Planning for COVID in Washington State

Program announcer

Welcome to the Peds Ethics Podcast, where we talk to leaders in pediatric bioethics about a hot topic or current controversy. Here's your host, John Lantos, from the Children's Mercy Bioethics Center in Kansas City.

Dr. John Lantos

Hi, this is John Lantos. Welcome back to the Pediatric Ethics Podcast, coming from Children's Mercy Hospital in Kansas City and the Children's Mercy Bioethics Center. Today, we're speaking with Dr. Doug who's a professor in the Department of Pediatrics at the University of Washington School of Medicine and attending physician and director of education for the Truman Katz Center for Pediatric Bioethics at Seattle Children's and has been living and working really at the center of the first big outbreak of COVID-19 in the United States. Thanks for taking time, Doug. I know you're busy.

Douglas Diekema

Yes, you're welcome.

Dr. John Lantos

Tell us a little bit about what's been going on there and from your perspective, where you've been working, what you've been seeing.

Douglas Diekema

Well, we, I think most people know, had I think the first known case of coronavirus in the United States not far from my house. And then we had a very large outbreak occur at one of the retirement communities, assisted living communities that is run by Evergreen Hospital. And that was really sort of the beginnings of what has now become a fairly large epidemic that grows in size every day and is involving more and more of the hospitals in the region and now the state. And obviously the adult hospitals have been impacted more than the children's hospitals have, but We are part of the region and will be expected to assume some of the burden that comes our way.

Dr. John Lantos

And have you been seeing patients in the ER? You yourself?

Douglas Diekema

Well, I personally have seen patients in the ER, but quite honestly, COVID-19 is... proving to be very rare in children. So, you know, the numbers I'm familiar with, the vast majority of testing we've done on kids who have influenza-like illnesses are negative for COVID. I think I'm only aware of about a half a dozen kids in the region that have tested positive, and most of them, to my knowledge, have not required admission.

Dr. John Lantos

Have you had enough tests? Are you able to get tests?

Douglas Diekema

Well, tests have been a bit of an issue. We are still in a position region-wide where we are only testing people who are symptomatic with findings consistent with COVID and for whom there's a good reason to do so. So we're actually asking people not to get tested if they have symptoms, but they're well enough to stay at home. And to some degree, I think the testing issues have been a little blown out of proportion. I mean, we have not had enough test kits to accomplish the public health goal, but in all honesty, the primary purpose of testing is epidemiology. There's little benefit to a patient at this stage and knowing whether they're COVID positive or not, since we have no treatments. I think the main issue, it's probably most important when you're at a point in an epidemic where you can still contain it and then it After that, it becomes important for tracking and cohorting. And beyond that, I think everybody just –

Dr. John Lantos

If a treatment becomes available, then it will –

Douglas Diekema

Then it changes. Then it's much more important for the patient then.

Dr. John Lantos

You've also been working with the state to try to figure out what's coming down the pike and how to respond. Can you tell a little bit about that?

Douglas Diekema

Yeah. Well, for years I've sat on our regional disaster – community advisory committee. And so we've been planning for some kind of a pandemic for years. And on the one hand, we had the materials in hand and we're sort of ready to roll those out. We'd actually already rolled them out. But I think we have all been surprised by the sorts of issues that come up that maybe hadn't been foreseen.

Douglas Diekema

It's made everybody very busy. But one of the advantages of the system we have in place is that we really do have a regional system. And so there's a lot of planning going on at the state level right now, which involves our disaster community advisory committee and health officials and hospital leaders around the state so that we have a coordinated effort that we're sharing. resources and probably the most important thing we've decided, which has been supported by the governor, is that we will not have any hospital go into crisis mode where they're actually making triage decisions about patients until every hospital in the state goes into triage mode. And the reasoning there is that if not every hospital is there, then we need to be transferring patients rather than denying them at some hospitals and not others of care that might be of benefit to them.

Dr. John Lantos

And is that happening yet? That

Douglas Diekema

has not happened yet. We have hospitals that are very close to crisis mode, and not surprisingly, Evergreen is one of them because they have a significant chunk of the adults in the region who are very sick. But others are starting to get there. But no, we're still in the parlance of the disaster preparedness community. We're still in contingency mode where we are making changes, but none of those actually jeopardize usual standards of care. But we're starting to talk about what it will look like in two weeks. I think most people realistically are assuming that we may need to declare statewide crisis mode in a couple of weeks where we'd be making hard decisions.

Dr. John Lantos

Particularly around ventilators?

Douglas Diekema

Ventilators will be an issue. ICU beds will be an issue. We already have regional efforts to increase our bed capacity. For instance, just north of Seattle, we're using a soccer field and putting up a huge tent that will house about 200 potential patients. I don't think we foresee taking care of sick patients. I don't think we see those as mobile ICUs. But one of the issues the adult hospitals are having right now, which is one of those things that maybe we didn't foresee when we talked about this in theory, is that they're having trouble freeing up beds because some of their older patients who are actually dischargeable communities from which they came, the nursing homes, for example, won't take them back. And our homeless population doesn't really have anywhere to go. So I think part of the idea with these additional beds is actually to have a place, maybe a step-down unit for some of these patients to go to allow the hospitals to take care of the sickest of the sick.

Dr. John Lantos

What about the health care workforce? With the need for more ICU beds, you need more ICU doctors and nurses.

Douglas Diekema

yes and and and just hospital staff i mean ers are busy and um not every patient with covid requires a hospital bed you know 80 of them are probably who are getting admitted are on the floor um and staffing i think is going to be the real barrier we we can probably create beds but then the question comes who's going to staff those and You know, right now, I think we're looking at two prongs. One is bringing physicians and nurses out of retirement, those who are willing to staff some of those areas. And the other is to retrain and redeploy other health care workers who have less to do.

Douglas Diekema

Dentists, occupational therapists, physical therapists, and a number of healthcare professionals actually have less work to do right now because clinics have been closed and almost all elective procedures, surgeons actually are another group that right now, because so many elective surgeries have been canceled, are sort of looking for ways to help. So that's probably... Those are probably the two ways we'll do this. But the other piece of the health care shortage is it's not just that we're expanding beds and need people to staff them, but our workforce is going to get sick. And that's already started to happen. And then you have professionals who are in high-risk groups, or at least believe they are, and they have concerns about their own health. And some of those are choosing not to work or in a small number may refuse to work because of the risks involved. And all of that cuts into, obviously, the workforce we have available.

Dr. John Lantos

How does the Community Disaster Planning Committee think about physicians or nurses who are in high-risk groups? Are there any criteria by which you say, no, you shouldn't work?

Douglas Diekema

Well, I don't know that we have any established criteria. And interestingly, the regional group has not looked at this in much detail. I've been spending a lot of time on this issue to help our local hospitals make those decisions. And what we're trying to do is tailor it to the disease because COVID looks different than influenza or some other pandemic. And right now, the clearest high-risk groups are probably those over 70.

Douglas Diekema

Now, we have an advantage in that there aren't that many people over 70 in the workforce. You know, we really don't know whether pregnant women are a high-risk group or not. We don't really know whether immunocompromised people are. There's some evidence that those with heart disease and pulmonary disease may be. So I think the strategy we've taken to date is to say, look, you're professionals. You have a duty to work. as long as we can protect you adequately. And as long as hospitals are able to provide adequate personal protective equipment, there is probably no reason not to have that expectation. I think the other piece that I found very compelling about this outbreak is that as it's gone on, it's become very clear to me. And again, it's hard to find really hard data to demonstrate this, but certainly My experience and what I'm reading, I think, would justify this conclusion. And that is that I really think right now that our workforce is more at risk working with patients who are not suspected to have COVID than they are working with patients who are because they're not wearing PPE when they see those patients. And at least from the World Health Organization.

Dr. John Lantos

Some percentage is infectious.

Douglas Diekema

Correct. Yeah. And they're getting it in the community and they're getting it from family members. And so I think there's kind of a false sense of reassurance. If you're a 65 year old, for example, and thinking, well, if I just avoid the COVID patients, I'll be fine. I think that's probably unjustified. I think if you really want to be rational about this, you either have to say groups we're worried about have to stay home and not leave the house. or they can come into work and wear personal protective equipment when it's appropriate and probably not be at all that much greater risk.

Dr. John Lantos

Yeah. When do you send health care workers home? What sort of criteria for self-quarantine?

Douglas Diekema

I think that's also evolved. You know, when the epidemic started, most of our hospitals were... sending anybody home with any sign of illness and anybody, obviously anybody who was positive for COVID or had international travel was actually supposed to be in isolation for 14 days and stay away from the hospital. As the epidemic has evolved and it's sort of moved into the community in sort of a widespread way, I think we've sort of changed our assumption to assume that almost anybody has had a potential contact. And it's not just the positive testers. And obviously, we can't just tell everybody to stay home because then we can't staff a hospital. So we've moved more in a direction of, and most of the hospitals are doing this now, screening everybody walking through the doors of the hospital, telling all non-essential, non-clinical staff to work from home.

Douglas Diekema

And so when you go through the doors of the hospital, you have your temperature taken and you have to screen that you're not having a cough or myalgias or sort of symptoms consistent with COVID. And if you screen positive or have a temperature over 100, you go home and self-monitor. We do have testing available to employees who screen positive for symptoms. So they do have that option to get tested.

Dr. John Lantos

That's up to them, though.

Douglas Diekema

Yeah, and even with a positive test, if they're still febrile, we're not going to let them come back because there are false, or with a negative test, rather, there are false negatives. So we have to kind of assume that they may still be carrying the virus.

Dr. John Lantos

What's your sense of the morale of the hospital staff?

Douglas Diekema

I think it's mixed. You know, there are always individuals who kind of get energized by the crisis atmosphere. They feel like they're really making a difference and they rise to the occasion and the energy level is good. I have sensed over the last week increasing levels of anxiety from bigger numbers of people.

Douglas Diekema

And part of it is just the barrage of information, not all of which is consistent. They hear different things from different sources. And so they're... you know, like the general public, not entirely sure who to believe and not entirely sure just how safe they are working in a hospital environment. So the anxiety levels are high.

Dr. John Lantos

You said at the beginning that you'd been planning for a long time, but there were some surprises in this particular disease or outbreak. What were some of those and what should other places be thinking about?

Douglas Diekema

Well, I think one of the things that struck me was that despite the fact that we've been planning for this and talking about it for years, it still took a while to get things off the ground. It took a while for people to realize we actually had a situation that had the potential to get really bad really fast. I think the rapidity with which this virus started to spread was striking to a lot of people. And So it does take time, particularly when you're dealing with a region with thousands of healthcare workers and hundreds of hospitals to get everybody on the same page, taking things seriously. And of course, some of the regional sort of non-healthcare interventions are pretty new to this country. I mean, the shelter in place mandates that some places are putting in, social distancing, the cancellation of almost everything. People are – and then the rush on grocery stores to buy toilet paper is all just – I never saw that

Dr. John Lantos

in any planning documents that

Douglas Diekema

I've read. No, we didn't plan for that.

Douglas Diekema

And the other thing we didn't plan for, quite honestly, which some places, businesses have started to implement really well, is – You know, there are these essential businesses like pharmacies and grocery stores that have to stay open. And we really didn't talk about how can we keep them open safely? You know, that person who's a cashier, a bagger at the grocery store, what sort of effort should we be thinking about to protect them from getting infected or spreading infection to customers? That was one of the things that, you know, we probably could have implemented weeks earlier if we'd thought about those issues long before, but we hadn't. So it took a while for people to say, hey, you know, this is an issue and we should be thinking about. A

Dr. John Lantos

lot of the surprises were outside the hospital system, outside the health care system.

Douglas Diekema

Yes.

Dr. John Lantos

Anything else you'd like to add and then we can wrap this up. I know you're busy.

Douglas Diekema

Oh, not at this point. I do think it's going to be interesting to. see what happens in the rest of the country. My assumption is places like Michigan and Iowa and Kansas City are probably a couple weeks ahead of Seattle and San Francisco and New York in terms of social distancing efforts. So if we're lucky, the impact will be less serious in places like that, having taken advantage of the fact that you could see what was happening in some of the hot spots.

Dr. John Lantos

That's what we're hoping. Well, thank you very much for taking the time. We've been talking to Doug Deakam, a professor in the Department of Pediatrics at the University of Washington and a physician at Seattle Children's Hospital. Thanks so much for joining us, Doug. This is the Pediatric Ethics Podcast from Children's Mercy Hospital in Kansas City. I'm John Lantos.