKER_00: It might say PPE, but I think the reality is it's not necessarily the PPE, it's the policies that go into place and the distribution channels and how things are activated.
• 8:18
  SPEAKER_00: So I think the biggest challenge for us in emergency medicine is that we often initiate treatment on these yet diagnosed illnesses that come in patterns and cohorts and start to recognize what is going to be in our community or what is in our community.
• 8:35
  SPEAKER_00: And then there's a lag until that sort of proof comes, often through organizations like yours, that the rest of the people who are looking at it are waiting for that guidance.
• 8:47
  SPEAKER_00: I think our biggest challenge, often in emergency medicine, which then sort of filters down to access to a lot of things, is that we recognize in many cases the risk in our communities, we recognize the likely prevalence in our communities, but the rest of the system is often set up to wait for that end point where there is some proof.
• 9:10
  SPEAKER_00: And so early on, for instance, you know, we all have watched the progression of protective equipment from you don't need a mask, it's there to help the surgeons to now masking everyone.
• 9:23
  SPEAKER_00: Early on, the emergency physicians often have looked at it and said, Why would we not wear a mask?
• 9:29
  SPEAKER_00: You know, and then you're working with hospital leadership that is looking for guidance from other locations.
• 9:34
  SPEAKER_00: So if I were to say our biggest challenge, I think it's helping people understand in our world of acute and undiagnosed illness and injury as well, but illness in this case, that we often have to act in many ways prior to that real evidence coming in to support what it is we're seeing in those communities.
• 9:57
  SPEAKER_00: And that obviously leads to, as I've said, a lot of the decisions that get made that don't filter down to us uh as quickly as we would like.
• 10:06
  SPEAKER_01: I completely agree with you, Dr.
• 10:07
  SPEAKER_01: Jackwis.
• 10:08
  SPEAKER_01: It has been extremely challenging because since this all started, all the evidence and all the guidelines were really coming out from China or other countries.
• 10:20
  SPEAKER_01: And of course the US was lagging behind because they didn't have any cases, so we didn't have enough evidence to put out or policies and procedures to put out.
• 10:29
  SPEAKER_01: But yes, since we have had so many cases in US that have been different guidance and guidelines from all different societies, it's infection prevention to as a part of infectious disease group or as a part of the infection prevention group through J.
• 10:46
  SPEAKER_01: We have tried to put out the best evidence-based guidance, but the other societies have done the same.
• 10:52
  SPEAKER_01: If you look at emergency physicians, anesthesiology, as well as surgery, so that has been extremely confusing even for us on not having a standardized guidance and uh trying to convince everyone to follow one guidance, has been uh really challenging.
• 11:10
  SPEAKER_01: The one aspect of this, which has been challenging from infection prevention standpoint for me in my organization, and I think from the town hall meetings for today, what we have realized is some of the healthcare workers.
• 11:24
  SPEAKER_01: So we would assume that healthcare workers we need our resources, we need our staff, but uh some of the healthcare workers would also get sick from this and need to report that and not come to the facilities like working while they have COVID, as this can easily transmit to patients as well as other healthcare workers.
• 11:45
  SPEAKER_01: So I think that has been our biggest challenge in educating employees because as employees as healthcare providers, we always try to get through the situation or not try to have a presentism, even though we are sick.
• 11:59
  SPEAKER_01: And that has been the biggest challenge on trying to convince employees to report their symptoms and get tested and stay at home, which has been probably a little bit uh easier to communicate through the public guidance, but through the institutional guidance, we have been trying to communicate and educate that multiple times.
• 12:19
  SPEAKER_01: Have you experienced anything similar, especially with ED staff being the main workforce at the front lines?
• 12:27
  SPEAKER_00: Yes, absolutely.
• 12:28
  SPEAKER_00: And I think it's a couple issues related to that.
• 12:30
  SPEAKER_00: It's not just the illness, it's also the exposure.
• 12:33
  SPEAKER_00: One of the difficulties just in talking about protective equipment that we seemed to figure out early on, although it was also difficult to convey, was if you wear a mask and you have a person across from you wearing a mask, as we know it so far, your risk is low.
• 12:49
  SPEAKER_00: In the beginning, we ended up with people who were exposed, had to be quarantined, and it was quite a few, based on that initial presentation being so unusual, but not wearing a mask, or also very interesting, we had people who ended up quarantined who saw a patient that they thought had COVID, put them in appropriate isolation or not, depending, had a mask on when they took care of the patient.
• 13:16
  SPEAKER_00: The patient had a mask on, then they removed their masks and walked out to talk to the family, who then, of course, tested positive for COVID.
• 13:24
  SPEAKER_00: And so they ended up being quarantined.
• 13:26
  SPEAKER_00: So it was a learning process, obviously, both to try to understand the spread and also to act appropriately according to that.
• 13:35
  SPEAKER_00: And true, as you said, making sure people who had any signs of illness wore a mask minimally at the beginning and certainly stayed home as we got to know more about the disease.
• 13:47
  SPEAKER_01: So, as there has been more guidance, have you implemented any cohorting of your staff as well as cohorting of patients in the emergency department at your organization?
• 14:00
  SPEAKER_00: Yes, staff, not so much.
• 14:02
  SPEAKER_00: That's an interesting question that we toss back and forth because you know I think if we try to get this in the shape of who are the people at risk, there was some effort, I think, to walk through how we might lower the risk by taking people who had more risk of serious disease and not putting them into direct patient care.
• 14:24
  SPEAKER_00: The trouble with that, of course, is twofold.
• 14:27
  SPEAKER_00: First, this is a hard disease to recognize at the front end.
• 14:31
  SPEAKER_00: And secondly, in many cases, depending on the size of the emergency departments, you might then have to take somebody off shifts for a significant amount of time to do so.
• 14:43
  SPEAKER_00: So I think mostly what we did with our staff is to have them work but try and enhance their protective equipment, certainly.
• 14:52
  SPEAKER_00: Patients, we also have cohorted.
• 14:55
  SPEAKER_00: We for a long time, as you well know, in most of our hospitals, we've sort of had the seasonal approach to things like influenza, where there's screening criteria and people are masked, and probably at some level that helped us with the spread of this particular illness because we were already in those seasons.
• 15:15
  SPEAKER_00: But we fairly quickly continued to have those screening criteria out front, enhance them as we got guidance, and then moved even outside our emergency departments in many cases.
• 15:26
  SPEAKER_00: For instance, if you go into my hospital now, as you come towards the entrance of the hospital in the emergency department, you will get a temperature check and a mask if you're not wearing one.
• 15:37
  SPEAKER_00: And then those people who screen positive, although I'm not sure actually what screen positive means anymore, those patients are also taken in many of our emergency departments to a separate area where there's understood to be more at risk, which is also difficult because does that mean we relax a little bit on the other side?
• 15:56
  SPEAKER_00: And I don't think so.
• 15:57
  SPEAKER_00: I think we've all learned from the physician side at least and the nursing side that we need to respect all the patients and this particular illness.
• 16:07
  SPEAKER_01: Thank you, Dr.
• 16:07
  SPEAKER_01: Jackvis.
• 16:08
  SPEAKER_01: I completely agree and understand the challenges associated with that.
• 16:13
  SPEAKER_01: I think at our organization we went through the same challenges we have at the front entrance as well, the temperature monitoring and symptom screening, but the symptom screening criteria has changed so much and it's so wide that almost everybody falls into that category.
• 16:33
  SPEAKER_01: It has also been challenging trying to make sure that uh the symptom screening is appropriate and occurring for every person who comes through the entrance.
• 16:42
  SPEAKER_01: One of the challenges in terms of patient care is that they could have alternate diagnosis as well, but COVID could still be another infection which they could have along with the other diagnoses like uh otitis media or appendicitis or intraabdominal abscess.
• 17:00
  SPEAKER_01: And we have seen this multiple times.
• 17:03
  SPEAKER_01: So, not missing those infections has been very important.
• 17:07
  SPEAKER_01: And we have implemented a similar strategy to cohort these patients based on the screening criteria.
• 17:13
  SPEAKER_01: And as you said, the mask, this is the same strategy we have applied to provide the best food protective equipment for the emergency care or the frontline workers so that there will be less exposure.
• 17:26
  SPEAKER_01: So currently we have each and every employee has to wear a mask while they are in the healthcare facility, and as well as they have to self-monitor for any symptoms and report to us immediately, we do the same for when the patients come through until they are screened, and all the visitors have to wear masks in the healthcare setting as well when they come to visit their family members.
• 17:49
  SPEAKER_00: Yes, I know even for me, in fact, when I worked, basically when I go into the emergency department, I'm likely to grab a surgical mask and an N95, but given the availability and given the difficulty of trying to diagnose based on symptoms, I often end up, as do many of my colleagues, putting the N95 on and just leaving that on for the entire shift.
• 18:13
  SPEAKER_00: That also I think helps with the issue of doffing and donning and whether that aerosolizes and all of those tough questions about aerosolization and the impact of that on actual infection.
• 18:26
  SPEAKER_00: So it has evolved, I think, to that part where in emergency departments in most places we just kind of treat every patient as if they're infected based on a lot of the things you said as well.
• 18:38
  SPEAKER_00: They may come in with back pain or belly pain or or any other type of symptom and then test positive.
• 18:43
  SPEAKER_00: And certainly we're trying to prevent any impact of that.
• 18:47
  SPEAKER_01: Yes, I agree.
• 18:48
  SPEAKER_01: That has been a common scenario in our organization, and I think this is a common practice across all the other facilities in the US as well.
• 18:59
  SPEAKER_01: So, have you made any changes in practice so far based on this COVID-19 crisis?
• 19:05
  SPEAKER_01: And what has driven those changes?
• 19:07
  SPEAKER_01: What are you doing differently and what challenges has that presented?
• 19:12
  SPEAKER_00: Yeah, I think it's uh we're certainly doing things differently, but it's just such a moving target.
• 19:16
  SPEAKER_00: It'd probably be hard to even keep up with all the changes we make as we we try to look at this on the fly and try to get the best evidence, but there's not a lot of evidence.
• 19:26
  SPEAKER_00: And with the rise of social media, of course, you get a person with his N of six or 10 that has absolute evidence that this or that works and it makes it difficult.
• 19:36
  SPEAKER_00: But I think, you know, just even giving one example, the issue of hypoxia is certainly a big one.
• 19:42
  SPEAKER_00: And at the beginning, of course, uh patients that were hypoxic got when they were otherwise doing well.
• 19:48
  SPEAKER_00: I think early, certainly, there was probably more early intubation of patients because we were uncomfortable with those levels of hypoxia.
• 19:58
  SPEAKER_00: As time has gone on, I think we have done more with oxygenation.
• 20:02
  SPEAKER_00: Certainly, we are concerned about aerosolization, but using hyphlonasal cannular, those sorts of things to stabilize people, but really intubate based on their actual other symptoms rather than just a low uh oxygen saturation.
• 20:18
  SPEAKER_00: And there are many things like that as we sort of work through the different changes and try and stay up and in terms of what the newest challenges are.
• 20:27
  SPEAKER_01: I agree completely.
• 20:29
  SPEAKER_01: Like there has been so much difference in guidance available regarding the use of masks for these uh patients who are near intubation through the infectious disease forum and all the discussions with other institutes.
• 20:44
  SPEAKER_01: We have had a lot of questions regarding what is aerosol generating and what is not.
• 20:50
  SPEAKER_01: And that has driven what masks you should wear.
• 20:53
  SPEAKER_01: So the early intubation point which you brought up is completely true in regards to how do you manage these patients because the early evidence which came showed that early intubation would be safer so that you avoid last minute rushing into the room and causing aerosol generation.
• 21:12
  SPEAKER_01: But what we observed here at our facilities that those who got early intubation and patients had a lot of comorbidities, it was difficult to wean them off the ventilator.
• 21:22
  SPEAKER_01: And unfortunately, some of those patients ended up having severe morbidity and mortality as well.
• 21:28
  SPEAKER_01: Since then, the ICU providers have moved away from that, and that has kind of stabilized our morbidity and mortality rate.
• 21:36
  SPEAKER_01: Not much, but at least by a few degrees.
• 21:39
  SPEAKER_01: So I completely agree with your points.
• 21:42
  SPEAKER_01: Lastly, let's see what opportunities are there for individuals working in the healthcare EPI and emergency medicine to work together to handle the pandemic and long term.
• 21:53
  SPEAKER_01: What are your thoughts?
• 21:54
  SPEAKER_00: Well, I think it is first of all understanding the different approaches and perspectives we come from.
• 22:00
  SPEAKER_00: Which is fantastic.
• 22:01
  SPEAKER_00: It's nice to have unique perspectives and understand them.
• 22:04
  SPEAKER_00: And I think we talked a little bit about this earlier, but one of the biggest challenges for these rapidly moving events that are yet undiagnosed is understanding the role of the emergency physician in both that getting to the diagnosis, but also understanding how to do it appropriately and safely.
• 22:24
  SPEAKER_00: And so I think, as you said, the time from that initial presence in the community of a disease like this to the time when that first patient who even gets a test is diagnosed can be several weeks.
• 22:39
  SPEAKER_00: And in the interim, we sort of sit in this sort of risky phase, I think, in some ways, in terms of trying to help people understand that the presence of disease is not a hundred percent the presence of a positive test, it's the presence of the symptom complex or some other indicator.
• 22:58
  SPEAKER_00: And I think we can help each other in that way by understanding both of those roles.
• 23:03
  SPEAKER_00: I think back to probably somewhere in early 2000s when we did a lot of syndromic surveillance in our communities.
• 23:12
  SPEAKER_00: These types of things really fit well into those things where you have a syndrome complex that is going to be unique, and therefore we need to adapt to how we approach it fairly quickly.
• 23:24
  SPEAKER_00: And often before you've had a chance to guide us on the other end of this testing spectrum, at least, guide us into how it will impact our communities, the broader reach of it, and what would be effective in terms of both prevention and mitigation.
• 23:39
  SPEAKER_00: So I see great opportunities in sort of dialogue in that sense.
• 23:43
  SPEAKER_01: Thank you, Dr.
• 23:44
  SPEAKER_01: Jakwis.
• 23:45
  SPEAKER_01: I completely agree.
• 23:46
  SPEAKER_01: There is a lot of opportunity in which we can work together.
• 23:50
  SPEAKER_01: Of course, the more evidence we have and the more knowledge we have, the better we can facilitate this guidance to come out so that we can help out the frontline workers as well as the community to take appropriate steps so as to protect themselves as well as their other loved ones.
• 24:09
  SPEAKER_01: So the point you brought up is at point that we have the presence of disease and the positive test result really doesn't just give us the true spectrum of what's going on in the community and awareness in the community needs to occur before even all these measures are put into place.
• 24:29
  SPEAKER_01: So we will definitely try to work more towards this and uh hopefully uh get all these guidance out and work through this pandemic together.
• 24:40
  SPEAKER_01: Thank you very much for your time and for joining us today and sharing your perspectives and experiences.
• 24:48
  SPEAKER_00: Thank you.
• 24:49
  SPEAKER_00: It was a pleasure to do so.
• 24:50
  SPEAKER_01: And a sincere thank you from Shay to all the healthcare personnel for all that you're doing to respond to the COVID-19.
• 24:57
  SPEAKER_01: This podcast can be accessed on Shay's online education centered learning CE under the Rapid Response Program.
• 25:05
  SPEAKER_01: You will also find additional resources such as the recorded webinars, healthcare facility outbreak preparedness, and the SHA COVID-19 town halls, as well as the additional podcast series, COVID-19 updates, what we know now, which is released every Thursday.
• 25:21
  SPEAKER_01: That concludes this episode of the COVID-19 Allies in Infection Prevention podcast series.
• 25:27
  SPEAKER_01: Thank you for tuning in.