Working on the Front Lines in the Emerging COVID-19 Pandemic: Health System and Public Health Leaders Share their Experiences

What does the COVID-19 pandemic look like right now from the front lines, both in multi-hospital systems, and in public health departments, across the U.S.? The Washington, D.C.-based Alliance for Health Policy, “a nonpartisan, not-for-profit organization dedicated to helping policymakers and the public better understand health policy,” sponsored a webinar midday on Thursday, March 19, and invited speakers from both sectors to speak.

The discussion was led by the Alliances, president and CEO, Sarah J. Dash, M.P.H.; and the speakers were Adriane Casalotti, M.P.H., M.S.W., chief of government and public affairs at the National Association of County and City Health Officials (NACCHO), and Craig Cordola, executive vice president and COO at the St. Louis-based, 150-hospital, 2,600-sites-of-care Ascension Health. The discussion was entitled “COVID-10 Webinar Miniseries Session 2—At the Front Line: Public Health and Health System Challenges.”

Dash began by asking Cordola what steps the Ascension system has been taking to address the crisis. “One of the good things,” Cordola said, “is that we have a fantastic team of emergency management professionals, and a tremendous command center at the health system. We also have a pandemic plan that provides additional guidance, and we regularly exercise these plans. We actually had one of the first cases, on January 20, in our Chicago-area ministry. And we treated patient number 5 shortly after that, and when that occurred, we immediately set up our incident command center, at [the Chicago-based] Amita Health in Illinois. So that was a bit of a practice run in January for our entire health community. And one critical element for us is keeping our patients and clinicians and staff safe. So we have an infection control team. And we’re standing firm in following the CDC guidelines on infection control.”

Dash the asked Casalotti about the range of public health departments encompassed by her association. “Thanks, Sarah,” she said. “Nearly 3,000 local public health agencies in the country are members. And we’ve been alerted since January” to the emergence of the pandemic. As for what the public health departments are doing, she reported that “They are doing a ton of data tracking and surveillance, looking at how to stop the spread and do everything to curb and stop the spread. They are… really being that adviser to local governments. Helping them to think through issues around large events, school closings, etc., as well as working with public housing issues, etc.”

“What are your biggest challenges, and what needs to be done next? Is the shortage of supplies of personal protective equipment one of the big issues?” Dash asked.

“Yes, the PPE supply shortage is definitely one of the big issues,” Cordola replied. “We have one of the largest GPOs [group purchasing organizations] in the country, which has been sourcing supplies for us for weeks, and four times a day, we’re tracking N-95 respirators, gowns, face shields. And we’ve gone through some of our construction vendors, too, to ensure we have an adequate supply of PPE. It’s something we are monitoring frequently. I believe that Ascension is in a very good position; however, it is a very limited supply. So we have implemented some guidelines around PPE, to ensure that we can preserve what we have. As an example, we’re following CDC [Centers for Disease Control and Prevention] guidelines around elective procedures. On Sunday, we began cancelling/postponing all the elective procedures that we could. One of the challenges is that this is a worldwide pandemic, and everyone around the world is essentially reaching into the same supply. But we’re well-positioned for right now at Ascension.”

With regard to protecting clinicians and staff members at hospitals and other patient care organizations, Dash said, “Obviously, people without COVID-19 continue to fall ill” or become injured, for a spectrum of reasons. “We saw last week an expansion of telemedicine capabilities,” being made possible by the federal government. “Also, with regard to the cancellation or postponement of elective surgeries, how are you meeting regular needs?”

With regard to the CDC’s recommendations on the cancellation or postponement of elective procedures, Cordola said, “At the end of the day, our fundamental premise is to follow CDC guidelines, but we are also deferring to the local clinical decision-making in individual ministries. We will never override local clinical decision-making. Per telemedicine, we’re fortunate that we already had a huge platform in place through AscensionConnect and through our employed physician group. We’ve accelerated that work so that we could increase televisits. We’ve had over 50,000 downloads, and in the past seven days, we’ve had 6,800 virtual visits, and we are continuing to accelerate virtual care,” while making participation in telehealth very affordable, with a $20 co-pay for any televisit.

“Adriane, how are city, county, local health departments, educating people” about telehealth and other opportunities? Dash asked.

“This is really where the two sides of public health and healthcare work together to preserve the resources of each,” Casalotti said. “Health departments are really doing a ton of work, working through the local press in their communities. Many have stood up call centers. And we have a workforce shortage in public health, so we’ve called up medical reserve corps members. We’re doing a ton of social media messaging. In Colorado, for example, they used the example of the length of skis to explain what six feet looks like, per social distancing. In NM, they said, wash your hands as though you’ve just cut your skin on cactus. Whenever there’s a public health information officer, those people are helping to build health literacy and are helping to try to build access to information. They’re trying to get accurate, useful information to the public.”

“You talked about the importance of the work that city and county public health departments are doing in order to emphasize social distancing and flattening the curve,” Dash continued. “Adriane, in terms of those terms, those are terms that maybe only in the past several days have jumped into the national consciousness. How’s that going?”

“There’s this combination of individual education and the development of policies at local levels to reinforce the message and make the choices easier,” Casalotti replied. “For example, the U.S. Senate passed the new bill that included provisions around the [Family and Medical Leave Act of 1993] expansion. Those make it easier to make the right choice when it comes to working at home, staying at home, when kids are at home. I’m personally dealing with that, and it’s hard. A lot of people are making the choice to keep a distance, but others are still going out to bars. So mayors said, we’re going to help you make the best choices by not keeping those places open. There are big economic consequences, but those policies are needed. I’ve actually really been impressed with how ‘flatten the curve’ has taken hold, actually. People are really impressed with how the world is handling this.

“So, I want to ask a question about testing,” Dash continued. “That obviously has been very much in the news. What is the process for testing patients, and for reporting those results?”

“Testing is a huge issue right now, and I would say that the situation depends on the community you’re in. The spectrum of containment to disease mitigation, depends on the locality,” Casalotti stated. “Testing is really necessary for people with severe symptoms, for those in medically fragile populations, and for healthcare workers. In certain communities, that [idea] is working. And, just because you have a testing kit doesn’t mean you have the personnel time to do it, or that you want to use up all your PPE on people who aren’t showing symptoms. So there’s a lot of calculus that goes into this. For example, in Pitkin County, Colorado, they’ve said, we’re not doing this. If you’re mildly sick, stay home; if you have more severe symptoms, we’ll figure out if we need to find a bed for you. They don’t have the resources to do broad testing. Pitkin County is where Aspen is. They have a health department of eight people, and while their population is small, they have a ton of people who come in as travelers. So that’s a decision that they have had to make. In other locations, they’re using ways to create more social distancing, such as through drive-through testing by appointment.”

Meanwhile, Casalotti continued, “From a scientific perspective, we would love to know the exact scientific burden, but we don’t have the resources, so communities are having to determine what resources they have. And there’s a complexity in the reporting now that maybe didn’t exist three weeks ago. There’s the public lab pipeline, but now, private labs, academic medical centers, and multi-hospital systems are now doing testing, so that adds another level of complexity to the reporting of numbers.”

Dash then relayed to the speakers a question from an audience member: without massive testing, as we look at the number of cases coming in, do you anticipate the number of cases that were already there, but not yet tested?

“Yes, absolutely,” both speakers agreed. “At the end of the day, whether it’s a couple of months from now or 18 months from now, it’s going to be really important for us to take the lessons of coronavirus and learn the lessons from them,” Casalotti added. “We were behind on the testing. And if nothing else, we should really learn from this experience in terms of how to be prepared for the future, so we’re starting a couple of steps ahead next time.”

Meanwhile, with regard to the issue of the extraordinary costs of patient care organizations operating during a pandemic, Cordola said that, “Eventually, there will have to be funds made available to sustain providers. Our health system [Ascension] is incredibly strong financially, but this [pandemic] will create problems for the vast majority of health systems.”

And, Dash asked, in closing, “What have the biggest lessons learned been from this pandemic so far?”

“I think that there are going to be many lessons learned, including around testing,” Casalotti said. “Public health departments lost a quarter of their staffs in the past recession, and they were never replaced. We’ve had 30-percent budget decreases as well. And when your system has cracks in it, you’ll find them when you have a crisis. We don’t just need to fund things in a crisis, we need to think more broadly, so that the system is there when we need it, because we never know when that will happen,” she said.

“Every healthcare disaster or event that occurs is unique in its own way,” Cordola added. “Many of us have been through hurricanes, tornadoes, fires, floods, bombings. Broadly, the supply chain and production of equipment and PPE is critically important for us to take care of families and of our staffs. The other element for us is the coordination that it takes to respond at scale across our Ascension health system and at the local level, so that we can provide support to all our teams. And that was our goal in standing up a crisis center, to decrease ambiguity and increase clarity. Those were a couple of key elements for us.”